Aesthetic plastic surgery in Asians: principles & techniques 9781482240870, 1482240874

Citation preview

K23345_Pu_c00_FM-Vol I_r5_cl_i-xxxvi.indd 2

4/10/2015 6:54:24 AM

Aesthetic Plastic Surgery in Asians Principles & Techniques

K23345_Pu_c00_FM-Vol I_r6_cl_i-xxxvi.indd 1

4/10/2015 11:50:26 AM

K23345_Pu_c00_FM-Vol I_r5_cl_i-xxxvi.indd 2

4/10/2015 6:54:24 AM

Aesthetic Plastic Surgery in Asians Principles & Techniques Edited by Lee L.Q. Pu, MD, PhD, FACS, FICS

Professor of Plastic Surgery, Division of Plastic Surgery, University of California Davis Medical Center, Sacramento, California

Co-editors Yu-Ray Chen, MD

Professor, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University Medical College, Taipei, Taiwan

Qingfeng Li, MD, PhD

Professor and Chairman, Department of Plastic and Reconstructive Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China

David Daehwan Park, MD, PhD, FACS

Professor, Department of Plastic Surgery, Daegu Catholic University Hospital, Daegu, South Korea

Susumu Takayanagi, MD

Clinical Professor, Department of Plastic and Reconstructive Surgery, Kyoto University, Kyoto; Director, Mega Clinic, Osaka, Japan

Woffles T.L. Wu, MD, MBBS, FRCS, FAMS

Medical Director, Woffle Wu Aesthetic Surgery and Laser Centre, Singapore City, Singapore

Fu-Chan Wei, MD, FACS

Distinguished Chair Professor, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University Medical College, Taipei, Taiwan

With illustrations and cover art by Bill Winn

2015

K23345_Pu_c00_FM-Vol I_r5_cl_i-xxxvi.indd 3

4/10/2015 6:54:25 AM

Director, Editorial Services: Mary Jo Casey International Production Director: Andreas Schabert International Marketing Director: Fiona Henderson International Sales Director: Louisa Turrell Director of Sales, North America: Mike Roseman Senior Vice President and Chief Operating Officer: Sarah Vanderbilt President: Brian D. Scanlan Library of Congress Cataloging-in-Publication Data is available from the publisher upon request.

Important note: Medicine is an ever-changing science undergoing continual development. Research and clinical experience are continually expanding our knowledge, in particular our knowledge of proper treatment and drug therapy. Insofar as this book mentions any dosage or application, readers may rest assured that the authors, editors, and publishers have made every effort to ensure that such references are in accordance with the state of knowledge at the time of production of the book. Nevertheless, this does not involve, imply, or express any guarantee or responsibility on the part of the publishers in respect to any dosage instructions and forms of applications stated in the book. Every user is requested to examine carefully the manufacturers’ leaflets accompanying each drug and to check, if necessary in consultation with a physician or specialist, whether the dosage schedules mentioned therein or the contraindications stated by the manufacturers differ from the statements made in the present book. Such examination is particularly important with drugs that are either rarely used or have been newly released on the market. Every dosage schedule or every form of application used is entirely at the user’s own risk and responsibility. The authors and publishers request every user to report to the publishers any discrepancies or inaccuracies noticed. If errors in this work are found after publication, errata will be posted at www.thieme.com on the product description page. Some of the product names, patents, and registered designs referred to in this book are in fact registered trademarks or proprietary names even though specific reference to this fact is not always made in the text. Therefore, the appearance of a name without designation as proprietary is not to be construed as a representation by the publisher that it is in the public domain.

© 2015 Thieme Medical Publishers, Inc. Thieme Publishers New York 333 Seventh Avenue, New York, NY 10001 USA +1 800 782 3488, [email protected] Thieme Publishers Stuttgart Rüdigerstrasse 14, 70469 Stuttgart, Germany +49 [0]711 8931 421, [email protected] Thieme Publishers Delhi A-12, Second Floor, Sector-2, Noida-201301 Uttar Pradesh, India +91 120 45 566 00, [email protected] Thieme Publishers Rio de Janeiro, Thieme Publicações Ltda. Edifício Rodolpho de Paoli, 25º andar Av. Nilo Peçanha, 50 – Sala 2508 Rio de Janeiro 20020-906, Brasil +55 21 3172 2297 eISBN 978-1-62623-794-0

This book, including all parts thereof, is legally protected by copyright. Any use, exploitation, or commercialization outside the narrow limits set by copyright legislation without the publisher’s consent is illegal and liable to prosecution. This applies in particular to photostat reproduction, copying, mimeographing or duplication of any kind, translating, preparation of microfilms, and electronic data processing and storage.

To my wife, Yu-Shan (Emily), and my children, Felix, Dustin, and Adrian, whose love, sacrifices, understanding, and unselfish support have made editing and writing this book possible. To my parents and my younger brother, who have supported me for all these years and have trusted me to pursue my dream to become a successful surgeon through more than a decade’s effort To all my former professors and teachers of my surgical education, who have inspired me to set a higher standard in my career and to work harder to achieve it or to do even better. To my worldwide friends and colleagues in plastic surgery, who have made so many remarkable contributions to our specialty and have consistently encouraged me to do the same.

Lee L.Q. Pu

• To my wife, Pauline, whose love, sacrifices, understanding, and unlimited support made my work possible. To all my colleagues in Chang Gung Memorial Hospital Department of Plastic and Reconstructive Surgery for their hard work—pursuing the best and always putting the patient first And to my friends and colleagues in Asia and worldwide, who have taught me in conferences, meetings, and workshops, and encouraged me to be better and better.

Yu-Ray Chen

• With gratitude to Dr. Lee L.Q. Pu as editor for his kind assistance with the writing of my contribution to this text. I wish to acknowledge all my colleagues in plastic and reconstructive surgery for their remarkable contributions to this book. I thank all my students for their efforts in collecting and collating medical materials. Finally, I would like to thank my parents, my wife, Wen Bei, and my daughter, ShiYu Li, for their support and understanding of my busy work for all these years.

Qingfeng Li

•

K23345_Pu_c00_FM-Vol I_r5_cl_i-xxxvi.indd 5

4/10/2015 6:54:25 AM

I dedicate my contributions to this book to my son, plastic surgeon David Kisoo Park, who will be an excellent plastic surgeon after me, and my daughter, ophthalmologist Soyoung Park, who will also become a smart oculoplastic surgeon after me. To my wife, Heesuk Bae, who has patiently and without complaint held my hand through the long period of writing my chapters of this book. To my teachers, who taught me Asian aesthetic plastic surgery, and my students, to whom I taught the things I have learned.

David Daehwan Park

• To my wife, Misako, my son, Go, and my daughters, Ai, Emi, and Mari, for their support and understanding of my work as a plastic surgeon for many years. To my mother and father for giving me the opportunity to study hard to be a doctor and the freedom to enjoy many different things, such as tennis, basketball, dance, drawing, painting, and piano. To all of my good friends in ISAPS who work with me and have shared their high-level techniques and knowledge. The most important mission of that organization is “Aesthetic Education Worldwide.” As the President of ISAPS, I hope this book will propel surgeons toward this goal. I thank Lee Pu, my wonderful friend, for working with us.

Susumu Takayanagi

•

K23345_Pu_c00_FM-Vol I_r5_cl_i-xxxvi.indd 6

4/10/2015 6:54:25 AM

I would not be where I am today if not for the love and support of my long-suffering family, Kong (OCB), Gran (LKE), Mum (OBK), and Dad (WTH), who let me meander my way through life, making my own silly mistakes, but who were always there to pick me up when I fell down and provided me with good counsel. At an early age they allowed me the creative freedom to pursue my many interests in art and design, multiple sports, film-making, writing, and, of course, plastic surgery. To all my dear friends and colleagues (you know who you are!) around the world who have mentored me, guided me, and brainstormed with me through the years. Your influence has made me a better plastic surgeon, and I thank you for the countless hours of wonderful friendship and free-flowing ideas we have shared together. Apologies, thanks, and much love to my dear wife, Juay, and my children, Waverly and Wellington. I should have spent more time with you these past 15 years instead of trotting around the globe giving lectures and demonstrations. You are what I live and work for.

Woffle T.L. Wu

• To my wife, Nancy, my son, William, my daughter, Shirley, and my son-in-law, Darren, for their love and unselfish support of my academic pursuits. To my grandson, Kyle, whose innocent admiration for the work of his grandfather has been an important incentive for me to publish more.

Fu-Chan Wei

•

K23345_Pu_c00_FM-Vol I_r5_cl_i-xxxvi.indd 7

4/10/2015 6:54:25 AM

EXECUTIVE EDITOR  Sue Hodgson SENIOR PROJECT EDITING MANAGER  Carolyn Reich SENIOR DEVELOPMENTAL EDITOR  Megan Fennell DEVELOPMENTAL EDITOR  Kathleen Sartori GRAPHICS MANAGER  Brett Stone DIRECTOR OF ILLUSTRATION AND DESIGN  Brenda Bunch MANAGING EDITOR  Suzanne Wakefiel MANUSCRIPT EDITOR/PROJECT MANAGER  Glenn Floyd PRODUCTION  Ngoc Thuy Khuu, Chris Lane, Debra Clark, Susan Trail, Madonna Gauding PROOFREADER  Linda Maulin INDEXER  Matthew White

K23345_Pu_c00_FM-Vol I_r5_cl_i-xxxvi.indd 8

4/10/2015 6:54:25 AM

Contributors

Tae Joo Ahn, MD Director, Division of Plastic Surgery, Gyalumhan Plastic Surgery, Seoul, South Korea Noriyuki Aoi, MD Associate Professor, Department of Plastic, Oral and Maxillofacial Surgery, Teikyo University School of Medicine, Tokyo, Japan Yuko Asano, MD, PhD Part-time Lecturer, Department of Plastic, Oral and Maxillofacial Surgery, Teikyo University School of Medicine, Tokyo; Co-Director, Breast Center, Kameda Medical Hospital, Chiba, Japan Rong-Min Baek, MD, PhD Professor, Department of Plastic and Reconstructive Surgery, College of Medicine, Seoul National University, Bundang Hospital, Seoul, South Korea Weigang Cao, MD, PhD Professor, Department of Plastic and Reconstructive Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China Fuan Chiang Chan, MD, FRCSI(Plast) Plastic Surgeon, Department of Plastic and Reconstructive Surgery, St. Vincent’s University Hospital, Dublin County, Dublin, Ireland Che-Wei Chang, MD Plastic Surgeon, Division of Plastic Surgery, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan

Cheng-Jen Chang, MD, PhD, FACS Director, Chang Gung Aesthetic Medical Center, Taoyuan; Professor, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University Medical College, Taipei, Taiwan Chien-Tzung Chen, MD Professor, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University Medical College, Taipei, Taiwan Chih-Hsuan Chen, MD Department of Surgery, Division of Plastic and Reconstructive Surgery, National Taiwan University Hospital, Taipei, Taiwan Hung-Chi Chen, MD, PhD, FACS Professor, Department of Plastic Surgery; Superintendent, International Medical Service Center, China Medical University Hospital, Taichung, Taiwan Philip Kuo-Ting Chen, MD Professor, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University Medical College, Taipei, Taiwan Ru Chen, MD  Breast Reconstruction and Aesthetic Surgery Center, Plastic Surgery Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China

ix K23345_Pu_c00_FM-Vol I_r5_cl_i-xxxvi.indd 9

4/10/2015 6:54:25 AM

x

Contributors

Shih-Heng Chen, MD Attending Plastic Surgeon, Chang Gung Memorial Hospital, Chang Gung University Medical College, Taipei, Taiwan

Emily C. Cleveland, MD Resident, Institute of Reconstructive Plastic Surgery, New York University Langone Medical Center, New York, New York

Yi-Chieh Chen, MD Chief of Orthognathic Surgery Center, Craniofacial Center, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University Medical College, Taipei, Taiwan

Haiyan Cui, MD, PhD Associate Professor and Chief of Hongmei Outpatient Department, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China

Yueh-Bih Tang Chen, MD, PhD Professor in Plastic Surgery, Division of Plastic Surgery, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan Yu-Ray Chen, MD Professor, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University Medical College, Taipei, Taiwan Kaixiang Cheng, MD Associate Professor, Department of Plastic and Reconstructive Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China Ming-Huei Cheng, MD, MBA, FACS Professor, Department of Plastic Surgery, Chang Gung Memorial Hospital, Chang Gung University Medical College, Taipei, Taiwan Ernest S. Chiu, MD FACS Associate Professor of Plastic Surgery, Department of Plastic Surgery, New York University Langone Medical Center, New York, New York Mihye Choi, MD, FACS Assistant Professor of Plastic Surgery, Department of Plastic Surgery, New York University School of Medicine, New York, New York

K23345_Pu_c00_FM-Vol I_r5_cl_i-xxxvi.indd 10

Jincai Fan, MD, PhD Ninth Department of Aesthetic and Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences, Beijing, China Rose Fu, MD Plastic Surgery Resident, Department of Plastic Surgery, New York Presbyterian Hospitals/ Cornell-Columbia Universities, New York, New York Raymond C.W. Goh, MD Plastic Surgeon, Department of Plastic and Reconstructive Surgery, Mater Private Clinic, Queensland, Australia Cheyenne X. He, MD, MS Volunteer Faculty, Assistant Clinical Professor, Department of Psychiatry, University of California, Davis, Sacramento; Staff Psychiatrist, Department of Psychiatry, Kaiser Permanente Hospital, Vacaville, California Toshitsugu Hirohi, MD Ritz Cosmetic Surgery Clinic, Tokyo, Japan Jung-Ju Huang, MD Assistant Professor, Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University Medical College, Taipei, Taiwan Wenyi Huang, MD Professor, Department of Plastic and Reconstructive Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China

4/10/2015 6:54:25 AM

Contributors

Kenneth C.W. Hui, MD Honorary Consultant in Plastic Surgery, Hong Kong Sanatorium and Hospital, Hong Kong, China Dong Hak Jung, MD, PhD Director, Shimmian Rhinoplastic Clinic, Seoul, South Korea Baek-Kyu Kim, MD Professor, Department of Plastic and Reconstructive Surgery, College of Medicine, Seoul National University, Seoul, South Korea Hye-Young Kim, MD International Fellow, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University Medical College, Taipei, Taiwan Hyunsoo Kim, MD, PhD Medical Director, N.O.S.E. Plastic and Reconstructive Surgery Center for Rhinoplasty, Busan, South Korea Jin Wang Kim, MD, PhD, JSD, MBA, Honorary Advisory Board of IPRAS Best Well Institute, Seoul, South Korea   K. Alex Kim, MD, FACS Volunteer Faculty, Division of Plastic Surgery, Department of Surgery, University of Southern California, Los Angeles, California

Ya-Wei Lai, MD Chief Resident, Division of Plastic Surgery, Department of Surgery, Kaohsiung Medical University, Chung-Ho Memorial Hospital, Kaohsiung, Taiwan Samuel H. Lance, MD Chief Resident, Division of Plastic Surgery, University of California Davis Medical Center, Sacramento, California Charles S. Lee, MD, FACS Plastic Surgeon, Enhance Medical Center, Beverly Hills, California; Adjunct Clinical Assistant Professor, Department of Plastic Surgery, Seoul National University, Bundang Hospital, Seoul, South Korea Edward I. Lee, MD Assistant Professor, Division of Plastic Surgery, Baylor College of Medicine, Houston, Texas Taesung Lee, MD, MS Surgeon, Facial Bone Center, ID Hospital, Seoul, South Korea Hua Lei, MD, PhD Attending Surgeon, Department of Plastic Surgery, Peking Union Medical College Hospital, China Academy of Medical Sciences, Beijing, China

Nam Ho Kim, MD Director, Gyalumhan Plastic Surgery, Seoul, South Korea

Qingfeng Li, MD, PhD Professor and Chairman, Department of Plastic and Reconstructive Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China

David S. Kung, MD, FACS President, Kung Plastic Surgery, Chevy Chase, Maryland

Wei Li, MD Plastic Surgeon, Department of Plastic Surgery, Daqing General Hospital, Heilongjiang, China

Chung-Sheng Lai, MD, EMBA, PhD Dean, College of Medicine, Kaohsiung Medical University; Professor, Department of Plastic Surgery, Kaohsiung Medical University, Chung-Ho Memorial Hospital, Kaohsiung, Taiwan

Cheng-Hui Lin, MD, MS Assistant Professor, Craniofacial Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan

K23345_Pu_c00_FM-Vol I_r5_cl_i-xxxvi.indd 11

xi

4/10/2015 6:54:25 AM

xii

Contributors

Jean-Yin Lin, MD Chief Plastic Surgeon, Department of Plastic Surgery, United Aesthetic Plastic Clinic; Attending Physician, Division of Plastic Surgery, National Taiwan University, Taipei, Taiwan Jeng-Yee Lin, MD, PhD Instructor, Division of Plastic Surgery, Taipei Medical University Hospital, Taipei, Taiwan Sin-Daw Lin, MD Professor, Department of Plastic Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan Tsai-Ming Lin, MD, PhD Director, Charming Plastic and Cosmetic Surgery Center, Chen-Ju Biotechnology Co., Ltd.; Assistant Professor, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan Hong Liu, MD Professor of Anesthesiology, Department of Anesthesiology and Pain Medicine, University of California Davis Health System, Sacramento, California Kai Liu, MD, PhD Associate Professor, Department of Plastic and Reconstructive Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China Yang Liu, MD, PhD Associate Professor, Department of Plastic and Reconstructive Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China Lun-Jou Lo, MD Professor, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University Medical College, Taipei, Taiwan Sunxiang Ma, MD Attending Surgeon, Department of Plastic and Reconstructive Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China

K23345_Pu_c00_FM-Vol I_r5_cl_i-xxxvi.indd 12

Takanobu Mashiko, MD Clinical Resident, Department of Plastic and Reconstructive Surgery, University of Tokyo School of Medicine, Bunkyo-Ku, Tokyo, Japan Roland T. Minami, MD, DDS, FACS Surgeon, Division of Plastic Surgery, Marin General Hospital, Greenbrae, California Lanhua Mu, MD, PhD Professor and Chief, Department of Aesthetic and Plastic Surgery, Peking University People’s Hospital, Beijing, China Dung H. Nguyen, MD Assistant Professor, Division of Plastic Surgery, Department of Surgery, Stanford University, Palo Alto, California Katsunori Niitsuma, MD Surgeon, Sapho Clinic, Minato-ku, Tokyo, Japan Rei Ogawa, MD, PhD, FACS Associate Professor, Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School Hospital, Tokyo, Japan Moohyun Paik, MD, PhD Director, Plastic Surgery Clinic, Department of Plastic and Reconstructive Surgery, Seoul, South Korea David Daehwan Park, MD, PhD, FACS Professor, Department of Plastic Surgery, Daegu Catholic University Hospital, Daegu, South Korea Jong Beum Park, MD Director, Division of Plastic Surgery, Gyalumhan Plastic Surgery, Seoul, South Korea Ro Hyuk Park, MD Director, Division of Plastic Surgery, Gyalumhan Plastic Surgery, Seoul, South Korea Sanghoon Park, MD, PhD Surgeon, Facial Bone Center, ID Hospital, Seoul, South Korea

4/10/2015 6:54:26 AM

Contributors

Yong-Chen Por, MD Adjunct Assistant Professor, Department of Plastic, Reconstructive and Aesthetic Surgery, KK Women’s and Children’s Hospital, Singapore

Chin-Ho Wong, MBBS, MRCS(Ed), M Med(Surg), FAMS(Plast Surg) Consultant Plastic Surgeon, W Aesthetic Plastic Surgery, Singapore

Lee L.Q. Pu, MD, PhD, FACS, FICS Professor of Plastic Surgery, Division of Plastic Surgery, University of California Davis Medical Center, Sacramento, California

Granger B. Wong, MD, DMD, FACS Associate Professor, Director of Craniofacial Surgery, Division of Plastic Surgery, University of California Davis Medical Center, Sacramento, California

Terumi Shirakabe, MD Sapho Clinic, Minato-ku, Tokyo, Japan Yukio Shirakabe, MD President, Sapho Clinic, Minato-ku, Tokyo, Japan Kyle Song, MD Former Chief Resident, Division of Plastic Surgery, University of California Davis Medical Center, Sacramento, California Susumu Takayanagi, MD Clinical Professor, Department of Plastic and Reconstructive Surgery, Kyoto University, Kyoto; Director, Mega Clinic, Osaka, Japan Feng-Chou Tsai, MD, PhD Chief, Division of Plastic Surgery, Department of Surgery, Taipei Medical University Hospital; Chief, Center for Mathematical Biology, Taipei Medical University, Taipei, Taiwan Jiping Wang, MD Chief Surgeon, Department of Burn and Plastic Surgery, First Hospital, General Hospital of PLA, Beijing, China Fu-Chan Wei, MD, FACS Distinguished Chair Professor, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University Medical College, Taipei, Taiwan Chau-Jin Weng, MD, FICS Chief, Department of Aesthetic Plastic Surgery, Chung San General Hospital; Director, Aesthetic Surgery Center, Private Clinic Center, Taipei, Taiwan

K23345_Pu_c00_FM-Vol I_r5_cl_i-xxxvi.indd 13

xiii

Michael S. Wong, MD, FACS Professor of Surgery, Division of Plastic Surgery, University of California Davis Medical Center, Sacramento, California Chih-Wei Wu, MD Professor, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University Medical College, Taipei, Taiwan Jung Wu, MD President, Max Beauty Aesthetic Surgery Center, Taipei, Taiwan Woffles T.L. Wu, MD, MBBS, FRCS, FAMS Medical Director, Woffle Wu Aesthetic Surgery and Laser Centre, Singapore City, Singapore Yun Xie, MD, PhD Attending Surgeon, Department of Plastic and Reconstructive Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China Feng Xu, MD Department of Plastic and Reconstructive Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China Akira Yamada, MD Division of Plastic and Reconstructive Surgery, Feinberg School of Medicine, Northwestern University; Division of Pediatric Plastic Surgery, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois

4/10/2015 6:54:26 AM

xiv

Contributors

Daping Yang, MD Professor and Chief, Division of Plastic Surgery, The Second Hospital of Harbin Medical University, Harbin, China Kotaro Yoshimura, MD Associate Professor, Department of Plastic Surgery, University of Tokyo, Tokyo, Japan Li Yu, MD, PhD Professor, Department of Plastic and Reconstructive Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China Haiming Zhang, MD President, Department of Plastic and Cosmetic Surgery, Zhanghaiming Plastic and Cosmetic Surgery Hospital, Beijing, China

Ruhong Zhang, MD, PhD Professor and Vice-Chairman, Department of Plastic and Reconstructive Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China Xue Zhang, MD, PhD Breast Reconstructive and Aesthetic Surgery Center, Plastic Surgery Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China Yuguang Zhang, MD, PhD Professor and Vice-Chairman, Department of Plastic and Reconstructive Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China

Qun Zhang, MD Professor, Department of Plastic and Reconstructive Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China

K23345_Pu_c00_FM-Vol I_r5_cl_i-xxxvi.indd 14

4/10/2015 6:54:26 AM

Foreword

I am honored to have been asked to write the foreword for Aesthetic Plastic Surgery in Asians: Principles & Techniques, which I believe is the most comprehensive English-language guide to aesthetic procedures in Asian people available today. I congratulate Dr. Pu, his co-editors, and his contributors for this comprehensive, beautiful, much-needed, and timely book. Over the past decade the worldwide growth of aesthetic surgery and cosmetic medicine has been rapid and shows few signs of slowing down. This is especially true in Asia, where the growth has been explosive. China has seen phenomenal expansion in aesthetic surgery—so much so that China has the third highest number of annual cosmetic procedures and number of plastic surgeons, and in both categories, the highest number in all of Asia, according to the worldwide procedural statistics compiled by the International Society of Aesthetic Plastic Surgeons (ISAPS). South Korea has the world’s highest per capita rate of cosmetic plastic surgery, and Hong Kong, Taiwan, Japan, and Thailand have long been centers for aesthetic surgery, attracting “medical tourists” from Asia and beyond. This astonishing growth in aesthetic procedures in Asia means that the timing of Dr. Pu’s book for Asians is particularly appropriate. Th s ambitious project comprehensively covers all aspects of aesthetic surgery and cosmetic medicine specific o Asians—from facial surgery to breast surgery and body-contouring procedures, as well as the use of injectables and noninvasive procedures. Dr. Pu is joined by many key surgical leaders from Asia as co-editors: Drs. Yu-Ray Chen, Qingfeng Li, David Daehwan Park, Susumu Takayanagi, Woffles .L. Wu, and Fu-Chan Wei, as well as more than 90 contributors. Each co-editor is a renowned plastic surgeon and an expert in Asian aesthetic surgery. All contributors are experienced in the art and science of aesthetic surgery in the Asian face and body. The book is accompanied by clear instructional videos of the key surgical procedures, and all of the content can be accessed online as well as in the more traditional print format. Appropriately, special emphasis and ample prominence is given to blepharoplasty and rhinoplasty, two of the most common procedures in Asians. Specific reast- and body-contouring procedures tailored for the characteristic structural frames of Asian individuals are featured and discussed in detail. Th s book is not only an asset for those who routinely operate on Asians, but also a must for those who occasionally perform such procedures. Although the principles of aesthetic surgery apply to all ethnic groups, each group has its own unique anatomic and morphologic characteristics, cultural sense, and norms of facial and bodily beauty.

xv K23345_Pu_c00_FM-Vol I_r5_cl_i-xxxvi.indd 15

4/10/2015 6:54:26 AM

xvi

Foreword

Beautifully designed and presented by the award-winning CRC Press production team, this full-color book is visually stunning, with more than 2500 operative and case photos and a bespoke artwork program especially developed for this title. I am convinced that these volumes will prove invaluable to aesthetic surgeons worldwide who operate on Asians. It is my pleasure to thoroughly recommend Aesthetic Plastic Surgery in Asians: Principles and Techniques. Foad Nahai, MD, FACS Professor of Surgery, Division of Plastic and Reconstructive Surgery, Emory University School of Medicine, Atlanta, Georgia; Editor-in-Chief, Aesthetic Surgery Journal

K23345_Pu_c00_FM-Vol I_r5_cl_i-xxxvi.indd 16

4/10/2015 6:54:26 AM

Preface

Aesthetic surgery in Asian patients can be quite different from surgery on Western patients. Many principles and techniques of cosmetic surgical procedures were established based primarily on Western norms, but there are signifi ant differences in anatomy, in cultural and social influences regarding ideals of beauty, and in patient demands and expectations. A growing economy, along with rapid social changes that make cosmetic surgery more acceptable, have resulted in more and more Asian patients seeking cosmetic surgery to improve their appearance and their quality of life. Unfortunately, there are few English-language textbooks for plastic surgeons planning to operate on an Asian patient seeking a particular cosmetic procedure. In general, the surgeon has to rely on the knowledge and skills learned from operating on patients with totally different ethnic backgrounds or the occasional reference book that can be found in the English literature. For far too long, there has been an urgent need for a comprehensive textbook of plastic surgery with a focus on Asian aesthetic surgery. In 2008 I organized the fi st World Congress for Plastic Surgeons of Chinese Descent in Beijing. Several plastic surgeons of Chinese descent presented a number of cosmetic surgery lectures, reporting their excellent outcomes in Asian patients. In 2009 and 2010 I attended the ISAPS teaching courses in mainland China as an invited faculty member. I witnessed several high-quality cosmetic surgery presentations, not only by Chinese plastic surgeons but also by other Asian plastic surgeons. Th s exposure to surgeons with an interest and expertise in Asian aesthetic surgery, as well as my interest and expertise in the practice of cosmetic surgery as an academic plastic surgeon in a university setting, inspired me to create a comprehensive aesthetic plastic surgery textbook for Asian patients. During the initial phase of the project, I communicated with several colleagues and friends in Asia who are also prominent aesthetic plastic surgeons and who frequently serve as teaching faculty for aesthetic surgery teaching courses organized by ISAPS. I was able to convince them to serve as co-editors of this exciting book project. With their help, advice, and enthusiastic support, we were able to put together a list of contributors and a draft of the book proposal. Karen Berger, then the CEO of Quality Medical Publishing, enthusiastically accepted our proposal, and we started a long journey to work toward the completion of this book. As one would imagine, to accomplish such a project can be extremely difficult and time consuming and has at times seemed hopelessly complex. First, the project has involved multiple authors primarily from several Asian countries or regions. Second, English is not the fi st language for many of these authors, so their writing styles can be quite different from authors established in Western countries. Thi d, most contributors are very busy plastic surgeons with clinical practices and responsibilities in their countries or regions. Accordingly, there were endless back-and-forth revisions, late-hour e-mail communications or

xvii K23345_Pu_c00_FM-Vol I_r5_cl_i-xxxvi.indd 17

4/10/2015 6:54:26 AM

xviii

Preface

phone calls, tireless editing from all editors, and managing support from QMP and CRC Press. However, we are now very happy to say that this remarkable book is completed after more than 5 years of effort— our mission is accomplished. Th s two-volume, 74-chapter textbook is divided into 10 parts covering the spectrum of Asian aesthetic surgery. Because breast reconstruction in many Asian countries or regions is still considered “cosmetic” in nature, breast reconstruction is also included in this book. There are two different types of chapters in this book: those that primarily discuss principles and those that are primarily procedure oriented. Each of the 10 parts starts with a chapter on the special considerations for the appropriate anatomy on which the Asian cosmetic surgery for that part is based. Part I primarily focuses on the evaluation of cosmetic surgery patients, the cultural and societal influences on cosmetic surgery, psychological and psychiatric considerations, scar management, and reoperation. Part II describes nonsurgical or minimally invasive procedures for facial rejuvenation. It includes treatments of skin hyperpigmentation and acne scars followed by laser skin resurfacing, soft issue fillers, fat grafting, botulinum toxin A injection, radiofrequency therapy, and thread lift for facial rejuvenation. Part III focuses on rejuvenation of the face. It starts with a chapter on special considerations in Asian facial rejuvenation surgery, followed by open brow lift, lassic face lift, hort-recovery face lift, ultimodal surgical approaches to the aging face, endoscopic approach to facial rejuvenation, and neck rejuvenation. Part IV covers cosmetic surgery of the eyelid, starting with special considerations in Asian cosmetic eyelid surgery, followed by upper blepharoplasty, secondary upper blepharoplasty, medial epicanthoplasty, corrections of blepharoptosis and tear trough deformities, lower blepharoplasty, lower eyelid shortening, management of the sunken eyelid, and periorbital rejuvenation. Part V addresses primary and secondary rhinoplasty. It includes special considerations in Asian cosmetic rhinoplasty as well as alloplastic material for rhinoplasty, autologous cartilage grafts, rimary closed rhinoplasty, primary and secondary open procedures, and secondary cleft rhinoplasty. Part VI focuses on cosmetic surgery of the ear. It starts with special considerations in Asian cosmetic surgery of the ear, followed by otoplasty for the prominent ear and correction of other congenital ear deformities. Part VII primarily describes cosmetic surgery of the facial skeleton. Special considerations for Asian patients is followed by aesthetic corrections of the facial skeleton for the upper face, midface, and lower face, as well as genioplasty, alloplastic augmentation of the facial skeleton, and orthognathic surgery. Part VIII addresses plastic surgery of the breast. It starts with special considerations in Asian breast surgery, followed by a discussion of breast augmentation with implants, an endoscopic approach to capsular contracture and implant malposition, breast augmentation with fat grafting and cell-assisted lipotransfer, vertical breast reduction, mastopexy, medial pedicle breast reduction, correction of nipple deformities, and breast reconstruction with a pedicled TRAM flap, microsurgical flap, and implant, as well as nippleareola complex reconstruction. Part IX covers cosmetic surgery of the body and extremities. It starts with special considerations in Asian cosmetic body-contouring surgery followed by abdominoplasty, liposuction to the trunk, hips, and extremities, gluteal augmentation, and cosmetic calf reduction.

K23345_Pu_c00_FM-Vol I_r5_cl_i-xxxvi.indd 18

4/10/2015 6:54:26 AM

Preface

xix

Part X describes a number of other cosmetic procedures commonly performed in Asians: hair transplantation, hymenorrhaphy, labial reduction, vaginal rejuvenation, and penile enhancement. It also includes correction of varicose veins with laser and correction of osmidrosis. The book is published with multiple DVDs showing key procedures in Asian patients and comes with a complementary electronic book (e-book) version that will work on many different platforms and devices. The DVDs and e-book version allow readers to take the information in the book with them wherever they go, without the need to carry the actual text volumes. We hope this book will provide our readers with comprehensive knowledge of Asian cosmetic surgery from a single and reputable source. The book aims to provide any surgeon who may encounter Asian patients in his or her practice with a “go-to” reference book. The book provides a high standard of scientific c ntent for Asian cosmetic surgical procedures that may help Asian plastic surgeons to expand their knowledge and skills and assist them to improve outcomes for their patients, whether they are from Far East Asia or Southeast Asia. For all trainees in plastic surgery, this book offers an accessible format to expand their knowledge and serves as a defin tive and reliable source of current techniques in Asian cosmetic surgery. We believe that this is the fi st comprehensive English-language textbook focused primarily on Asian aesthetic surgery. Our primary goal has been to set a standard for Asian aesthetic surgery and to serve plastic surgeons, residents, and fellows in training worldwide by providing a major reference to learn the principles and techniques of Asian aesthetic surgery. We sincerely hope that you enjoy reading this book and fi d it benefic al for your aesthetic surgery practice. Lee L.Q. Pu

K23345_Pu_c00_FM-Vol I_r5_cl_i-xxxvi.indd 19

4/10/2015 6:54:26 AM

K23345_Pu_c00_FM-Vol I_r5_cl_i-xxxvi.indd 20

4/10/2015 6:54:27 AM

Acknowledgments

In 1997 I started my plastic surgery residency at the University of South Florida in Tampa under Dr. Thomas J. Krizek, then professor and director of the division of plastic surgery. I was fortunate to have excellent training, including aesthetic surgery, with close interaction with several world-renowned plastic surgeons such as Drs. Krizek, Martin C. Robson, and James J. Baker, Jr. The inspiration to achieve excellence in plastic surgery from these great men has sustained me throughout my career. In 2000 I started my first job as a full-time faculty member at the University of Kentucky in Lexington, where I found a rich clinical experience including aesthetic surgery that has contributed signifi antly to my skills as an aesthetic plastic surgeon. As a relatively junior attending plastic surgeon, I felt very comfortable performing all types of cosmetic surgery procedures, such as facial rejuvenation, periorbital procedures, cosmetic breast surgery, and body-contouring procedures. In 2007 I moved to the University of California, Davis, as a more senior attending plastic surgeon. I have been able to provide more cutting-edge aesthetic surgery procedures to my patients based on what I learned during my residency and early career at the University of Kentucky. I have developed expertise in minimally invasive facial cosmetic surgery, fat grafting, short-scar cosmetic surgery of the breast, and less-invasive procedures for body contouring. The consistently good outcomes that I have been able to provide to my patients has resulted in many national and international invitations for invited or keynote presentations as well as publications in plastic surgery journals. Th s kind of clinical experience, along with my worldwide connections with many excellent plastic surgeons, has built the foundation for me to be able to edit such a comprehensive textbook in Asian aesthetic surgery. My heartfelt appreciation goes to my six co-editors, who are my close friends and colleagues in Asia. Dr. Yu-Ray Chen from Chang Gung Memorial Hospital in Taiwan is a world-renowned craniofacial surgeon and a frequently invited speaker and contributor to Asian cosmetic surgery. He also gathered a very capable group of plastic surgeons from his institution to contribute to this book. Dr. Qingfeng Li, professor and chairman in the Department of Plastic and Reconstructive Surgery at Shanghai Ninth People’s Hospital, has led his team to contribute their remarkable clinical experience from mainland China and has defin tely added different flavors and perspectives to the book. Dr. David Daehwan Park, chairman of the Department of Plastic Surgery at Daegu Catholic University Hospital in South Korea, is a true expert on Asian eyelid surgery. He has not only contributed extensively to this book but also brought a number of excellent Korean plastic surgeons on board. Dr. Susumu Takayanagi, the current president of ISAPS, is a frequent invited teaching faculty member throughout the world for Asian cosmetic surgery and a major contributor to ISAPS. He has brought to this book his unique set of skills and vision. Dr. Woffle T.L. Wu, a frequent invited speaker for ISAPS congresses and teaching courses, has brought his unique innovations to this book. Dr. Fu-Chan Wei, who needs no introduction as a world-renowned reconstructive microsurgeon, has shared with the readers his skill as an aesthetic plastic surgeon and has provided valuable input to the composition of this book.

xxi K23345_Pu_c00_FM-Vol I_r5_cl_i-xxxvi.indd 21

4/10/2015 6:54:27 AM

xxii

Acknowledgments

All my co-editors not only bring a wealth of clinical experience in Asian cosmetic surgery from Asia, but also have provided their vision and skills on how to write a world-class textbook in Asian aesthetic surgery. It has been an incredible honor for me to work with each of them. With our combined efforts, we set and maintained a high bar for every chapter of the book. My sincere appreciation also goes to all contributors of this book for sharing their clinical expertise and devoting the time to promote excellence in Asian cosmetic surgery. During the preparation of the book, I had an opportunity to work with many talented plastic surgeons from mainland China, Taiwan, Hong Kong, Japan, South Korea, Singapore, and the United States. They have contributed some invaluable chapters to this book. I will be forever grateful to all of these contributors for their far-reaching expertise, innovation, hard work, support, and friendship. I wish to express my gratitude to Karen Berger and her entire publishing team, based in St. Louis, Missouri. As we all know, Karen gathered an excellent team at Quality Medical Publishing, Inc. (QMP). Her company published many world-class textbooks in plastic surgery. Karen is an incredible woman and has been an extraordinarily motivated publisher who has delivered unparalleled service in medical publishing. Under her visionary leadership this book project was launched with an admirable table of contents, invitations to the contributors, and then rounds of editing and reediting of chapters. Karen oversaw the entire process, with attention to detail and the greatest enthusiasm. It has been a pleasure and a privilege to work with Karen and her team. Over the past 5 years, I have had many interactions with Kathleen Sartori, Megan Fennell, Glenn Floyd, Suzanne Wakefi ld, Brenda Bunch, Carolyn Reich, Lane Wyrick, Brett Stone, Thuy Khuu, Amy Debrecht, Michelle Berger, Andrew Berger, and others. Th s incredible publishing group has ensured the best possible quality of each chapter, and this book could not be successful without their extraordinary effort and attention to detail. I also wish to express my gratitude to Sue Hodgson, executive editor for plastic surgery publishing for CRC Press/Taylor & Francis Group, who are carrying forward QMP’s book publishing tradition. Sue has provided her incredible vision, dedication, and determination to oversee this book project to completion. She has ensured the highest standard for every aspect of Aesthetic Plastic Surgery in Asians: Principles & Techniques. I have been very fortunate to hold full-time academic positions at two outstanding institutions, the University of Kentucky and the University of California, Davis. Both institutions have superb faculty, staff, and residents. Many of my former and current faculty associates have created an intellectually stimulating environment for me to write and edit such a textbook in plastic surgery. They have helped cover my patients while I was concentrating on writing the book chapters or traveling to meet contributors or editors. I would like to thank my past and current assistants of the division, Mr. Shadi Kanaan, Ms. Amy Dykstra, and Ms. Lisa Madden, who provided me with tireless administrative support in preparation of manuscripts for the book. Finally, I wish to express my heartfelt gratitude to my wife, Yu-Shan (Emily), who has supported me for all these years of my academic career and has kept everything in order at home so that I can concentrate on my work for this project in the late evenings and weekends. I thank my children, Felix, Dustin, and Adrian. They have taught me the joy of life outside of work. I thank my younger brother, Lijun (Leo). He has always encouraged me to take on difficult tasks. I also wish to express my gratitude and respect to my former professors and training program directors, Drs. Zhong-Gao Wang, James F. Symes, Marvin A. McMillan, and Thomas J. Krizek. It was with their in-

K23345_Pu_c00_FM-Vol I_r5_cl_i-xxxvi.indd 22

4/10/2015 6:54:27 AM

Acknowledgments

xxiii

spiration and support that I have been able to successfully edit such a comprehensive textbook in Asian plastic surgery. In addition, I also wish to thank my friends and colleagues in plastic surgery throughout the world who have encouraged and supported me during this book project. Lee L.Q. Pu

First, I would like to thank Dr. Lee L.Q. Pu for his great vision in identifying the need for this book, for his persistence in bringing it to publication, for his passion for teaching plastic surgeons in this part of the world, and for his constant encouragement so that I could fulfill my commitment to this book. Second, I would like to thank my three masters. I was the fi st resident of Dr. Samuel Noordhoff at Chang Gung Memorial Hospital, the fi st clinical fellow of Dr. Kenneth Salyer in Dallas, Texas, and the fi st 1-year craniofacial fellow with Dr. Ian Munro in Toronto. I have learned plastic surgery, cleft lip/palate surgery, and craniofacial and maxillofacial surgery from these three giant surgeons. After I became an attending plastic surgeon in Chang Gung, these mentors gave me suggestions, advice, and encouragement and are still providing these to this day! They have taught me how to perform a good surgery as well as how to be a good surgeon. Third, I would like to express my gratitude to Mr. Y.C. Wang, the founder of Chang Gung Memorial Hospital. He set up this hospital with a good management system and gave me the opportunity to practice plastic and craniomaxillofacial surgery effici tly, with support for teaching and research. Fourth, my appreciation goes to my associate surgeons, Philip K.T. Chen, Lun-Jou Lo, Z.C. Chen, Yi-Chieh Chen, Cheng-Huei Lin, and Ying-An Chen, and my orthodontists, Chiung-Shing Huang, Eric Liou, Ellen Ko, Yu-Fang Liao, and Sam Hsu, as well as my international fellows from different parts of the world. Their assistance, questions, energetic enthusiasm, and hard-working attitude make my part of the work possible. Finally, I want to express my deepest gratitude to my wife, Pauline. She always keeps our family and our social aff irs in order so that I can fully concentrate on my work. Her unlimited support, unselfish sacrific , and positive criticism make my professional life vital. Yu-Ray Chen

My medical career can be traced all the way back to Gannan Medical College in the Jiangxi province of the People’s Republic of China. I graduated from this college in 1985 and then went to Shanghai Medical University for 5 years of postgraduate training. From 1994 to 1996 I completed my postdoctoral research work in the Department of Plastic and Reconstructive Surgery at the Ninth People’s Hospital of Shanghai Jiao Tong University School of Medicine under the guidance of Professor Ti-sheng Chang, the founder of plastic and reconstructive surgery in China. As a research fellow, I spent 1 year at Mount Sinai School of Medicine in New York in the United States, where I acquired considerable knowledge; I was very grateful to have been given the opportunity to observe and learn from everyone at the school and hospital.

K23345_Pu_c00_FM-Vol I_r5_cl_i-xxxvi.indd 23

4/10/2015 6:54:27 AM

xxiv

Acknowledgments

I currently serve as department chairman and professor in the Department of Plastic and Reconstructive Surgery at the Shanghai Ninth People’s Hospital. We have turned the department into one of the biggest medical centers of plastic surgery in the world, helping it earn an international reputation as an “encyclopedia” of plastic surgery in China. With a capacity of 200 beds, the annual number of outpatients totals approximately 200,000, and the annual number of operations totals approximately 50,000. We have helped to build many special groups, including Divisions of Reconstructive Surgery, Aesthetic Surgery, Hand Surgery, and Post-burn Surgery, and Groups of Lymphedema, Rhinoplasty, Hemangioma, Hair Transplantation, Urinary-Reproductive Surgery, and others. The road to success was paved with challenges, but it was navigated with courage, knowledge, patience, and perseverance. I believe in the importance of communication, so I managed to maintain frequent contact with domestic experts in plastic surgery. In this book I have gathered the experience of all my colleagues in aesthetic plastic surgery. I trust that this book will not be just a memorial of past glories, but that it will serve as a guide to newcomers and offer intriguing new alternative techniques to seasoned surgeons. Toward the successful publication of this book, I would like to thank my team members, who made a concerted effort to collect and write chapters representing more than 20 years of clinical experience in our department. Medical progress is based on continuously facing challenges. We give many thanks for our patients and our family members. Because of the cooperation and assistance of our families, we can accept challenges and reach the peak of perfection in the fi ld of plastic and reconstructive surgery. I wish to acknowledge other authors for sharing their knowledge and techniques without reservation. Meanwhile, I sincerely hope that surgeons and their patients benefit considerably from this world-class textbook in Asian aesthetic surgery. Qingfeng Li

One of my true pleasures is to write books and articles and share knowledge and information with plastic surgeons who have common interests. I want to acknowledge my sincere appreciation to everyone who encouraged me to write chapters for this book. First of all, a special thanks to Professor Pu, who provided me with the opportunity to contribute a magnum opus. When Professor Pu suggested writing about aesthetic plastic surgery in Asians, I resisted this temptation because of the awesome, overwhelming scope of the subject and the language problem. I am not good at writing in English. However, I decided to take on this challenge, because I know there is a real need for such an Asian cosmetic surgery book written in English. I have had the true luxury and happiness of working with Dr. Pu, a respectful editor, and the five co-editors. My major fi ld is Asian blepharoplasty. I have been published in more than 30 international journals and have written 10 books and 20 book chapters in the fi ld of Asian blepharoplasty in the United States, China, and Korea. I also developed an Asian upper blepharoplasty technique and several instruments used in ptosis surgery. I wrote the fi st (1998), second (2003), and third (2009) editions of a book on reconstructive and cosmetic oculoplastic surgery, but they were written in Korean. The Chinese version of the recent Korean-style Asian blepharoplasty textbook (2009) was also my publication, but it was written in Chinese. A good deal has been published on the topic of Asian cosmetic plastic surgery, especially Asian eyelid surgery, in Korean, Japanese, and Chinese; thus they are not easily accessible to Western readers. I am very happy that my Asian blepharoplasty chapters were written in English in this book so that Western readers

K23345_Pu_c00_FM-Vol I_r5_cl_i-xxxvi.indd 24

4/10/2015 6:54:27 AM

Acknowledgments

xxv

can easily understand the specific Asian techniques of blepharoplasty. I hope my chapters will help to formulate a unifying concept of Asian blepharoplasty and aid surgeons in gaining fundamental knowledge of the current state of Asian blepharoplasty. I have enjoyed the privilege of teaching and learning from over 30 residents and 30 foreign fellows since joining the faculty at the Daegu Catholic University Hospital Department of Plastic Surgery in South Korea. My chapters would not have been possible without the invaluable teaching of my professors. I have too many teachers to thank individually when I reflect on what I have learned from my plastic surgery residency until now. I am indebted to my outstanding current and former staff, the Korean and Asian plastic surgeons who trained under me, and the residents. They helped me with all parts of my chapters, including proofreading and medical illustrations. I hope my daughter, Soyoung Park, who is currently a resident in ophthalmology, will study this book and become an excellent oculoplastic surgeon. I hope my son, David Kisoo Park, who is currently a resident at my institution, will also study this book and become an excellent plastic surgeon. I want to become a model for my son and bequeath my work to him. I hope that he will contribute to the second and third editions of this book, which is certain to become a classic. Finally, I want to thank my wife, Heesuk Bae, for her patience and understanding while I missed many weekends and evenings at home to prepare my manuscripts. David Daehwan Park

After graduating from Kyoto University, I learned many fundamental techniques from Dr. Ryosuke Fujimori, who was my fi st teacher of plastic surgery. His techniques on how to treat skin problems through surgery are outstanding. Most of his cases were burn contractures, cancer of the face, and severe damage to the face, and I learned so much from him. I then visited many universities and clinics around the world and met many wonderful plastic surgeons. I learned numerous successful surgical techniques from Foad Nahai, Nicholas Georgiade, Stanley Klatsky, Jack Fisher, Ulrichi Hinderer, and Gordon Letterman. All of these gentlemen are very kind to everyone around them; learning from them is a warm memory for me. Also, as president of ISAPS, I am happy to have many high-quality plastic surgeons in our big family worldwide. Because of the knowledge they have shared with me and other colleagues in this society, this contribution to the literature on Asian surgery has been made all the richer. Susumu Takayanagi

K23345_Pu_c00_FM-Vol I_r5_cl_i-xxxvi.indd 25

4/10/2015 6:54:27 AM

K23345_Pu_c00_FM-Vol I_r5_cl_i-xxxvi.indd 26

4/10/2015 6:54:27 AM

Contents

VOLUME I Part I General Principles

  1

Evaluation of Asian Cosmetic Surgery Patients 

  2

Cultural and Societal Considerations for Asian Cosmetic Surgery Patients 

Lee L.Q. Pu, Hong Liu, Michael S. Wong

3

Cheyenne X. He, Lee L.Q. Pu

15

  3 Psychological and Psychiatric Considerations for Asian Cosmetic Surgery Patients  21 Cheyenne X. He, Lee L.Q. Pu

  4

Scar Management for Asian Cosmetic Surgery Patients 

  5

Reoperations in Cosmetic Surgery 

Rei Ogawa

Kyle Song, Lee L.Q. Pu

31

45

Part II Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

  6

Skin Hyperpigmentation in Asians: Classification, Diagnosis, and Treatment 

  7

Treatment for Acne and Acne Scars 

  8

Laser Skin Resurfacing 

Takanobu Mashiko, Kotaro Yoshimura

Takanobu Mashiko, Kotaro Yoshimura

Cheng-Jen Chang

53

71

85

xxvii

xxviii

Contents

  9

Soft Tissue Fillers for Facial Rejuvenation 

10

Fat Grafting for Facial Contouring 

11

Total Facial Rejuvenation With Microautologous Fat Transplantation 



1

97

David S. Kung

Yun Xie, Qingfeng Li, Lee L.Q. Pu

117

Tsai-Ming Lin

129

11-1  MAFT for Forehead—Tsai-Ming Lin



11-2  MAFT for Temporal Fossa—Tsai-Ming Lin



11-3  MAFT for Upper Sunken Eye—Tsai-Ming Lin



11-4  MAFT for Nasojugal Groove—Tsai-Ming Lin



11-5  MAFT for Nasal Dorsum—Tsai-Ming Lin



11-6  MAFT for Nasolabial Fold—Tsai-Ming Lin



11-7  MAFT for Cheek—Tsai-Ming Lin



11-8  MAFT for Lips—Tsai-Ming Lin



11-9  MAFT for Chin and Prejaw Depression—Tsai-Ming Lin

12

Botulinum Toxin A Injections for Facial Rejuvenation and Reshaping 

13

Botulinum Toxin A Injections for Facial Contouring 



1

14

Radiofrequency for Facial Rejuvenation 

15

Facial Rejuvenation With Th ead Lift 

Woffle T.L. Wu

149

171

Nam Ho Kim, Tae Joo Ahn, Ro Hyuk Park, Jong Beum Park, Edward I. Lee

13-1  Botulinum Toxin A Injections—Gyalumhan Plastic Surgery, Seoul, South Korea

Jin Wang Kim, Haiyan Cui

Woffle T.L. Wu

183 203

Part III Rejuvenation Surgery of the Face

16

Special Considerations in Rejuvenation Surgery of the Asian Face 

17

Open Brow Lift 

225

18

Classic Face Lift 

239

Daping Yang, Lee L.Q. Pu

Fuan Chiang Chan, Raymond C.W. Goh, Yu-Ray Chen

Dung H. Nguyen, Fu-Chan Wei

217

xxix

Contents

19

Short-Recovery Face Lift 



1

20

Multimodal Surgical Approaches to the Aging Face 



1

21

Endoscopic Approach to Facial Rejuvenation 



1

22

Neck Rejuvenation 

247

Yukio Shirakabe, Terumi Shirakabe, Katsunori Niitsuma

19-1  Short-Recovery Lift—Yukio Shirakabe, Terumi Shirakabe, Katsunori Niitsuma

263

Shih-Heng Chen, Hung-Chi Chen, Che-Wei Chang, Chih-Hsuan Chen, Yueh-Bih Tang Chen

20-1  Multimodal Surgical Approaches—Yueh-Bih Tang Chen

Jung Wu

275

21-1  Endoscopic Face-Lift Surgery—Jung Wu

David S. Kung

317

Part IV Cosmetic Surgery of the Eyelid

23

Special Considerations in Cosmetic Surgery of the Asian Eyelid 

24

Upper Blepharoplasty 



Expert Commentary for Upper Blepharoplasty 



David Daehwan Park

David Daehwan Park

345

Susumu Takayanagi

1

337

372

24-1  Upper Blepharoplasty—David Daehwan Park



24-2  Expert Commentary—A Personal Approach—Susumu Takayanagi

25

Secondary Upper Blepharoplasty 

26

Medial Epicanthoplasty 

27

Correction of Blepharoptosis 



2

Chau-Jin Weng

Haiming Zhang

Chung-Sheng Lai, Ya-Wei Lai

377

395 405

27-1 Correction of Blepharoptosis—Chung-Sheng Lai, Yu-Hao Huang, Tung-Ying Hsieh, Ming-Jer Tsai, Chih-Pang Lin, Ya-Wei Lai

xxx

Contents

28

Correction of Tear Trough Deformity 



2

29

Lower Blepharoplasty 



Expert Commentary for Lower Blepharoplasty 

Chin-Ho Wong

425

28-1  Tear Trough Deformity—Chin-Ho Wong, Michael K.H. Hsieh, Bryan Mendelson

David Daehwan Park

443

Kenneth C.W. Hui

464



2

30

Lower Eyelid Shortening for Vertical Enlargement of the Palpebral Aperture 

31

Management of Sunken Eyelid 



2

32

Periorbital Rejuvenation 



2

29-1  Lower Blepharoplasty—David Daehwan Park

Toshitsugu Hirohi, Kotaro Yoshimura

David Daehwan Park

467

483

31-1  Sunken Eyelid Correction by Aponeurosis Surgery—David Daehwan Park

David Daehwan Park

497

32-1 Asian Upper Lid Rejuvenation With Double Fold Formation—David Daehwan Park

Part V Primary or Secondary Rhinoplasty

33

Special Considerations in Asian Cosmetic Rhinoplasty 

34

Alloplastic Implants for Rhinoplasty 

35

Autologous Cartilage Grafts for Rhinoplasty 



2

36

Primary Closed Rhinoplasty 

Charles S. Lee

Fuan Chiang Chan, Yong-Chen Por, Yu-Ray Chen

Dong Hak Jung

533 539

35-1  Costal Cartilage Harvesting—Dong Hak Jung

555

Raymond C.W. Goh, Yong-Chen Por, Fuan Chiang Chan, Yu-Ray Chen

523

xxxi

Contents

37

Primary and Secondary Open Rhinoplasty 



Expert Commentary for Primary and Secondary Open Rhinoplasty 



Hyunsoo Kim, Moohyun Paik, Lee L.Q. Pu

590

Susumu Takayanagi

2

37-1  Septal Extension Graft—Hyunsoo Kim



38

567

37-2  Open Rhinoplasty in Asians—Hyunsoo Kim

Secondary Cleft Rhinoplasty  Philip Kuo-Ting Chen

595

Part VI Cosmetic Surgery of the Ear

39

Special Considerations in Cosmetic Surgery of the Asian Ear 

40

Otoplasty for Prominent Ear 

41

Correction of Other Congenital Ear Deformities 

Akira Yamada

Ruhong Zhang, Qun Zhang

613

627

Ruhong Zhang, Feng Xu

641

VOLUME II Part VII Cosmetic Surgery of the Facial Skeleton

42

Special Considerations in Cosmetic Surgery of the Asian Facial Skeleton 

43

Aesthetic Corrections of Facial Skeleton: Forehead Contouring 

44

Aesthetic Corrections of Facial Skeleton: Midface Contouring 

45

Aesthetic Corrections of Facial Skeleton: Mandibular Contouring 



3

Roland T. Minami, Samuel H. Lance, Granger B. Wong

667

Chien-Tzung Chen, Yi-Chieh Chen, Fuan Chiang Chan, Yu-Ray Chen

Rong-Min Baek, Baek-Kyu Kim

Raymond C.W. Goh, Hye-Young Kim, Lun-Jou Lo

45-1  Mandibular Angle Resection—Lun-Jou Lo

677 691

657

xxxii

Contents

46

Aesthetic Osseous Genioplasty 



3

47 48

Sanghoon Park, Taesung Lee

703

46-1  Osseous Genioplasty—Sanghoon Park, Taesung Lee

Aesthetic Augmentation of the Facial Skeleton With Alloplastic Implants 

Yi-Chieh Chen, Fuan Chiang Chan, Raymond C.W. Goh, Yu-Ray Chen

Aesthetic Orthognathic Surgery 

729

743

Yu-Ray Chen, Yi-Chieh Chen, Fuan Chiang Chan, Raymond C.W. Goh, Cheng-Hui Lin

Part VIII Plastic Surgery of the Breast

49

Special Considerations in Plastic Surgery of the Asian Breast 

50

Breast Implants 

51

Breast Augmentation With Implants: Transaxillary Approach 

52

Breast Augmentation With Implants: Inframammary Approach 

53

 ndoscopic-Assisted Transaxillary Approach for Treatment of Capsular E Contracture and Implant Malposition  823

Ming-Huei Cheng, Jung-Ju Huang

Rose Fu, Ernest S. Chiu

763

771

Jean-Yin Lin

Susumu Takayanagi

783 803

Li Yu

54

Breast Augmentation With Conventional Fat Grafting 

837

55

Breast Augmentation With Cell-Assisted Lipotransfer 

849



3

56

Mastopexy 

57

Medial Pedicle Breast Reduction 

58

Correction of Common Nipple Deformities 

Qingfeng Li, Lee L.Q. Pu

Kotaro Yoshimura, Noriyuki Aoi, Yuko Asano

55-1 Breast Augmentation With Fat Grafting (Mini-CAL Technique)—Kotaro Yoshimura

865

Mihye Choi, Emily C. Cleveland, David S. Kung, Lee L.Q. Pu

Lee L.Q. Pu, Jeng-Yee Lin

Kai Liu, Qingfeng Li

881 895

xxxiii

Contents

59

Breast Reconstruction With Pedicled TRAM Flap 



3

60

Breast Reconstruction With Microsurgical Flap 



3

61

Breast Reconstruction With Implant 

62

Nipple-Areola Complex Reconstruction 

911

Sin-Daw Lin, Lee L.Q. Pu

59-1  Augmentation With Pedicled TRAM Flap—Sin-Daw Lin

Jung-Ju Huang, Ming-Huei Cheng

931

60-1 Reconstruction With Microsurgical Flap—Ming-Huei Cheng, Jung-Ju Huang, Chia-Yu Lin

Chih-Wei Wu, Ming-Huei Cheng

947

Lanhua Mu, Ru Chen, Xue Zhang, Wei Li, Lee L.Q. Pu

961

Part IX Cosmetic Surgery of the Body   and Extremities

63

Special Considerations in Asian Cosmetic Body Contour Surgery 

64

Abdominoplasty 



3

65

Liposuction of Trunk, Hips, and Extremities 



3

K. Alex Kim

K. Alex Kim

983

64-1  Abdominoplasty—K. Alex Kim

Weigang Cao

65-1  Upper Arm—Weigang Cao



65-2  Trunk, Hips, and Thi hs—Weigang Cao



65-3  Leg—Weigang Cao

66

Gluteal Augmentation in Asians 

67

Cosmetic Calf Reduction 



3

David S. Kung

Feng-Chou Tsai

1023

1041

67-1  Neurectomy—Feng-Chou Tsai

999

975

xxxiv

Contents

Part X Other Cosmetic Surgical Procedures

68

Hair Transplantation 

69

Hymenorrhaphy 

1077

70

Labial Reduction 

1085

71

Vaginal Rejuvenation 

72

Penile Enhancement 

73

Correction of Varicose Veins With Endovascular Laser 

74

Correction of Osmidrosis 



3



Index 

1057

Jiping Wang, Jincai Fan

Sunxiang Ma, Hua Lei, Wenyi Huang, Qingfeng Li

Yuguang Zhang

Yang Liu, Kaixiang Cheng

Yang Liu, Kaixiang Cheng

1093 1101

Cheng-Jen Chang

David Daehwan Park

1123

74-1  Correction of Osmidrosis—David Daehwan Park

I-1

1111

Aesthetic Plastic Surgery in Asians Principles & Techniques

K23345_Pu_c00_FM-Vol I_r6_cl_i-xxxvi.indd 35

4/10/2015 12:05:13 PM

K23345_Pu_c00_FM-Vol I_r5_cl_i-xxxvi.indd 36

4/10/2015 6:54:28 AM

Part I

Gener al Principles

K23345_Pu_c01p_Eval Plast Sur Patient_r5_cl_0001-0014.indd 1

4/1/2015 1:19:54 PM

K23345_Pu_c01p_Eval Plast Sur Patient_r5_cl_0001-0014.indd 2

4/1/2015 1:19:54 PM

1 Evaluation of Asian Cosmetic Surgery Patients

E

Lee L.Q. Pu, Hong Liu, Michael S. Wong

valuation of a patient who requests cosmetic surgery is more comprehensive than that of a medical or surgical patient, because the evaluation should encompass the patient’s general medical, cosmetic surgical, and psychosocial conditions. The initial consultation, which takes place in the plastic surgeon’s offi , involves other specific ssues that need to be addressed with a cosmetic surgical patient. In addition, the individual’s risk factors for the desired surgical procedure should be assessed carefully so that the plastic surgeon can ensure the best possible surgical outcome with minimal complications. In this chapter, we introduce a practical guideline for evaluation of candidates for aesthetic plastic surgery, including topics specific to cosmetic surgery and risk factors that should be identifi d before performing any cosmetic surgical procedure.

General Medical Assessment Medical assessment of a cosmetic surgery patient is similar to that for a medical or surgical patient. Plastic surgeons should start by asking their patients about their general medical condition and past medical and surgical history before asking about their cosmetic concerns or complaints. A complete patient history and physical examination will include a personal health history, any significant medical conditions, social and family history, medications (prescribed and not prescribed and herbal supplements), allergies (drugs, latex, or adhesive tape), and reaction to previous local, regional, or general anesthetics. It should also include a review of the body’s systems and the availability of a responsible person to assist with postoperative instructions and care. The physical examination should include an assessment of general health and appearance, measurement of height and weight, vital signs, heart and lung evaluation, and examination of specifi anatomic areas for which the surgery is requested. Sample preoperative history and physical examination forms for the patient and plastic surgeon are shown in Figs. 1-1and 1-2. An important part of the patient’s medical assessment is to identify any underlying medical conditions that are relevant to the procedure or that may predispose the patient to intraoperative or postoperative complications. When assessing a patient, the plastic surgeon should pay particular attention to factors such as age, weight, and history of other signifi ant medical conditions such as diabetes, cardiac diseases, and respiratory problems, as well as a history of or predisposition for venous thromboembolism.

3

4

Part I 

General Principles

History and Physical Examination Form (Patient’s Part) Name: ___________________________________________________ Date: _______________________ Date of Birth: ____________________________________________ Age: _ ________________________ Occupation: ______________________________________________ Sex: _ ________________________ Responsible Adult Person: ___________________________________ Marital Status: _ ________________ Referring Physician: __ _____________________________________

PURPOSE OF THIS CONSULTATION Past Medical History Bleeding Disorders: ______________________________________________________________________ DVT or PE: _____________________________________________________________________________ Sleep Apnea: ___________________________________________________________________________ Any Significant Illness: ____________________________________________________________________

Past Surgical History _____________________________________________________________________________________ _____________________________________________________________________________________

Complications After Previous Anesthesia _____________________________________________________________________________________ _____________________________________________________________________________________

Personal History Smoking: ___________________________________ Alcohol Consumption: ______________________

Medications (Including Herbals and Supplements) _____________________________________________________________________________________ _____________________________________________________________________________________

Drug Allergy Medication(s): _ ________________________________________________________________________ Food or Agent(s): ________________________________________________________________________

Family History Hypertension, Stroke, Heart Attack: _ _______________________________________________________ Asthma: ______________________________________________________________________________ Diabetes: _____________________________________________________________________________ Cancer: _ _ _____________________________________________________________________________ Bleeding Disorders: ______________________________________________________________________

Women Only May be Pregnant: ______________________________ Menstrual Period: _ __________________________ Mammogram: _________________________________

Fig. 1-1  Patient’s part of the history and physical examination form.

K23345_Pu_c01p_Eval Plast Sur Patient_r5_cl_0001-0014.indd 4

4/1/2015 1:19:54 PM

Chapter 1 

Evaluation of Asian Cosmetic Surgery Patients

5

History and Physical Examination Form (Plastic Surgeon’s Part) Name: __________________________________________ MRN: ______________ Date: __ _____________

Physical Examination Blood Pressure: ____________ Pulse: ___________ Respiration: _ __________ Temperature: ____________ Weight: ___________________ Height: _ ___________ BMI: _________________

General Status HEENT: _____________ Vision: _ ___________ Pharynx: _ _____________ Dental Devices: _ _____________ Pulmonary: _____________________________________________________________________________ Heart: _ ________________________________________________________________________________ Abdomen: ______________________________________________________________________________ Extremities: ___________________________________________________________________________ Skin: _ _________________________________________________________________________________ Skeletal: _______________________________________________________________________________ Neurologic: _____________________________________________________________________________ Others: _ _______________________________________________________________________________

Cosmetic Evaluation Face: _ _______________________________________________________________________________ Neck: ________________________________________________________________________________ Eyelids: ________________________________________________________________________________ Nose: _________________________________________________________________________________ Breasts: ______________________________________________________________________________ Extremities: ____________________________________________________________________________ Body: ________________________________________________________________________________

Laboratory Tests CBC: __________________ Electrolytes: _________ LFT: ______________ BUN/Creatine: _ _____________ PT/PTT: _______________ Urine: _ ______________ EKG: _ ______________ Chest X-Ray: _ ______________

Diagnoses and Recommended Procedures _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

Fig. 1-2  Plastic surgeon’s part of the history and physical examination form.

K23345_Pu_c01p_Eval Plast Sur Patient_r5_cl_0001-0014.indd 5

4/1/2015 1:19:55 PM

6

Part I 

General Principles

The plastic surgeon should refer the patient with a signifi ant medical condition to an appropriate medical specialist, if necessary.1 The surgeon should also be aware that patients commonly take medications or supplements; therefore potential side effects of these medications or supplements should be properly addressed before surgery2 (Table 1-1).In general, patients should continue all the medications that they have been routinely using for hypertension, diabetes mellitus, long-term pain, thyroid disorders, and so on. Based on the patient’s preoperative history and physical examination, pertinent preoperative tests should be ordered. For example, an electrocardiogram should be ordered for patients more than 45 years of age or for patients of any age with known cardiac conditions. A complete blood cell count and blood chemistries are most likely needed for a detailed evaluation of specific edical conditions, such as anemia, diabetes, or hypertension, or for patients on diuretic therapy. Additional preoperative tests—for example, liver and kidney function tests or chest radiographs—may also be required, depending on the patient’s condition. The patient’s classifi ation status according to the rating system of the American Society of Anesthesiologists (ASA; Table 1-2) can be determined based on a combination of the preoperative history and physical

Table 1-1  Ten Medicinal Herbs and Supplements Commonly Used by Patients Perioperative Management

Name

Common Uses

Potential Problems

Chondroitin

Osteoarthritis

Bleeding

Discontinue 2 weeks before surgery

Ephedra

Energy, weight loss, asthma

Hypertension, cardiac instability

Discontinue 1 day before surgery

Echinacea

Infection, ulcer, arthritis, bruising

Anesthetic toxicity, allergic reaction, immunosuppression

Discontinue 2 weeks before surgery

Glucosamine

Osteoarthritis

Hypoglycemia

Discontinue 2 weeks before surgery

Ginkgo biloba

Dementia, tinnitus, asthma, antiinflammatory

Bleeding

Discontinue 1.5 days before surgery

Goldenseal

Laxative, antiinflammatory

Volume depletion, sedation, photosensitivity

Discontinue 2 weeks before surgery

Milk thistle

Liver protection, antiinflammatory

Volume depletion

Discontinue 2 weeks before surgery

Ginseng

Antioxidant, energy, lowering blood glucose

Bleeding

Discontinue 1 week before surgery

Kava

Anxiolytic, muscle relaxant

Sedation

Discontinue 1 day before surgery

Garlic

Infection, hypertension, hypercholesterolemia, cancer prevention

Bleeding

Discontinue 1 week before surgery

Table 1-2  American Society of Anesthesiologists (ASA) Classifi ation Status Class 1

Class 2

Class 3

Class 4

Normal healthy patient

Patient with mild systemic disease

Patient with severe systemic disease

Patient with severe systemic disease that is a constant threat to life

Chapter 1 

Evaluation of Asian Cosmetic Surgery Patients

examination, comorbidities, preoperative laboratory tests, and medical specialist’s evaluation. Based on this rating, the plastic surgeon can select the appropriate facility for the cosmetic procedure, such as the offic or hospital, and the appropriate type of procedure, such as inpatient or outpatient.1,3

Preoperative Assessment The proper assessment of any potential plastic surgery patient is essential. Once the patient expresses specific concerns for or dislikes of a certain part of his or her face, breasts, or body, the plastic surgeon should effectively identify the problems that the patient has and formulate a surgical procedure to correct such cosmetic deformities. Although the patient’s “cosmetic complaint” is important and should be respected, one of the most important tasks of the plastic surgeon during the surgical assessment is to identify any surgically correctable cosmetic deformities. Because many cosmetic surgical deformities are not associated with any functional problems, the plastic surgeon should plan a surgical procedure that specifi ally addresses the patient’s cosmetic concerns. In addition, any preexisting congenital deformities should be taken into consideration before formulating a procedure for the patient. Table 1-3 provides some important physical examinations to conduct in each specific rea when assessing a patient; detailed surgical assessments for each specific anatomic region may be found in appropriate chapters of this textbook. Standard photographic documentation is also indispensable for the proper assessment of a candidate for plastic surgery. Uniform patient photographs create permanent medical records that are important to every plastic surgeon’s practice. These photos are an essential part of every patient’s medical record, facilitating surgical planning and an objective follow-up.

Table 1-3  Important Features on Physical Examination by Anatomic Region Anatomic Region

Important Features

Face

Facial proportion (upper, middle, lower) Asymmetry, facial nerve function Fitzpatrick skin type and skin quality Soft tissue atrophy or descent

Neck

Excess skin or fat or both Skin quality Platysma bands

Eyelids

Ptosis, asymmetry, dry eye, lower eyelid support

Nose

Nose in relation to face Dental occlusion Nasal airway obstruction Septal deviation, collapse of internal and external values Turbinate hypertrophy

Breasts

Asymmetry, congenital deformity Nipple and/or breast position in relation to inframammary fold Skin condition

Extremities

Asymmetry, other deformity or condition Excess skin or fat or both Skin quality

Body

Excess skin or fat or both Underlying muscle condition Skin quality

7

8

Part I 

General Principles

Psychosocial Assessment A psychosocial assessment is also an essential part of the assessment of any cosmetic surgery patient. Based on a recent study, social acceptance of cosmetic surgery and an individual’s body image are the strongest predictors of success for patients who seek cosmetic surgery.4 Therefore psychosocial and proper body image assessments are critical to ensure a good outcome after surgery. As part of the psychosocial assessment, the plastic surgeon should be able to answer who, what, when, and why before he or she operates on any potential patient.5 Commonly asked questions are summarized in Box 1-1. Two acronyms summarize a good or bad patient description in cosmetic surgery based on psychosocial assessment. The acronym SIMON designates a patient who is single, immature, male, overly expectant, and narcissistic. The acronym SYLVIA, on the other hand, describes a female patient who is secure, young, listening, verbal, intelligent, and attractive. If the plastic surgeon feels that a particular patient has a diffi ult personality, he or she should not operate on this patient.6 Body image is widely considered to consist of two components: body image orientation, which refers to how important body image is for a person, and body image evaluation, which indicates how satisfied a person is with his or her own body. Body dysmorphic disorder is a well-described mental disorder. In general, patients with this disorder have a disproportionate preoccupation with minor or imaginary physical flaws in their body. These patients believe that the distorted image that they have of their body truly exists. It is common for them to perceive a poor outcome, even when the outcome is excellent. These patients may spend hours focusing on their physical features and doing time-consuming repetitive behaviors, resulting in decreased social interaction.5 A comprehensive diagnosis of body dysmorphic disorder is beyond the scope of this chapter. However, five useful questions can be asked by a plastic surgeon to evaluate the patient with possible body dysmorphic disorder7 (Box 1-2).

Box 1-1  Questions to Consider Regarding Candidates for Plastic Surgery • Who is the patient? What are his or her personality traits, likes, and dislikes? • What are his or her goals for surgery? Can we accomplish these goals safely? • When is the best time to perform the surgery? Is he or she experiencing problems that may make surgery a bad option at this time? • Why does the patient want this procedure? Does he or she have realistic expectations and understand the limitations of surgery?

Box 1-2  Five Useful Questions for Evaluating Patients With Possible Body Dysmorphic Disorder 1. Do you worry about the appearance of your face or body? If so, what is your concern? 2. How unacceptable do you think your face or body appears? 3. How much time do you spend worrying about the appearance of your face or body? 4. Have you done anything to hide the problem or rid yourself of the problem? 5. Does this concern with your appearance affect any aspect of your life, such as school, your job, or your social life?

Chapter 1 

Evaluation of Asian Cosmetic Surgery Patients

Cosmetic Surgery Consultation The surgical consultation for a plastic surgery patient is unique and quite different from the any other type of medical or surgical consultation. The initial consultation with a potential patient is the most important and difficult one, because fi st impressions are typically lasting. The plastic surgeon should put the patient at ease by introducing himself or herself with honesty and compassion. The plastic surgeon should talk about his or her expertise in a specific cos etic surgery procedure, describe what preliminary tests may be necessary, explain how the surgical plan will be formulated, and inform the patient thoroughly of common complications and problems that may occur after a specific rocedure. The plastic surgeon should not talk the patient into a procedure that is not necessary from the patient’s point of view. Remember, the fi st impression is made in the fi st few minutes of the consultation and is lasting.8 During the cosmetic surgery consultation, the plastic surgeon should spend adequate time with the patient and display the greatest care, compassion, and listening skills. It is best to explain plastic surgery procedures simply, clearly, and completely. The best way to communicate with patients is to tell the truth and to avoid denying reality when a deformity does exist. Plastic surgeons should demonstrate that they are appropriately concerned about patients’ problems and willing to apply their skills to achieve a successful outcome. It is important to define realistic expectations with a potential patient. During the consultation, the plastic surgeon should use his or her best judgment to evaluate the relationship between a cosmetic deformity and the patient’s expectations. In this way, unrealistic expectations can be identified and addressed. It is much better if a potential patient has a surgically correctable cosmetic deformity and realistic expectations than a difficult-to-correct cosmetic deformity and unrealistic expectations. During the consultation, the most important task is to match the right operation to the right patient. Appropriate patient selection may come with experience and may take years to master. A patient’s decision to seek cosmetic surgery is usually not a spontaneous one. Most potential patients have done extensive research about the desired procedure, the plastic surgeon, and the plastic surgeon’s practice. Some potential patients may rely solely on the recommendations of their friends and family; others may look to the Internet, the media, other physicians, or physician-sponsored advertising to guide them in locating a plastic surgeon. However, satisfi d patients are the best source of referrals and are far more valuable than any advertising that money can buy.8 Plastic surgeons must know when to say “no” to their potential cosmetic surgery patients. Not every person that one sees is a good candidate for plastic surgery. For example, some patients have unrealistic expectations, some are not ready for a specific cosmetic procedure, and some are mentally unstable.8 It is widely believed by plastic surgeons that the single most important determinant of success in cosmetic surgery is proper patient selection. When a patient expresses a concern about a minimal deformity, the plastic surgeon should be alerted to a potential problem if the patient’s concern is disproportionate to his or her comparatively minimal anatomic deformity. The surgeon should also fully realize the impact of the family dynamic, because an operation on a loved one can represent a crisis for the entire family. For example, if the patient undergoes an elective surgical procedure that is against the wishes of his or her family members and then has a complication or unsatisfactory result, the family relationship can potentially deteriorate. It is quite helpful to have another family member present for the consultation. The family member can often help to remember or explain the issues that were discussed during the consultation and can help the patient maintain a more objective viewpoint about the surgery and its possible outcomes in relation to his or her expectations.

9

10

Part I 

General Principles

The surgeon should learn what to say to a potential patient who is clearly shopping around for a plastic surgeon. Most potential patients will consult with at least one other plastic surgeon before making his or her choice; getting a second or even third opinion is no longer unusual. Occasionally, a potential patient will not only come in with an information package from another plastic surgeon but also will tell the plastic surgeon that a different procedure was recommended. Although this situation is not considered a red flag, it does require extra time and discussion with this patient. The surgeon may have to explain that his or her recommendations differ from those of other surgeons, which does not necessarily mean that the other surgeons are not correct. The surgeon should honestly tell the patient that in his or her hands, the recommended procedure will give the patient the best results.8 During the consultation, the surgeon should also inform the patient of his or her fi ancial responsibilities. We all know that a result that does not meet expectations is a major reason for patient dissatisfaction; however, a fi ancial misunderstanding can also be a common reason for patient dissatisfaction. Many patients who are initially happy with their surgical result become unhappy and fi d fault with their result if unexpected charges appear long after the operation has been completed; therefore financial surprises should be avoided if at all possible. It is wise to clearly delineate the patient’s fi ancial responsibility during the initial office isit. The patient should be given an itemized price quote that includes the plastic surgeon’s fee, facility fees, operating room fees, anesthesia fees, charges for a potential overnight stay, and the cost of any implant materials to be used. It should also be made clear that there will be additional cost if the patient requests that other procedures be added between the time that the patient prepays for the procedure and the actual operation. Another important issue is additional fees for reoperation if there is a complication from the initial operation or unsatisfactory results. Although each practice may have different policies for additional reoperation, fi ancial responsibility for reoperations should be clearly explained. Additional costs related to reoperations, such as an unexpected hospital stay or consultation with other specialists, should also be explained.8 Box 1-3 summarizes some tips for plastic surgeons when dealing with cosmetic surgery ­patients.

Box 1-3  Tips for Dealing With Cosmetic Surgery Patients • The fi st impression is lasting. • Spend enough time with the patient. • Respect the patient’s culture and privacy. • Listen to the patient. • Help the patient to develop realistic expectations for the procedure’s outcome. • Inform the patient thoroughly. • Understand your patient’s expectations. • Learn when to say “no.” • Prevent postoperative fi ancial surprises.

Chapter 1 

Evaluation of Asian Cosmetic Surgery Patients

Identifying Risk Factors for Cosmetic Surgery Patients Ag e

Although most cosmetic surgery patients are healthy and younger than 65 years old, the surgeon should realize that patients who are 65 years or older are 1.5 times more likely to experience an intraoperative event and twice as likely to experience an intraoperative cardiovascular event.9 Therefore older patients may have a moderately increased risk of intraoperative and/or postoperative complications associated with any surgical procedures. However, other than age, ASA classifi ation might be a better predictor in terms of overall complications after a surgical procedure in the elderly population.

Body Ma ss Ind ex

Although obesity is less common in Asia, individuals who are overweight (body mass index [BMI] of 25 to 29.9 kg/m2) or obese (BMI above 30 kg/m2) may often present with multiple comorbidities that can complicate their perioperative management.9 Very commonly, obese patients may present with potential airway problems before or after general anesthesia, and they have a higher risk of developing deep vein thrombosis or pulmonary embolism. In addition, obese patients have an increased likelihood of wound infection, failed regional anesthetic block, and unplanned hospital admissions.9

Obstr uctive Sleep Apnea

The signifi ance of obstructive sleep apnea as a risk factor for complications during a surgical procedure under general anesthesia remains unclear. However, based on ASA guidelines, individuals with obstructive sleep apnea are at increased risk for airway obstruction and respiratory depression, which may require a longer postoperative stay and monitoring.9

Car dio va scul ar Cond itio ns

In general, patients affected by various cardiovascular conditions—history of heart disease, past stroke, or elevated blood pressure—are at increased risk of intraoperative hemorrhage and postoperative complications. However, there is a general agreement in the medical community that patients with a low-grade or remote cardiovascular symptom—such as angina or myocardial infarction more than 6 months ago, wellcontrolled congestive heart failure, or asymptomatic valvular disease—are suitable candidates for elective operations, whereas those with more severe conditions are not. Therefore any patient with an active cardiovascular condition such as unstable coronary symptoms, decompensated heart failure, signifi ant arrhythmias, or severe valvular disease should be evaluated and treated before any elective cosmetic surgery.9

Bleed ing Diso r ders

Occasionally, patients with bleeding disorders seek to undergo cosmetic surgery. Although plastic surgeons are not expected to diagnose or manage bleeding disorders, they should be able to recognize which patients are suitable for plastic surgery and which patients should be referred to a hematologist before a cosmetic surgical procedure. During the preoperative assessment, plastic surgeons should evaluate potential patients for a history of bleeding, bruising, or thrombosis, including any family history of these conditions.

11

12

Part I 

General Principles

Evidence of unusual postsurgical bleeding, epistaxis, gingiva bleeding, and in women menorrhagia and a history of pregnancy complications, may be a sign of an undiagnosed bleeding disorder. In addition, patients should be asked about their use of antithrombotic drugs and other drugs or supplements that may affect coagulation. Increased complication for this unique group of patients should be anticipated and conveyed to the potential cosmetic surgery patient. An appropriate hematologic consultation is likely required to aid perioperative management.10

Deep Vein Thr ombos is or Pulm onar y Embolis m

The potential to develop a DVT or PE remains a small yet significant risk for cosmetic surgery patients, especially for those undergoing body-contouring procedures such as abdominoplasty. Although these events may be quite rare in the Asian population, certain patients with genetic or acquired hematological disorders, or women with current or recent history of contraceptive or postmenopausal hormone replacement use, are at increased risk for DVT or PE. As part of the patient history and physical examination, attention should be paid to the factors that predispose the patient to thrombosis or embolism, including the use of contraceptives and hormone replacement, past episodes of thrombosis or embolism, and a genetic predisposition to clotting disorders. A physical examination should look for the signs of venous insufficiency in the lower extremities, such as edema or swelling. Any pertinent laboratory screen tests can also be ordered. On the basis of this information, patients can be categorized as low, moderate, or high risk for cosmetic surgery, and prophylactic measures can be implemented accordingly11 (Table 1-4).

Sur gical Pr o ced ur es

Most aesthetic surgery procedures take longer than 1 hour to complete, and it is not uncommon for several procedures to be performed during the same operation, thereby increasing the total duration of surgery time. Several studies performed in various office ased surgery settings have found that operations lasting beyond 30 minutes to 2 hours put the patient at increased risk for minor complications, such as postoperative pain, bleeding, delay in discharge, and/or unplanned admission. These risks may directly

Table 1-4  Risk Rating and Categorization of Venous Th omboembolism and Perioperative Management for Cosmetic Surgery Patients Risk Rating

Categorization

Recommendation

Low

Age ,40 years No risk factors Short surgery (,30 minutes)

Comfortable position on OR table with knees slightly fle ed

Moderate

Age .40 years No additional risk factors Longer surgery (.30 minutes) On estrogen replacement

Same as for low risk Intermittent pneumatic compression devices placed before induction

High

At least one risk factor Longer surgery (.30 minutes) History of chronic disease or malignancy Previous history of DVT or PE

Same as for moderate risk Prophylactic antithrombotic therapy

Chapter 1 

Evaluation of Asian Cosmetic Surgery Patients

relate to the duration of the procedure performed, or they may indirectly refl ct the complexity of the surgery. Regardless, long and complex procedures should be scheduled early enough in the day to allow for adequate recovery time before discharge, and elective operations should ideally be limited to less than 6 hours. In addition, the cumulative effects of multiple procedures performed during a single operation may increase the likelihood of postoperative complications.9 Judgment regarding the planned duration of surgery should take into account the type of case, the combination of procedures to be performed, and the general health of the patient.

Medicolegal Considerations The nature of aesthetic surgery may increase the odds of a medical malpractice claim. In general, claims usually arise from a patient’s response to a disappointing surgical result. Clearly, the best way to avoid medical malpractice claims is to carefully select the patient and to provide good preoperative informed consent. It is vital to maintain healthy and effective communication with the patient. Regarding good informed consent, plastic surgeons are required to provide the patient with a diagnosis, a written and spoken description of the nature of the planned procedure including its risks and benefits, and an explanation of the consequences of not having the procedure. The potential complications, both common and rare, and their management should be clearly conveyed to the patient. In addition, discussions about the informed consent should be documented and maintained as permanent medical records.12

Pearls for Success • Measures such as appropriate patient assessment and selection, thorough preoperative planning, routine perioperative monitoring, and postoperative follow-up are essential to ensure a good outcome and safety for cosmetic surgery patients. • We think that both the patient’s safety and the optimal outcome after cosmetic surgery can be achieved based on the principles and practices described in this chapter. • It is paramount that cosmetic surgeons remember to keep the patient’s best interests fi st and that happy patients are the best source of referrals.

Refer ences 1. Iverson RE, Lynch DJ; ASPS Task Force on Patient Safety in Office-Based Surgery Facilities. Patient safety in office ased surgery facilities: II. Patient selection. Plast Reconstr Surg 110:1785-1790; discussion 1791-1792, 2002. 2. Heller J, Gabbay JS, Ghadjar K, et al. Top-10 list of herbal and supplemental medicines used by cosmetic patients: what the plastic surgeon needs to know. Plast Reconstr Surg 117:436-445; discussion 446-447, 2006. 3. Iverson RE; ASPS Task Force on Patient Safety in Office ased Surgery Facilities. Patient safety in office ased surgery facilities: I. Procedures in the office ased surgery setting. Plast Reconstr Surg 110:1337-1342; discussion 1343-1346, 2002. 4. von Soest T, Kvalem IL, Skolleborg KC, et al. Psychosocial factors predicting the motivation to undergo cosmetic surgery. Plast Reconstr Surg 117:51-62; discussion 63-64, 2006. 5. Rohrich RJ. The who, what, when, and why of cosmetic surgery: do our patients need a preoperative psychiatric evaluation? Plast Reconstr Surg 106:1605-1607, 2000.

13

14

Part I 

General Principles

6. Rohrich RJ, Ahmad J. Postoperative management of the rhinoplasty patient. In Rohrich RJ, Adams WP Jr, Ahmad J, eds. Dallas Rhinoplasty: Nasal Surgery by the Masters, ed 3. St Louis: Quality Medical Publishing/Taylor & Francis Group, 2014. 7. Slaughter JR, Sun AM. In pursuit of perfection: a primary care physician’s guide to body dysmorphic disorder. Am Fam Physician 60:1738-1742, 1999. 8. Nahai F. The patient. In Nahai F, ed. The Art of Aesthetic Surgery: Principles & Techniques, ed 2. St Louis: Quality Medical Publishing, 2011. 9. Haeck PC, Swanson JA, Iverson RE, et al; ASPS Patient Safety Committee. Evidence-based patient safety advisory: patient selection and procedures in ambulatory surgery. Plast Reconstr Surg 124(4 Suppl):6S-27S, 2009. 10. Haeck PC, Swanson JA, Schechter LS, et al; ASPS Patient Safety Committee. Evidence-based patient safety advisory: blood dyscrasis. Plast Reconstr Surg 124(4 Suppl):82S-95S. 2009. 11. McDevitt NB. Deep vein thrombosis prophylaxis. Plast Reconstr Surg 104:1923-1928, 1999. 12. Haeck PC. The plastic surgery consultation and patient selection. In Guyuron B, Eriksson E, Persing JA, eds. Plastic Surgery: Indications and Practice. Philadelphia: Elsevier, 2009.

K23345_Pu_c01p_Eval Plast Sur Patient_r5_cl_0001-0014.indd 14

4/1/2015 1:19:55 PM

2 Cultural and Societal Considerations for Asian Cosmetic Surgery Patients

C

Cheyenne X. He, Lee L.Q. Pu

ultural and societal influences are signifi ant factors that drive patients to seek cosmetic surgery. Th s chapter reviews the cultural and societal aspects of physical appearance in contemporary society and their relationship with plastic surgery. Beginning with a historic review of Asian beauty, this chapter describes changes in the concepts of ideal beauty over time, the increasing acceptance of cosmetic surgery with mass media influence, and the effect of such surgery on a person’s life and social relationships. Our goal is to provide plastic surgeons with a better understanding of the cultural and societal aspects of plastic surgery that pertain to Asian patients.

Historical Overview of Asian Beauty Humans have long been attracted to beautiful people. The defin tion of beauty and what is considered attractive seem to be consistent across cultures and societies, although the view of ideal beauty—symmetry, proportion, and youthfulness remain the basic standards of beauty—changes over time. Wideset, large eyes, high cheekbones, full lips, clear and smooth skin, a relatively smaller lower face—as portrayed by the bust of Queen Nefertiti in ancient Egypt and the Mona Lisa in the fi eenth century—continue to be regarded as characteristics of beauty, even by modern-day standards, with examples such as Angelina Jolie, Halle Berry, Shalom Harlow, and Zhang Ziyi. White or black, Hispanic or Asian, beautiful people appear to share these characteristics in almost every culture. Standards of beauty and physical attractiveness are determined by the prevailing culture. Every ethnic group has its own consensus of ideas and beliefs about what is beautiful and attractive. In the last several years of Chinese history, four beautiful women have been well known for their beauty and their legendary impact on their surroundings: the fishes sunk deep in the river when Xi Shi came to wash clothing; the flying geese fell from the sky when Wang Zhaojun crossed their path; the moon faded away into the clouds when Diaochan came out at night; and fl wers folded their blossoms when Yang Yuhuan toured the garden. In Japanese art history, one of the greatest ukiyo-e (woodblock print) designers of late eighteenth century Japan, Kitagawa Utamaro,1 was the foremost artist in the genre of bijin-ga (paintings of beautiful

15

16

Part I 

General Principles

women). His work, “Th ee Beauties of the Present Day,” was inscribed with the title and the names of the three women depicted, who were famous for their beauty. The women’s faces appear similar, with high arched eyebrows, single eyelids, rather long noses, and small, delicate mouths. Another Japanese artist of the same period, Suzuki Harunobu,2 was famous for his paintings of beautiful young girls with delicate features, slender figu es, and dainty hands.

Changes of Ideal Beauty With Time The standards of beauty have changed with time. In Chunqui War Time in China several thousand years ago, the “beautiful cheery mouth” referred to a small mouth with thin lips; the shelved and charcoalpainting eyebrows were once widely accepted fashion; and delicate shoulders and very slender waist as Zhao Feiyan, the imperial dancer, characterized, were the most desirable features of women in her time. By the Tong Dynasty, thin and delicate body images were replaced by the full figu e of Yang Yuhuan, the most beloved imperial concubine. In contemporary society, the historically praised features regarded as beautiful and attractive have evolved into different views and standards. The advent of motion pictures and television in the twentieth century, and Internet and digital mass media in the twenty-fi st century, have ignited the widespread dissemination of images of models, actors, and actresses who represent the ideal beauty. The beauty ideals found in the mass media have shifted from the voluptuous figu es of the fi st half of the twentieth century to the often strikingly thin and fit figu es seen today. For the past decade, there have been speculations about plastic surgeries among popular Hollywood celebrities that give them younger and more attractive appearances. Crocket et al3 surveyed fi st-time patients seeking cosmetic surgery and examined the influence of reality TV on their perception of the risks and benefits of surgery and their overall decision-making process. They found that plastic surgery reality TV plays a signifi ant role in the perceptions and decision-making of patients who elect to undergo cosmetic surgery. Patients who regularly watched more reality TV shows reported a greater influence from television and media to pursue surgery, felt more knowledgeable about plastic surgery in general, and felt that plastic surgery reality TV was more similar to real life than did viewers who watched fewer programs. The influence of the Asian entertainment industry and rapid growth of reality TV shows in many countries seem to have increased the popularity of plastic surgery among Asians worldwide. Contemporary Korean movies and TV shows typically feature young, beautiful actors and actresses (Fig. 2-1) and have contributed to the rapid increase in plastic surgery among Asians. These procedures include not only some of the

Fig. 2-1  Prototypical characteristics

considered attractive among Koreans include natural-appearing wide-open eyes, a balanced nose bridge, and an overall oval-shaped face with a small to moderate jawline/chin.

Chapter 2 

Cultural and Societal Considerations for Asian Cosmetic Surgery Patients

traditional surgical procedures for Asians, such as double-eyelid blepharoplasty and augmentation rhinoplasty, but also some newer procedures, such as mandibular angle reduction, zygomatic reduction, breast augmentation, and liposuction. The glamorous appearance of Korean movie stars represents the ideal lifestyle, wealth, and social standing that are appealing not only to young girls, but also to middle-aged and even older Asians, including those who are successful and wealthy, who are increasingly seeking surgery to improve what they perceive as their less attractive, aging faces and bodies.

Cultural and Societal Influences on Physical Appearance In the late nineteenth century, European merchants, priests, and soldiers with large blue eyes, high-bridged noses, and yellow or red hair were viewed by Asians as alien. By the early twentieth century, the increase in economic and cultural exchange between Europe and Asia had gradually changed the Asian view of the physical appearance of “Europeans.” Today Asians have a greater acceptance of Western standards of beauty. On the other hand, Asia’s old and mysterious cultures have always added a rich and complex backdrop against which Asian beauty has been showcased to non-Asians. The perception that Asian women are docile and superfeminine has made them less threatening and more acceptable to Western minds. Societal influence on the perceptions of beauty and attractiveness has received a great deal of attention in research and popular culture. A variety of external factors influence our perception of beauty and attractiveness as we grow up. Parents influence their children’s perception of attractiveness with their own attitudes and behaviors toward their children’s appearances. Mothers may receive more outside pressure and play a more signifi ant role than fathers in improving their children’s appearance.4 Peer interactions at school also play an important role in the development of personal values and sense of self that are largely related to physical attractiveness. Peers model and reinforce conformity to certain appearance standards, such as what clothing and hairstyles are most popular and desirable. The combination of parental influences and peer interactions may solidify a young person’s perceptions about his or her own physical attractiveness during adolescence. Adults show a preference for attractive babies and are more likely to attribute characteristics such as intelligence, cheerfulness, health, and likeability to attractive babies than to less attractive ones.5 Infants as young as 2 to 3 months of age show a preference for attractive faces.6,7 Such preferences for attractiveness have been reliably established, regardless of age.8 Subsequently, these preferences also influence self-esteem, social competence, and rating of attractiveness by others. Physical attractiveness not only plays a central role in the formation of childhood friendships and popularity in school, especially for girls, but also affects academic performance and classroom relationships with teachers. In adulthood, attractiveness unarguably influences the development of romantic relationships. One’s initial impression about a potential romantic partner is based on his or her physical attractiveness. A positive reciprocal response often sparks a romantic interest and may eventually develop into a relationship. From an evolutionary standpoint, it is reasonable that men and women would seek the most attractive partner possible to pass on the genes for a strong, healthy, and beautiful body; however, the desire for the most attractive partner is also balanced by other characteristics, such as personality, intelligence, sense of humor, and loyalty. In general, men place greater importance on having a beautiful, attractive mate than do women.9 Men prefer attractive women and have less concern about their mate’s profession and fi ancial status.10 In contrast, women have a greater preference for average men who are fi ancially successful than for attractive men of low fi ancial status.

17

18

Part I 

General Principles

Change of Views and Acceptance of Cosmetic Surgery Cultural and societal influences have shaped our views on physical attractiveness and caused us to change our behaviors toward more beautiful people. Physically attractive people are judged more favorably and receive preferential treatment. Teachers are more likely to rate their attractive students as having greater academic potential, higher intelligence, and being more socially competent and popular. 11 Men are more likely to help attractive women than unattractive ones. Whereas attractive individuals are more likely to ask for and receive help, they are less likely to be asked for help. Attractive victims appear to be more successful in winning their legal cases.12 People in general are more sympathetic to attractive people and more likely to forgive them for their mistakes. Societal views of successful people seem to attribute physical attractiveness and beauty as part of success. Wideset eyes, double eyelids, high nose bridges, and wide mouths with full lips are common features of many individuals of European ancestry. Characteristic features of Asians include a wider intercanthal distance in relation to a shorter palpebral fissure and a broad prominent forehead, single eyelid, broad nasal base, and a small mouth.13 The influence of Western culture has gradually changed the view of Asian beauty. For example, double-eyelid blepharoplasty and augmentation rhinoplasty are more and more commonly sought by Asian women of all ages. There has been a rapid growth of acceptance of cosmetic surgery by both women and men.14 In 2004, rhinoplasty, blepharoplasty, and rhytidectomy were among the most popular surgeries in the United States, which is understandable because the face is an individual’s most prominent and defini g physical feature. Compared with men, women report greater self-ideal incongruence, more frequent negative views of their own body, and more emotional distress related to negative views of their physical appearance. They are also invested more in their appearance as a source of self-defin tion and confide ce.15 Furthermore, the growing interest in physical appearance is not only found in younger women, but also in men,16 as well as in older women.17 Although Asians have common aesthetic priorities, there can be differences among Asian aesthetic values. Dobke et al18 identifi d the different beauty criteria among seemingly similar-appearing Asians. They surveyed preferences regarding the periorbital region, nose, lip features, and overall harmony of the face among Korean and Japanese women. Korean women preferred a larger fold paralleling the lid margin, with elimination of the epicanthal fold. Japanese women desired thinner lips and more delicate facial features. In Asian culture, light skin color, large eyes, double eyelids, and a high-bridged nose are usually considered beautiful in women. However, typical characteristics of the Asian eyelid include puffiness, single (nonfolded) upper eyelid, epicanthus, an upslanting appearance, a vertically narrow palpebral aperture, and deep-set eyes. These distinctive features sometimes project an impression of tiredness, maliciousness, or anger. Some consider smaller eyes with single upper eyelids unattractive. Many Eastern Asian women request a larger, more open, and more rounded oval contour to the eyes. Therefore procedures such as double-eyelid blepharoplasty, brow lifting, epicanthoplasty, and lateral canthoplasty are generally performed to satisfy the desires of these patients.19 Although these operations are well accepted and effective, some patients are not fully satisfied with the postoperative results—especially if they have characteristics of body dysmorphic disorder preoperatively— and they usually request additional surgery to meet their expectations (see Chapter 3). In addition to eyes, basic facial skeletal patterns, which can greatly influence facial aesthetics, differ among whites and Asians. Whites have a dolichocephalic pattern, whereas Asians exhibit a mesocephalic pattern. Therefore a promi-

Chapter 2 

Cultural and Societal Considerations for Asian Cosmetic Surgery Patients

nent zygoma would cause a white person’s face to appear balanced and feminine but an Asian face to appear wide and stubborn. Young Korean women with prominent zygomata may have stress and unhappiness in daily life, because the Asian physiognomy often associates prominent zygomata with bad luck. For aesthetic improvement, zygomatic reduction is popular among Asians who desire a more cheerful and youthful face.20 Plastic surgeons should be sensitive to different ethnic concepts of beauty and appreciate a wide range of values and expectations from cosmetic surgery.

Pearls for Success • Cultural and societal influences may have signifi ant effects on Asians who seek cosmetic surgery. • Failure to recognize these influences may create obstacles preoperatively and dissatisfaction postoperatively. • Plastic surgeons who deal primarily with Asian patients should understand these important issues and attend to the special considerations of beauty, physical features that need to be improved, and expectations related to Asian cosmetic surgery.

Refer ences 1. Utamato, Kitagawa. “Th ee Beauties of the Present Day,” c 1793 (Museum of Fine Art, Boston). In Graham-Dixon A, ed. Art: Over 2,500 Works from Cave to Contemporary, ed 2, p 287. New York: DK Publishing, 2010. 2. Harunobu, Suzuki. “Osen of the Kagiya Serving Tea to a Customer,” c 1768-1769 (British Museum, London). In Graham-Dixon A, ed. Art: Over 2,500 Works from Cave to Contemporary, ed 2, p 287. New York: DK Publishing, 2010. 3. Crocket RJ, Pruzinsky T, Persing JA. The influence of plastic surgery “reality TV” on cosmetic surgery patient expectations and decision making. Plast Reconstr Surg 120:316-324, 2007. 4. Striegel-Moore R, Kearney-Cook A. Exploring parents’ attitudes and behaviors about their children’s physical appearance. Int J Eat Disord 15:377-385, 1994. 5. Stephan CW, Langlois JH. Baby beautiful: adult attributions of infant competence as a function of infant attractiveness. Child Dev 55:576-585, 1984. 6. Langlois JH, Roggman LA, Casey RJ. Infant preference for attractive faces: rudiments of a stereotype. Dev Psychol 23:363-369, 1987. 7. Rubenstein AJ, Kalakanis L, Langlois JH. Infant preferences for attractive faces: a cognitive explanation. Dev Psychol 35:848-855, 1999. 8. Jackson LA. Physical Appearance and Gender: Sociobiological and Sociocultural Perspectives. Albany, NY: SUNY Press, 1992. 9. Feingold A. Gender differences in effects of physical attractiveness on romantic attraction: a comparison across five research paradigms. J Pers Soc Psychol 59:981-993, 1990. 10. Townsend JM, Levy GD. Effects of potential partner’s costume and physical attractiveness on sexuality and partner selection. J Psychol 124:371-389, 1990. 11. Ritts V, Patterson MI, Tubbs ME. Expectations, impressions, and judgments of physically attractive students: a review. Rev Ed Res 62:413-426, 1992. 12. Hatfi ld E, Sprecher S. Mirror, Mirror…The Importance of Looks in Everyday Life. Albany, NY: SUNY Press, 1986. 13. Grimes PE. Aesthetics and Cosmetic Surgery for Darker Skin Types. Philadelphia: Lippincott Williams & Wilkins, 2008. 14. ISAPS International Survey on Aesthetic/Cosmetic Procedures, 2011.Available at www.isaps.org/Media/Default/ global-statistics/ISAPS-Results-Procedures-2011.pdf.

19

20

Part I 

General Principles

15. Muth JL, Cash TF. Body-image attitudes: what difference does gender make? J Appl Soc Psychol 27:1438-1452, 1997. 16. Cash TF, Pruzinsky T, eds. Body Image: A Handbook of Theory, Research, and Clinical Practice. New York: Guilford Press, 2002. 17. Sarwer DB, Whitaker LA, Wadden TA, et al. Body image dissatisfaction in women seeking rhytidectomy and blepharoplasty. Aesth Surg J 17:230-234, 1997. 18. Dobke M, Chung C, Takabe K. Facial aesthetic preference among Asian women: are all oriental Asians the same? Aesth Plast Surg 30:342-347, 2006. 19. Hirohi T, Yoshimura K. Vertical enlargement of the palpebral aperture by static shortening of the anterior and posterior lamellae of lower eyelid: a cosmetic option for Asian eyelids. Plast Reconstr Surg 127:396-406, 2011. 20. Lee JG, Park YW. Intraoral approach for reduction malarplasty: a simple method. Plast Reconstr Surg 111:453460, 2003.

K23345_Pu_c02_Cultural Societal_r7_dc_0015-0020.indd 20

4/2/2015 5:11:37 PM

3 Psychological and Psychiatric Considerations for Asian Cosmetic Surgery Patients

P

Cheyenne X. He, Lee L.Q. Pu

sychological   or psychiatric evaluation of patients who are considering cosmetic surgery is important to ensure proper patient selection, good surgical outcome, and satisfi d patients. In this chapter, we review the psychological aspects of physical appearance in contemporary society and their relationship to cosmetic surgery. We focus on identifying patients who have emotional distress, evaluating patients with unrealistic expectations for cosmetic surgery, and managing patients with psychological problems before and after surgery. In addition, we discuss formal psychiatric evaluation and management. Our goal is to provide plastic surgeons with a better understanding of psychological and psychiatric considerations in Asian patients who desire cosmetic surgery.

Understanding Motivation and Expectations of Cosmetic Surgery Patients As cosmetic surgery becomes more accepted, the number of individuals seeking cosmetic procedures is increasing, as is the need to understand the psychological characteristics of patients who seek these procedures. Patients who seek cosmetic surgery usually want to enhance their appearance or restore a more youthful appearance, or change their appearance in line with society’s current aesthetic standards. The general postoperative expectation is to be more beautiful and attractive; however, patients may be unaware of underlying motivations such as the need to alleviate dissatisfaction associated with their physical appearance, and the desire to enhance their self-esteem and confide ce. The motivations for patients who seek cosmetic surgery can be categorized as internal and external. An example of internal motivation is improving one’s self-esteem, whereas external motivations include obtaining a promotion or a new job, or starting a new romantic relationship.1-2 Some studies have indicated that internally motivated patients are more likely to have their goals met by surgery,3 whereas surgery in externally motivated patients, who seek surgery to please others, is often associated with a poor postoperative outcome.4-6

21

22

Part I 

General Principles

The decision-making process for surgery often involves patients’ romantic partners, family members, and close friends. The role of the feelings and influence of these people on the patients’ decision-making process should be assessed. Negative postoperative responses from romantic partners, family members, and close friends can alter psychosocial outcomes. Therefore the patient’s social relationships and their influence on the decision-making process should be included in the preoperative evaluation.

Preoperative Psychological Assessment The goal of the preoperative psychological assessment is to allow surgeons to identify patients with unrealistic expectations, emotional distress, or mental disorders; to make appropriate referrals to mental health specialists; to determine whether patients have contraindications to cosmetic surgery; and to ultimately minimize the likelihood of adverse psychological outcomes. For patients who choose to undergo cosmetic surgery, adverse psychological outcomes are more prevalent than physical complications.7 These patients are often looking for more than changes in their physical appearance. If cosmetic surgery does not improve patients’ sense of body satisfaction, self-esteem, and/or quality of life, the risk of postoperative dissatisfaction and legal responses is increased. Identifi ation of patients who are not suitable for cosmetic surgery can prevent frustration in both surgeons and patients, and adverse outcomes.

Scr eening

The initial communication between the surgeon and the patient can determine the success of the cosmetic surgery. Patients often feel vulnerable, anxious, and intimidated when fi st meeting with surgeons. By acknowledging the patient’s anxiety, offering reassurance, asking open-ended questions, and providing clarification or explanation, plastic surgeons can build initial trust and form an appropriate therapeutic alliance. Lyne8 proposed a structured interview to stratify patients’ psychological risks. The important teaching points are summarized in Box 3-1.

Box 3-1  Proposed Structured Interview for Plastic Surgery Patients Ask Patients 1. When they fi st noticed the specific area of concern and how it has affected their lives 2. To describe the level of severity of the deformity and how the deformity has influenced their behavior 3. Why they are seeking treatment now and about any history of surgery for the same deformity and its outcome 4. About their relationship with the surgeon who performed the previous surgery 5. What they hope to gain from surgery that will improve their lives 6. Any past history of psychiatric treatment and/or current episodes of depression or suicidal ideation Observe Patients For 1. Inappropriate views of the surgeon as the only doctor to provide the desired outcome 2. Attempts to manipulate or pressure the surgeon 3. Persistent negativity, hopelessness, and inability to enjoy life 4. Signs of resentment or anger, sense of entitlement, and/or an unrealistic need for perfection

Chapter 3 

Psychological and Psychiatric Considerations for Asian Cosmetic Surgery Patients

Ass ess ment of Psycho l o gical Risks and Psychi atr ic Illness

It is important to obtain a psychiatric history and to assess psychological risks when selecting patients for cosmetic surgery. The rate of mental health concerns is signifi antly higher among individuals seeking cosmetic surgery compared with noncosmetic surgery patients.9 Mental illness, substance abuse, and suicide were more prevalent in a breast augmentation group compared with the control group.10 Women who had undergone single or multiple facial cosmetic surgeries were found to be more narcissistic and to have more problems with separation-individuation than women in the control group.11 Surgeons should incorporate psychiatric history-taking as a part of general medical history and physical examination, recognize psychological risks and red flags, and identify patients who should be referred to mental health specialists. In addition, surgeons should pay special attention to signs and symptoms of body dysmorphic disorder (BDD) during the initial assessment.

Body Dysmor phic Diso r der

BDD is characterized by a preoccupation with and dislike of one’s appearance despite a normal or nearnormal appearance. The core feature is the person’s pervasive fear that he or she is unattractive, or even repulsive. Th s fear can rarely be ameliorated by reassurance. These patients often have signifi ant impairment in social and/or occupational functioning. All problems in their lives are illogically attributed to the defect, and this is accompanied by unrealistic expectations that cosmetic surgery will correct the defect and their “deficie t life.” The diagnostic criteria for BDD are summarized in Box 3-2.12 Many patients with BDD have poor insight and are unable to recognize that their concerns about body defects are excessive, or even delusional. The obsessive thoughts are usually coupled with compulsive and ritualistic behaviors, such as inspecting, improving, or camouflaging the perceived defects. 13 These compulsive behaviors often interfere with social and occupational functioning, and interpersonal relationships. Patients with BDD usually experience higher levels of depression, anxiety, poor self-esteem, and in severe cases, suicidal ideation and attempt.14,15 In addition, there may be cultural and social influences on patients with features of BDD because of stereotyped concepts of beauty that are emphasized in certain cultures. Plastic surgeons’ high vigilance for BDD and possible comorbid psychopathologic conditions may facilitate early detection and appropriate referral to mental health specialists.

Box 3-2  DSM-5 Diagnostic Criteria for Body Dysmorphic Disorder A. Preoccupation with one or more perceived defects of physical appearance that are not observable or appear slight to others. B. At some point during the course of the disorder, the individual has performed repetitive behaviors. From American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition: DSM-5. Washington, DC: American Psychiatric Publishing, 2013.

23

24

Part I 

General Principles

Understanding Personality and Managing Difficult Behavior Although it is important to screen for psychopathology preoperatively, such screening may not be sufficient to determine psychological risk factors. Screening of prospective patients should include identification of personality disorders and/or traits and understanding patients’ emotional states and fears, and their social relationships. What is personality? Personality may be understood as a cluster of behavioral responses that are based on a person’s past experiences, predispositions, social context, and view of future. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) defi es personality disorder as “an enduring pattern of inner experiences and behavior that deviates markedly from the expectations of the individual’s culture.”12 Patients with personality disorders can present special challenges to plastic surgeons and the treatment team. The patterns of thought and behaviors associated with the disorders can stir powerful feelings in other people, such as dislike, hate, strong attraction, or sexual thoughts. These feelings can influence the surgeon’s response to the patient. Therefore it is particularly important for surgeons to be aware of these personality concerns, and to effectively identify and manage these challenging patients. Table 3-1 summarizes the classification of personality disorders.12 Each cluster of personality disorders has its own specific characteristics that distinguish one from the others. Table 3-2 summarizes the characteristics of personality disorders.12 We provide the following discussion for specific personality disorders and suggest appropriate measures for working with these patients.

Parano id Patient s

Patients with paranoid personality disorder may be a concern for plastic surgeons because of their tendency to be critical, evasive, suspicious, unforgiving, and hostile. They may misread the behavioral cues of surgeons or staff nd perceive conspiracies in natural events. The surgeon’s warmth and empathy may be viewed with suspicion. These patients can be extremely mistrustful, may question the surgeon’s recommendations and treatment program, and may retaliate based on a perception of having been wronged. The surgeon must remain formal, respectful, courteous, and well prepared to provide detailed explanation for each decision or planned procedure, and to react nondefensively to the patient’s suspicions.

His tr io nic Patient s

The hallmark of histrionic personality disorder is an overly gregarious presentation with an exaggerated but shallow sense of emotionality. Patients with this personality disorder are dependent on admiration and affection. They tend to act seductively with surgeons because they have an unconscious need for reassurance that they are still attractive, and because they fear that they will not be taken seriously unless they are found to be sexually desirable. They often dress in revealing clothing and are charming, flirtatious, and lively while being interviewed. Approval and attention are central to their sense of identity, which is overly dependent on their appearance; consequently these patients may have unrealistic expectations of cosmetic surgery. The surgeon needs to be calm, reassuring, fi m, and nonfli tatious.

Chapter 3 

Psychological and Psychiatric Considerations for Asian Cosmetic Surgery Patients

25

Table 3-1  DSM-5 Personality Disorders Cluster A

Cluster B

Cluster C

Paranoid, schizoid, schizotypal

Antisocial, borderline, histrionic, narcissistic

Avoidant, dependent, obsessivecompulsive

From American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition: DSM-5. Washington, DC: American Psychiatric Publishing, 2013.

Table 3-2  Characteristics of Personality Disorders Cluster A

Cluster B

Cluster C

Lack of basic trust of others, defensive and hostile; cold, emotionally withdrawn, and distant; odd, eccentric, constricted affect, and a strange sense of humor.

Superfic al charm, manipulative and exploitative; dramatic, emotional, or erratic; selfinterest or entitlement, and demanding of favorable treatment.

Oversensitive, vague, anxious, and suspicious; trusting, deferential, has difficulty voicing opinion; fi ed on perfectionism, stingy, and has difficulty tolerating mistakes or imperfection.

These disorders are most likely present in patients seeking cosmetic surgery.

These disorders, especially obsessive-compulsive personality disorder, are frequently seen in patients seeking cosmetic surgery.

These disorders are not likely present in patients seeking cosmetic surgery.

From American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition: DSM-5. Washington, DC: American Psychiatric Publishing, 2013.

Nar ciss is tic Patient s

The core features of narcissistic personality disorder are a pervasive sense of grandiosity, need for admiration, lack of empathy, and chronic intense envy. Patients with narcissistic personality disorder usually present with fantasy of unlimited success, power, and beauty; these individuals believe that they are special and unique, and they have an exceptional sense of entitlement and inflated self-importance, and make unreasonable demands for favorable treatment. They tend to react to perceived criticism with anger, rage, and humiliation. Surgeons should be wary of patients with narcissistic personality disorder. These patients are likely to have an unrealistic expectation of results, a fragile sense of self that is dependent on looks and is easily shattered, and a sense of entitlement that could lead to litigation.

Patient s With Bor der line Perso nalit y Diso r der

The essential features of borderline personality disorder (BPD) include a pervasive pattern of instability of mood, self-image, and interpersonal relationships, as well as marked impulsivity. Individuals with BPD are sensitive to abandonment and tend to misinterpret the behavior of others as indicating rejection. They often make frantic efforts to avoid perceived abandonment or rejection by responding with inappropriate rage, unfair accusations, and impulsive behaviors such as self-mutilation and suicidal gestures, which often elicit a guilty or fearful protective reaction from others. Their view of others, as is the case with surgeons, may alternate between extremes of idealization and devaluation. These patients may quickly compliment the surgeon as caring, nurturing, and simply the best, whereas the surgeon who previously treated them is

K23345_Pu_c03_Psych Consid_r5_st_0021-0030.indd 25

4/1/2015 1:25:35 PM

26

Part I 

General Principles

characterized as cold, uncaring, and rejecting. Inevitably, the new surgeon will be placed, with the slightest dissatisfaction, into the same group as the surgeon before. These previously well-relating and charming patients will return with criticism, rage, and even violent behavior toward their surgeons. Surgeons must calmly set fi m limits, clearly defi e acceptable and unacceptable behaviors, and hold the patients responsible for their actions. Surgeons must proceed carefully when they suspect that a patient has BPD, and should require the patient to undergo psychiatric evaluation and possibly treatment.

Antiso ci al or So cio pathic Patient s

Patients with antisocial personality disorder are sometimes referred to as sociopaths. They do not appear to experience remorse or empathy. Th s disorder is more commonly diagnosed in men than in women. These individuals may appear charming, socially adept, and intelligent, but they can actually be manipulative and exploitative. They have low frustration tolerance, and can easily become angry and critical if surgeons do not submit to their manipulations. They are often self-destructive and may abuse substances, and they may be aggressive or violent. They can inspire legitimate fear in others. Surgeons and staff must treat these patients with respect and with a heightened sense of vigilance. Surgeons who feel threatened by these patients should seek assistance and see the patients only when accompanied by other staff. Firm limits must be set on the patients’ behavior, and the consequences of violation of the limits must be clearly stated. If inappropriate behavior occurs, the patients must be calmly but directly confronted and escorted from the clinic by security personnel.

Obsess ive and Contr olling Patient s

Patients with obsessive-compulsive personality disorder are orderly, punctual, and overly concerned with details. To the extent that these patients are fix ted on detail, initial evaluation can be challenging, and it may be difficult to establish rapport. These patients have difficulty tolerating mistakes or imperfection. Their obsessive personality trait is the most common personality trait among patients seeking rhinoplasty.16 The outcome of any cosmetic surgery is likely to be disappointing to these patients, who tend to be perfectionists and highly critical, and this may lead to litigation. It is important that surgeons are aware of the potential problems.

Over l y Compli ant Patient s

Overly compliant patients are unable to openly express their feelings. They may have avoidant personality disorder or dependent personality disorder. Patients with avoidant personality disorder are socially isolated and hypersensitive to criticism and rejection. They often present as tense, vague, worried, and withdrawn. Patients with dependent personality disorder are likely to be trusting and deferential. They have difficulty making decisions; they regard the surgeon as an expert and tend to have confide ce in the surgeon’s recommendations. Surgeons should encourage involvement of the patients’ family members, learn about signifi ant others in the patient’s life, and determine whether they may play a role in the patient’s decision to seek cosmetic surgery. Although a suspected personality disorder is not an automatic disqualifi ation for patient selection, it is an important indicator that surgeons should precede with caution. Surgeons should not hesitate to refer such patients to mental health professionals for consultation.

Chapter 3 

Psychological and Psychiatric Considerations for Asian Cosmetic Surgery Patients

27

Psychiatric Consultation and Management Psychiatric consultation for patients who are undergoing cosmetic surgery not only involves preoperative evaluation, but is also related to different stages of surgery. Psychiatric management during intraoperative and postoperative periods is as important as the initial psychiatric consultation.

Initi al Consul t atio n

Obtaining a psychiatric history is an important initial step in determining if patients are appropriate candidates for cosmetic surgery. Th s process should be incorporated into the medical history. Surgeons should ask patients about a history of psychiatric diagnosis, therapy and/or psychotropic medication, and psychiatric hospitalizations. They should inquire about patients’ mood, anxiety, and any neurovegetative symptoms. Two fi dings warrant special care: the diagnoses of BDD and major depressive disorder. In both disorders, patients may expect the surgery to cure the underlying mental disorder. In addition to BDD and major depressive disorder, eating disorders, especially the difficult-to-detect bulimia, may be a special concern among female patients who seek lipoplasty and abdominoplasty because of their fanatical pursuit of thinness and overwhelming fear of becoming fat. Another red flag is a history of multiple elective cosmetic surgeries with outcomes that were unsatisfactory to the patient. Provision of service can involve clarifi ation of the patient’s motivation and expectation, as well as formation of a therapeutic alliance in the event that surgery is actually performed. Special care needs to be considered in initial psychiatric consultation with Asian patients. Historically, Confucianism and Buddhism have had a profound influence on Eastern philosophical approaches to life and family interactions. Most Asians address their psychological problems by relying on their family, relatives, or resources in their community, and do not seek professional mental health services; this is especially true for the older generations. Although younger Asians are more open to seeking mental health services, they may seek help first from family elders, spiritual leaders, ministers, monks, herbalists, or fortune tellers. Even when the surgeon identifies s mptoms of mood, anxiety, or other psychiatric concerns, the referral of an Asian patient for psychiatric consultation may be met with resistance or refusal. It may be useful to advise patients that a decision to permanently alter their appearance is important and that the treatment may change how they feel about themselves—positively or negatively—thus seeking a psychiatrist may help them decide if this is the right time for the surgery.

Intra opera tive Man a gement

The objectives of psychiatric consultation and management in this period are the reduction of preoperative anxiety and management of traumatic intraoperative reactions. If the patient experiences severe anxiety or panic attacks before the surgery, delay of surgery and further exploration of diagnostic and personality issues are warranted. Traumatic reactions may be observed in patients who did not expect the degree of swelling, bleeding, or discoloration immediately after the surgery. They may complain and become very anxious or angry. In these situations, the surgeon or psychiatric consultant should be prepared to spend more time with the patient to provide realistic reassurance and support. Treatment for the anxiety and panic attacks is usually a combination of brief psychotherapy and psychotropic medications. Benzodiazepines and sleep medications may help reduce the anxiety.

K23345_Pu_c03_Psych Consid_r5_st_0021-0030.indd 27

4/1/2015 1:25:35 PM

28

Part I 

General Principles

Postoperative Care Postoperative psychological reactions may be difficult to diagnose and treat in patients who have undergone cosmetic surgery. During the postoperative period, patients may experience the full extent of what was beginning to occur during the preoperative and/or intraoperative periods. They may feel acutely traumatized and very disappointed. Their responses may range from severe depression, to anxiety, panic attacks, withdrawal/isolation, anger/rage, and sometimes even violent aggressive behavior toward the surgeon and staff. Management of such responses requires substantial reassurance and empathy. A visit by the surgeon may be more anxiety-reducing for the patient than any therapy or medication. Postoperative delirium may result from undetected substance withdrawal—such as in alcoholism, chronic mental illness, surgical complications, or reactions to medications. Haloperidol is the usual choice of treatment combined with effort to correct other causes of delirium. Long-term postoperative psychiatric intervention should focus on treatment of any psychiatric sequelae, regardless of whether the surgical outcome is positive or negative. Possible psychological reactions to a technically successful surgery may range from disappointment or dissatisfaction to a sense of lost identity. These reactions may stem from previously undetected or untreated psychiatric problems that were not addressed by the surgery, lack of understanding of realistic outcome of the surgery, or failure to receive expected approval or praise from family or friends for surgical changes.17 These patients usually repeatedly ask for reoperation, especially for rhinoplasty and blepharoplasty. The treatment for this particular population requires intensive therapy that moves well beyond psychiatric consultation.

Pearls for Success • The need for psychological screening and assessment of patients seeking cosmetic surgery is universally recognized. • Careful preoperative psychological evaluation of patients who are seeking cosmetic surgery, and understanding the motivations and expectations for the surgery, is a vital part of the management and treatment of these patients. • The purpose of the psychological evaluation is to help determine if patients’ preoperative motivations and postoperative expectations are realistic and to identify patients who have psychiatric conditions that may contraindicate the treatment. • Failure to identify the patients with severe mood, anxiety, BDD, or personality disorders, who may not be appropriate candidates for cosmetic surgery, may lead to signifi ant problems for the surgeons and staff, and for patients themselves. • Surgeons should obtain a psychiatric history on all patients, and should be encouraged to refer patients with psychiatric problems to psychiatrists. • The successful collaboration between plastic surgeons and psychiatrists will create a better opportunity for patient satisfaction after cosmetic surgery.

Chapter 3 

Psychological and Psychiatric Considerations for Asian Cosmetic Surgery Patients

29

Refer ences 1. Sarwer DB. Psychological assessment of cosmetic surgery patients. In Sarwer DB, Pruzinsky T, Cash TF, et al, eds. Psychological Aspects of Reconstructive and Cosmetic Plastic Surgery: Clinical, Empirical, and Ethical Perspectives. Philadelphia: Lippincott Williams & Wilkins, 2006. 2. Edgerton MT, Knorr NJ. Motivational patterns of patients seeking cosmetic (aesthetic) surgery. Plast Reconstr Surg 48:551-557, 1971. 3. Meyer E, Jacobson WE, Edgerton MT, et al. Motivational patterns of patients seeking elective cosmetic surgery. Psychol Med 22:193-202, 1960. 4. Edgerton MT, Langman MW, Pruzinsky T. Plastic surgery and psychotherapy in the treatment of 100 psychologically disturbed patients. Plast Reconstr Surg 88:594-608, 1991. 5. Beale S, Lisper H, Palm B. A psychological study of patients seeking augmentation of mammaplasty. Br J Psychol 136:133-138, 1980. 6. Edgerton MT, Meyer E, Jacobson WE. Augmentation mammaplasty: II. Further surgical and psychiatric evaluation. Plast Reconstr Surg 27:279-301, 1961. 7. Wright MR, Wright WK. A psychological study of patients undergoing cosmetic surgery. Arch Otolaryngol 101:145-151, 1970. 8. Lyne J, Ephros H, Bolding S. The need for preoperative psychological risk assessment. Oral Maxillofac Surg Clin North Am 22:431-437, 2010. 9. Sarwer DB, Zanville HA, LaRossa D. Mental health history and psychiatric medication usage among persons who sought cosmetic surgery. Plast Reconstr Surg 14:1148-1156, 2004. 10. Lipworth L, Nyren O, Ye W. Excess mortality from suicide and other external causes of death among women with cosmetic breast implants. Ann Plast Surg 59:569-580, 2007. 11. Dunofsky M. Psychological characteristics of women who undergo single and multiple cosmetic surgeries. Ann Plast Surg 39:223-228, 1997. 12. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition: DSM5. Washington, DC: American Psychiatric Publishing, 2013. 13. Phillips KA, McElroy SL, Keck RE. Body dysmorphic disorder: 30 cases of imagined ugliness. Am J Psychiatry 150:302-310, 1993. 14. Philips KA, Siniscalchi JM, McElroy SL. Depression, anxiety, anger, and somatic symptoms in patients with body dysmorphic disorder. Psychiatr Q 75:309-319, 2004. 15. Phillips KA, Mernard W. Suicidality in body dysmorphic disorder: a prospective study. Am J Psychiatry 163:12801282, 2006. 16. Zojani R, Javanbakht M, Ghanadan A, et al. High prevalence of personality abnormalities in patients seeking rhinoplasty. Otolaryngol Head Neck Surg 137:83-87, 2007. 17. Macgregor FC. Patient dissatisfaction with results of technically satisfactory surgery. Aesthetic Plast Surg 5:2732, 1981.

K23345_Pu_c03_Psych Consid_r5_st_0021-0030.indd 29

4/1/2015 1:25:36 PM

K23345_Pu_c03_Psych Consid_r5_st_0021-0030.indd 30

4/1/2015 1:25:36 PM

4 Scar Management for Asian Cosmetic Surgery Patients

E

Rei Ogawa

very cosmetic procedure has the potential to generate noticeable scars. Even the pinhole resulting from a filler injection may cause obvious scars. In general, Asian patients tend to develop red, elevated, and wide scars more frequently than white patients do. Moreover, pathologic scars such as keloids and hypertrophic scars are common among Asians after any surgical procedure. In this chapter, the mechanisms of scarring, general prevention of scars, and scar treatment strategies are described.

Mechanisms of Cutaneous Wound Healing and Scarring The following four factors hamper proper cutaneous wound healing: (1) an inadequately moist environment (either too dry or too wet), (2) strong and cyclical mechanical forces on the wound, (3) foreign body reaction and allergy, and (4) infection. If these factors cause severe and continuous inflammation, then noticeable and/or growing pathologic scars can develop. For this reason, patients should be asked about a history of allergies to filler or implant materials before a procedure is performed.

Inad eq uatel y Mois t Envir onment

Cell growth requires an adequately moist environment.1 To ensure that the wound environment is adequately moist after surgery, it is necessary to eliminate dead spaces and place adequate drains intraoperatively, and to absorb excess exudate by applying suffici t wound dressings postoperatively. In addition, wound exudate provides the different cells of the immune system with the ideal conditions needed to destroy invading pathogens such as bacteria, foreign bodies, and necrotic tissues, thereby reducing the chance of infection. Thus, to promote rapid wound healing, it is important to have an adequate balance between wound moistness and dryness.

Str ong and Cyclical

Mech anical For ces

During wound healing after surgery, fibroblasts, myofibroblasts, and endothelial and epithelial cells are affected by intrinsic and extrinsic mechanical stimuli2 (Fig. 4-1). The wound itself contracts because of

31

32

Part I 

General Principles

forces produced by myofibroblasts. In addition, the speed and time course of wound healing are affected by extrinsic forces, including the natural tension within the skin. Moreover, fibroblasts secrete collagen and fibronectin and regulate the volume of the extracellular matrix by secreting collagenase, and it has been suggested that this molecular regulatory process is largely controlled by mechanical forces. If the balance between the synthesis and degradation of collagen is not carefully maintained, scars can become hypertrophic or atrophic.

Wounds

Granulation tissues

Cyclical stretching forces (extrinsic forces)

Scar contractures (intrinsic forces)

Abnormal scars

Continuous inflammation caused by mechanical forces

Blood vessel overgrowth

Nerve overgrowth

Cell proliferation

Matrix hyperproduction

Fig. 4-1  The relationship between mechanical forces and scarring. (From Ogawa R, Akaishi S, Huang C, et al. Clinical applications of basic research that shows reducing skin tension could prevent and treat abnormal scarring: the importance of fascial/subcutaneous tensile reduction sutures and flap surgery for keloid and hypertrophic scar reconstruction. J Nihon Med Sch 78:68-76, 2011.)

Fig. 4-2  Late-onset infection caused by a nasal implant.

Fig. 4-3  Early-onset infection caused by nonabsorbable unknown materials injected into the buttock.

K23345_Pu_c04_Scar Mgmnt_r7_cl_0031-0044.indd 32

4/7/2015 8:06:26 AM

Chapter 4 

Scar Management for Asian Cosmetic Surgery Patients

For eign Body Rea ctio n and Aller gy

Injections or implantation of foreign body materials has the potential to induce immunologic reactions and late-onset complications (Figs. 4-2 and 4-3). Once these complications arise, the inflammation can become chronic and induce obvious scars around the wound or injected/implanted areas. Such cases require scar revision with the removal of the injected/implanted materials. Thus foreign body materials should be carefully selected before use.

Infectio n

Infection can result from unhygienic intraoperative procedures or inadequate wound dressings. It can also develop later with hematogenous origin in cases with implanted foreign bodies. Surgical site infections (SSIs) can occur at the site of surgery within 30 days of an operation or within 1 year of an operation if a foreign body is implanted as part of the surgery. Wound ischemia caused by faulty suture techniques may be one of the mechanisms that generate SSIs. Indeed, a good suturing technique can prevent the likelihood of such ischemia. Because infection delays wound healing, it can promote the development of obvious scars with pigmentation.3 Thus, to prevent noticeable scars, clean procedures and careful suture techniques should be applied intraoperatively and appropriate care provided postoperatively.

Prevention of Scars High-R isk and Low-R isk Regio ns

A statistical study of the anatomic regions in Japanese patients that are affected by heavy scarring revealed that such scars tend to arise on specific sites4 (Fig. 4-4).

High-Risk Regions The anterior neck and chest, scapular region, suprapubic region, and joints are constantly or frequently subjected to mechanical forces, including skin stretching due to daily body movements. Special attention is needed when surgery is performed in these regions.

Fig. 4-4  High-risk (red) and low-risk (blue) regions of scarring.

33

34

Part I 

General Principles

Low-Risk Regions Noticeable scars rarely occur on the parietal region, anterior lower leg, eyelids, and palm, even in patients with multiple keloids or hypertrophic scars on other parts of their body. In both the parietal region and the anterior lower leg sites, the bones lie directly under the skin, so the skin at these sites is rarely subjected to mechanical forces. Eyelids are moved frequently as a result of blinking, so the tension on this site does not increase during these movements, even when the eye is fully closed. The palm has a thick keratin layer that may hamper transmission to the dermis of the extrinsic forces that produce scars. Th s site-specific ty of noticeable scar development suggests that mechanical forces may not only promote scar growth, but also that they may be a primary trigger of scar generation.5 Although severe and long-term inflammation is another trigger for the generation of scars, we think that mechanical forces play a more signifi ant role in this process.6 Thus operations on high-risk sites should be conducted with great care.

Intra opera tive Techniq ue

Because keloids and hypertrophic scars arise from the dermis, we have speculated that eliminating mechanical forces on the dermis could reduce the risk of heavy scar formation after surgery.4 One approach is to apply a specific type of suturing technique. In plastic surgery, three-layered sutures consisting of separate subcutaneous/dermal/superfic al sutures are conventionally used; these sutures are associated with a clear decrease in the risk of both SSIs and hypertrophic scars. However, to prevent the development of severe hypertrophic scars and keloids, further modifi ations of suture techniques are needed, because even three-layered sutures place tension on the dermis. Consequently, we have begun to use subcutaneous/fascial tension reduction sutures where the tension is placed on the layer of deep fascia and superfic al fascia (Fig. 4-5). Th s means that the use of dermal sutures is minimized; indeed, dermal sutures can be avoided altogether if the wound edges can be joined naturally under very low tension. We prefer 2-0 or 3-0 PDS

Epidermis Dermis Fat Superficial fascia Fat Deep fascia Muscle

Epidermis Dermis Fat Superficial fascia Fat Deep fascia Muscle

Fig. 4-5  Subcutaneous/fascial sutures to avoid high tension on the dermis. (From Ogawa R, Akaishi S, Huang C, et al. Clinical applications of basic research that shows reducing skin tension could prevent and treat abnormal scarring: the importance of fascial/subcutaneous tensile reduction sutures and flap surgery for keloid and hypertrophic scar reconstruction. J Nihon Med Sch 78:68-76, 2011.)

Chapter 4 

Scar Management for Asian Cosmetic Surgery Patients

sutures for subcutaneous/fascial sutures, 4-0 or 5-0 for dermal sutures (if they are necessary), and 6-0 or 7-0 polypropylene or nylon sutures for superfic al sutures. The consequence of such suturing is that the wound edges are elevated smoothly, with minimal tension on the dermis. Th s appears to prevent the development of red, elevated, and wide scars. Sometimes after suturing, small nodules under the skin can be detected when the wound surface is touched. These nodules likely refl ct surgical damage to the dermis. We have noticed that keloids and hypertrophic scars tend to recur from these nodules; indeed, it seems that keloid recurrence usually originates from the suture marks rather than from the sutured surfaces. For this reason, we ensure that we do not nick the dermal layer during surgery.

Postoperative Care One t o Two Weeks After Sur ger y

Th s period is associated with the beginning of the proliferation phase of wound healing. It is important to stabilize the wound to prevent exposure to extrinsic mechanical forces, because when skin resident cells such as fibroblasts and endothelial cells perceive mechanical forces, they can promote excessive growth of blood vessels, nerve fibers, and collagens. These changes prolong and increase inflammation as well as increase the risk of immature scar formation with redness, which can be followed by hypertrophic scars with pigmentation. To stabilize the wound before suture removal, skin closure tape can be combined with skin adhesive7 (Fig. 4-6). In addition, bandages, splints, and garments are helpful (Fig. 4-7). To ensure that the wound environment is moist, one can apply moist wound dressing materials or a petrolatum-based ointment.

One Month After Sur ger y

The 4-week period after surgery is associated with the start of the remodeling phase of wound healing. At this stage, the sutures have been removed. External fix tion with surgical tape, silicone gel sheet, polyethylene gel sheet, soft silicone tape, bandages, or foam compression tape should be considered (Fig. 4-8).

Fig. 4-6  Stabilization of the wound using skin closure tapes and skin adhesives.

Fig. 4-7  Bandage to stabilize the wound and the scar.

35

36

Part I 

General Principles

Fig. 4-8  External fix tion of the scar using surgical tape.

Fig. 4-9  Nd:YAG laser treatment of hypertrophic scars on the neck.

To prevent pigmentation, sunscreen lotion and cream should be used on the scars. These topical agents can be used over the surgical tapes. It has been suggested that vitamins B2, B6, and C and tranexamic acid may prevent the overproduction of melanin and accelerate the skin metabolism that results in the egestion of melanin granules. In addition, petrolatum-based, heparinoid, and urea ointments are useful for accelerating scar maturation.

Six Months After Sur ger y

The end of the scar maturation stage is achieved within 6 months. Unless there are special concerns, such as a genetic disposition to keloids or hypertrophic scars, minimum protection from UV rays is suffici t for scar management. Vitamins B2, B6, and C and tranexamic acid can still decrease melanin levels at this stage. If scars and pigmentation or depigmentation are noticeable at this stage, the natural recovery process will take a long time, and aggressive treatments such as scar revision surgery and laser treatment can be initiated (Fig. 4-9).

Chapter 4 

Scar Management for Asian Cosmetic Surgery Patients

Techniques for Wound Healing The common techniques that can be used to promote optimal wound healing are summarized in Table 4-1.

Skin Cl os ur e Tap e and Sur gical Adhes ive

Skin closure tape and skin adhesive are helpful for stabilizing suture wounds. Because neither the tape nor the adhesive can provide suffici t stabilization alone, it is best to use them in combination with sutures7 (see Fig. 4-6). Application of the tape in a reticular pattern will result in superior stabilization. Use of the tape in combination with surgical adhesive also effectively stabilizes sutured wounds.

Wound Dr ess ings

Before the sutures are to be removed, wound dressings such as polyurethane films help to protect the wound and keep it moist (Fig. 4-10). A dressing change every 2 to 3 days is suffici t to keep the wound clean. It is also useful to apply nonadhesive gauze or absorbent dressings for the fi st 1 to 3 days to absorb minimal bleeding that may continue.

Table 4-1  Methods of Postoperative Care for Scar Management Within 1-2 Weeks After Surgery

Within 1 Month After Surgery

Within 6 Months After Surgery

Skin adhesive

Surgical tape

Ultraviolet cut cream

Skin closure tape

Silicone gel sheets

Vitamins B2, B6, and C

Polyurethane film

Polyethylene gel sheets

Tranexamic acid

Petrolatum-based ointment

Soft silicone tape

Bandage

Bandage

Garment

Foam

Splint

Fig. 4-10  Polyurethane film dressing of the wound.

37

38

Part I 

General Principles

Fig. 4-11  Stabilization of the wound using surgical tapes.

Sur gical Tap es

Surgical tapes are useful for stabilizing the wound after suture removal. For the high-risk sites mentioned earlier, taping fix tion should be continued for at least 3 to 6 months (Fig. 4-11).Patients do not need to change the tapes every day, even if they bathe daily; rather, to prevent epidermal injury arising from tape removal, patients should change the tape only when it becomes unstuck naturally. In general, most patients tend to change the tapes every 1 to 2 weeks. If contact dermatitis occurs, corticosteroid ointment can be applied over the tapes. Th s agent can penetrate into the tapes and reach the skin.

Gel Shee t s

Silicone gel8 or the cheaper polyethylene gel sheets are available. Gel sheets effectively keep the wound moist; in addition, they reduce tension on the border between the scar and normal skin. 9 It has been suggested that gel sheets transfer the tension from the border of the scar to the lateral edge of the sheet. Moreover, gel sheets can protect wounds from extrinsic mechanical forces and are easy to use. However, it is difficult to use gel sheets in weather conditions that induce sweating. In such cases, silicone gel is an alternative choice, although it does not have a mechanical force-reduction effect.

Band a ges, Garment s, Foams, and Sponges

Bandages, garments, foams, and sponges can stabilize and compress the wound, although the mechanisms by which compression improves wound healing have not yet been analyzed precisely. These products are effective for wounds on a joint or a movable region.

Mois tur izer

To accelerate scars, moisturizers such as petrolatum-based, heparinoid, and urea ointments are useful. Silicone gels are widely used, especially in Asian countries, because gel sheets are difficult to use in humid conditions that induce sweating.

Chapter 4 

Scar Management for Asian Cosmetic Surgery Patients

Treatment of Scars The method used to treat a particular scar should be based on the type of scar. Because red scars such as keloids, hypertrophic scars, and immature scars are characterized by chronic inflammation, the cause of the inflammation should be diagnosed on the basis of the region of the scar, and appropriate treatment to reduce the inflammation should be selected fi st. Such scars with inflammation should be observed for at least 6 to 12 months to await their maturation. However, white scars such as mature scars and depigmented scars are not associated with inflammation, and noticeable changes are not expected; thus a wait-and-see approach is not suitable for these scars. Black scars, namely pigmented scars, are characterized by melanin deposition in the skin, and thus reducing the pigmentation is the treatment target in such cases.

Sur gical Therap y

Because keloids and hypertrophic scars recur readily, simple extirpation and re-suture are not suffici t.10 To prevent recurrence, one should apply subcutaneous/fascial tensile reduction sutures 4 and use a tensionreleasing surgical technique such as Z-plasty, W-plasty, or a small-wave incision.11In addition, multimodal therapy that includes radiation, laser (dye or Nd:YAG) therapy, and steroid injections/ointment/tape should be applied if the scars seem intractable (Box 4-1). Linear or broadband mature scars can be treated with surgery. Linear scars can be excised completely and resutured (Fig. 4-12), and tape fixation should be applied to prevent the scars from getting wider over time. For broadband, mature scars, the depigmented or pigmented regions can be removed by surgery. Mass or area reduction is a reason for surgery in mature scars. If the contour of the scar does not match the surrounding tissues, total replacement with healthy skin using a tissue expander is an option. Skin grafting can be performed, but contour and color differences between the donor skin and the recipient site can make this choice problematic.

Box 4-1  Common Surgical Options for Scars • Surgical excision • Local tissue rearrangement (that is, Z-plasty, W-plasty, or small-wave incision) • Tissue expansion and flap advancement • Skin grafting

Fig. 4-12  Reconstruction of hypertrophic scars using Z-plasties.

39

40

Part I 

General Principles

Fig. 4-13  Silicone tape fix tion for stabilization of the scar.

Nonsur gical Therap y Compression Therapy

The mechanisms by which pressure can accelerate scar maturation should be elucidated. It is possible that compression therapy has benefic al effects simply because it promotes wound resting and reduces stretching forces on the wound. However, in the meantime, it may be useful to apply appropriate pressure on hypertrophic scars. Sponges, foams, and gel sheets can be used for this purpose.

Scar-Resting Therapy Effective elimination of mechanical stimuli accelerates scar maturation. Th s can be achieved with surgical tape and silicone tape (Fig. 4-13). The tapes should be left n the scar until they fall off n their own, because frequent attachment and detachment of the tape can cause epidermal injury.

Gel Sheeting Gel sheeting therapy can be used to prevent hypertrophic scars after surgery and to treat hypertrophic scars. To treat hypertrophic scars, gel sheets can prevent mechanical forces around the scar9 and keep the scar surface moist. However, to date, there is no evidence that gel sheets are effective for treating hypertrophic scars. Moreover, since the temperatures in Asian countries can be high, it can be difficult to continue using gel sheets because of sweating. Gel sheets are made not only from silicone but also polyethylene. A computer analysis showing that gel sheeting reduces the tension on the hypertrophic scar confi med that it is vital that gel sheets are soft and elastic.9

Corticosteroid Treatment Corticosteroid can be administered locally by injection, ointment, cream, or tape,10 and it can rapidly and effectively reduce inflammation in pathologic scars. However, the disadvantages of corticosteroid treatment include severe pain from the injection and systemic side effects, including menstrual dysfunction in women, the suppression of adrenal cortical function, and the development of cataracts or glaucoma. The local side effects include thinning and atrophy of the skin and subcutaneous tissues, the development of steroid acne, capillary dilation, and hypopigmentation. These complications can hamper the use of corticosteroids in combination treatments.

Chapter 4 

Scar Management for Asian Cosmetic Surgery Patients

Laser Pulsed dye laser has long been used to treat pathologic scars such as keloids and hypertrophic scars12 (see Fig. 4-9). Recently, Nd:YAG laser therapy has been suggested as a new effective laser for red scars; the target of this therapy is the capillary vessels in the scar. It has been theorized that the Nd:YAG laser has a deeper reach to the tissues than pulsed dye lasers. Fractional lasers can be used to treat mature scars. By using the various wavelengths of these lasers, this technology can be used for ablative laser resurfacing or nonablative laser skin rejuvenation. Th s fractional approach (ablative and nonablative), as well as conventional ablative laser resurfacing with an Er:YAG or CO2 laser (depending on the depth and severity of wrinkles), is believed to improve the skin, but without associated side effects or down time. Because collagen remodeling and skin tightening continue for some time after fractional treatment, the peak improvement is usually visible after about 2 to 3 months.

Radiation Surgery combined with postoperative radiation therapy has been reported as a more effective treatment for keloids than radiation monotherapy. The success rate of this combined approach varies between 67% and 98%, although few randomized control trials have been performed to test the effectiveness of this technique.10 In many institutions, radiation is initiated directly after surgery and the total dose is limited to 20 Gy over several administrations. It has been suggested that keloid treatment using high-dose-rate brachytherapy is more effective than superfic al x-ray or low-energy electron beam administration. An important concern associated with keloid radiotherapy is the risk of inducing malignant tumors. We conclude that the risk of carcinogenesis from keloid radiotherapy is considerably low when the surrounding tissues, including the thyroid and mammary glands, are adequately protected.13 Such protection is especially important in children. If adequate protection of the surrounding tissues is routinely undertaken, radiation therapy is acceptable as a keloid treatment modality.

Antitumor/Immunosuppressive Agents Previous attempts to treat keloids with 5-fluorouracil (5-FU), bleomycin, and interferons suggest that at present, monotherapy with these agents does not achieve excellent results. Combination therapy with corticosteroid and 5-FU may be useful, but this approach requires repeated injection over several years.

Cryotherapy Cryotherapy has been used to treat keloids and hypertrophic scars, either as monotherapy or in combination with other therapies. Cryotherapy delivery methods include direct contact, sprays, and intralesional needles. Cryotherapy should be limited to treatment of small regions, because it induces severe pain and hypopigmentation. The mechanism by which cryotherapy reduces keloids is interesting. It is well known that hypertrophic scars and keloids occur on burned skin areas, but not on frostbitten areas. It appears that although burning and frostbite both induce apparent tissue necrosis, they also result in the secretion of quite different proinflammatory mediators. The responses to these inflammatory signals by the fibroblasts may also differ. Further basic research should be undertaken to elucidate these mechanisms.

Makeup Therapy (Rehabilitation Makeup, Camouflage Therapy) To manage psychological stress in patients, makeup or camouflage therapy should be considered, because these therapies improve not only the cosmetic appearance of the scars but also reportedly promote physiologic changes14 (Fig. 4-14). Th s issue warrants further scientific study.

41

42

Part I 

General Principles

Fig. 4-14  Rehabilitation makeup therapy for mature scars.

Other Treatments Medical needling of mature scars may be useful. Th s entails using the needle to make small pinholes on the scar to induce skin regeneration. In addition, NSAIDs are useful for treating hypertrophic scars, although their effects are limited because they mainly reduce subjective symptoms (for example, itching and pain). The oral administration of the antiallergy drug tranilast (Rizaben) appears to reduce the symptoms of hypertrophic scars, such as itching and pain. In addition, heparinoid ointment can be used to accelerate scar maturation.

Pearls for Success • There are four primary factors that hamper proper cutaneous wound healing: (1) an inadequately moist environment, (2) strong and cyclical mechanical forces on the wound, (3) foreign body reaction and allergy, and (4) infection. • These factors should be eliminated as soon as possible after surgery. • Special attention is needed when performing surgery on regions at high-risk for heavy scarring (for example, the anterior neck and chest, the scapular region, the suprapubic region, and the joints). • To prevent the development of heavy scars, some modifi ations of suture techniques are needed, because even three-layered sutures place tension on the dermis. • Subcutaneous/fascial tension-reduction sutures should be recommended where tension is placed on the layer of deep fascia and superfic al fascia. • After surgery, wound stabilization and moisturizing and prevention of UV exposure are needed.

K23345_Pu_c04_Scar Mgmnt_r6_cl_0031-0044.indd 42

4/1/2015 1:27:36 PM

Chapter 4 

Scar Management for Asian Cosmetic Surgery Patients

43

Refer ences 1. Mustoe TA, Gurjala A. The role of the epidermis and the mechanism of action of occlusive dressings in scarring. Wound Repair Regen 19(Suppl 1):s16-s21, 2011. 2. Ogawa R. Mechanobiology of scarring. Wound Repair Regen 19(Suppl 1):s2-s9, 2011. 3. Akaishi S, Ogawa R, Hyakusoku H. Visual and pathologic analyses of keloid growth patterns. Ann Plast Surg 64:80-82, 2010. 4. Ogawa R, Akaishi S, Huang C, et al. Clinical applications of basic research that shows reducing skin tension could prevent and treat abnormal scarring: the importance of fascial/subcutaneous tensile reduction sutures and flap surgery for keloid and hypertrophic scar reconstruction. J Nihon Med Sch 78:68-76, 2011. 5. Ogawa R. Keloid and hypertrophic scarring may result from a mechanoreceptor or mechanosensitive nociceptor disorder. Med Hypotheses 71:493-500, 2008. 6. Ogawa R, Okai K, Tokumura F, et al. The relationship between skin stretching/contraction and pathologic scarring: the important role of mechanical forces in keloid generation. Wound Repair Regen 20:149-157, 2012. 7. Chigira M, Akimoto M. Use of a skin adhesive (octyl-2-cyanoacrylate) and the optimum reinforcing combination for suturing wounds. Scand J Plast Reconstr Surg Hand Surg 39:334-338, 2005. 8. O’Brien L, Pandit A. Silicon gel sheeting for preventing and treating hypertrophic and keloid scars. Cochrane Database Syst Rev (1):CD003826, 2006. 9. Akaishi S, Akimoto M, Hyakusoku H, et al. The tensile reduction effects of silicone gel sheeting. Plast Reconstr Surg 126:109e-111e,2010. 10. Ogawa R. The most current algorithms for the treatment and prevention of hypertrophic scars and keloids. Plast Reconstr Surg 125:557-568, 2010. 11. Hyakusoku H, Ogawa R. The small-wave incision for long keloids. Plast Reconstr Surg 111:964-965, 2003. 12. Allison KP, Kiernan MN, Waters RA, et al. Pulsed dye laser treatment of burn scars. Alleviation or irritation? Burns 29:207, 2003. 13. Ogawa R, Yoshitatsu S, Yoshida K, et al. Is radiation therapy for keloids acceptable? The risk of radiation-induced carcinogenesis. Plast Reconstr Surg 124:1196-1201, 2009. 14. Kazuki R. The role of rehabilitation makeup in modern medical care. Jpn J Plast Reconstr Surg 44:1029, 2001.

K23345_Pu_c04_Scar Mgmnt_r6_cl_0031-0044.indd 43

4/1/2015 1:27:36 PM

K23345_Pu_c04_Scar Mgmnt_r6_cl_0031-0044.indd 44

4/1/2015 1:27:36 PM

5 Reoperations in Cosmetic Surgery

R

Kyle Song, Lee L.Q. Pu

eoperation after aesthetic plastic surgery has an understandably negative connotation. To most patients, a reoperation inherently implies secondary surgery to address a surgical complication or technical error. Th s may be the case, yet reoperation is a global term that is more appropriately, and simply, defi ed as a secondary surgical procedure in the same site. No qualifying or justifying factors should be linked to this defin tion, because reoperation may be indicated for a variety of elements connected to primary aesthetic surgery. Many surgical complications require reoperation to ensure a better outcome; however, a planned staged procedure or further revision will obviously necessitate reoperation at the same surgical site, and this should not be classifi d as a “complication.” Furthermore, the perception of a procedure’s success is highly subjective, and despite a plastic surgeon’s appraisal of an outcome, secondary surgery may be indicated solely based on the patient’s judgment that the result is less than desirable.1-4 Inherent to aesthetic plastic surgery, where the purpose is to transform normal into supernormal, secondary surgery is often indicated for improving or refini g an already acceptable result. There are many acceptable reasons for reoperations in plastic surgery. In this chapter, we will discuss the common elements and unique challenges of reoperative plastic surgery.

Common Reasons for Reoperations Complications and necessary reoperations befall even the most experienced and senior plastic surgeons; in fact, it is likely that these very complications are directly responsible for many of these surgeons’ own experiences. A wise plastic surgeon embraces his or her fallibility, and understands that mistakes and complications lead to portals of discovery. Those who adhere to this principle will undoubtedly experience fewer complications and fewer less-than-satisfactory results as they mature in their careers. Unfortunately, information gleaned from reoperative procedures often fails to be recorded in the surgical literature, thus condemning future plastic surgeons to repeat this nonsensical process of self-enlightenment. Therefore the concept of learning from others’ mistakes is regrettably confi ed to a local spread of information through forums such as Morbidity and Mortality conferences and direct surgeon-to-surgeon conversations.

Complica tio ns

Elective plastic surgery offers a unique challenge, because it focuses on improving the patient’s self-image by changing his or her external appearance. Unlike reconstructive procedures, the presurgical deformity is often not even a deformity at all, but rather a less attractive or harmonious variation within the normal

45

46

Part I 

General Principles

range. Plastic surgeons evaluate a patient’s aesthetic appearance, and employ the construct of “physical deformity” to identify a problem that plastic surgery may augment or enhance; therefore complications after plastic surgery procedures are much more devastating than those after reconstructive surgery. All surgical procedures balance risk versus reward; thus plastic surgeons should only operate on patients who demonstrate a thorough understanding of the potential risks and have realistic expectations. Complications, both universal and operation-specific, hould always be fully disclosed to the patient before the operation, and should be properly managed based on the standard of plastic surgery practice to avoid short- or long-term sequelae. Although not all surgeries require reoperation, all surgeries precipitate some degree of physical and emotional consequence that must be skillfully managed to arrive at a mutually satisfactory outcome.

Pl anned St a ged Pr o ced ur es

Certain objectives are only, or best, attained through a planned staged approach. In these situations, the necessity of a second procedure at the same surgical site does not indicate failure or inexperience on the part of the plastic surgeon; rather, a second procedure is a data-driven and physiologically supported strategy to achieve the best possible outcome. It is well documented in the literature that revision and complication rates are signifi antly higher for augmentation-mastopexy than augmentation or mastopexy alone.5-7 The complexity of the one-stage procedure of augmentation-mastopexy is further compounded by the fact that it carries the highest litigation rate of all plastic surgery procedures. Although augmentation and mastopexy are commonly performed in a single-stage procedure, many experienced plastic surgeons caution against the difficulties of achieving a consistently predictable outcome from augmentation-mastopexy, and therefore advocate a two-stage surgery. All facial rejuvenation surgeries are designed to respect and protect blood fl w. The addition of two procedures—augmentation and mastopexy—competing for a limited volume of blood fl w, may result in a less-than-satisfactory outcome, or worse, tissue necrosis. Skin flaps created in rhytidectomy are further stressed if fat transfer or resurfacing modalities are applied to enhance the overall effect. When excessive inflammation and surgical interruption of blood supply overcome the ability of a flap to be adequately perfused, wound-healing problems are inevitable. For this reason, it is safest and most advantageous to stage these procedures based on surgical complexity and human physiology.

Less-T han-S atis f a ct or y Out c ome

Patient dissatisfaction after plastic surgery may be caused by technical error and suboptimal aesthetic results, or more commonly, poor communication and misinterpretation of the patient’s objectives. Results that are deemed as suboptimal by the plastic surgeon are likely a result of inadequate preoperative planning, technical error, or poor postoperative management. Unfortunately, in the practice of medicine, all surgeons are likely to experience growing pains, but they should view patients necessitating reoperation as learning opportunities to prevent future occurrences. More signifi antly, failure to understand a patient’s specific desires may result in reoperation, and this is largely preventable by exercising a few simple preoperative actions. Listening is not only one of the fi st skills that medical students learn, but also one of the most overlooked and ignored skills. Plastic surgeons are trained to recognize asymmetry and deformity, and to develop an operative plan that addresses these issues. However, an operative plan is rarely simple, and a plastic surgeon’s analysis may not be aligned with a patient’s desires, whether realistic or not. Consultations and

Chapter 5 

Reoperations in Cosmetic Surgery

47

preoperative visits should focus on elucidating the patient’s true motivation for surgery and his or her expectations. Nebulous expectations such as “I want to look better” or “I don’t like my breasts” should be explored with meticulous and specific questioning until the plastic surgeon has an explicit understanding of the patient’s true aesthetic goals. It is during these visits that unrealistic expectations and false beliefs are managed and dispelled. The presurgical goal of the plastic surgeon should always be to enter surgery with the exact same goal as the patient.

Fur ther Refinement

Regardless of the fi al aesthetic outcome, the learning process dictates that plastic surgeons should always be critical of their results. Perfect surgery may not exist, but it should always be the primary objective. Falling short of perfection does not involuntarily commit the patient to reoperation, but should lead to a cooperative decision based on the subjective evaluations of both the patient and surgeon. As is often said, the enemy of good is better, but by the nature of plastic surgery, better is the priority. However, the plastic surgeon must expect that any future surgery searching for a more aesthetic result will be signifi antly more challenging than the original surgery.

Special Considerations for Reoperative Surgery Reoperative procedures challenge the plastic surgeon with novel and unique variables that demand proper understanding to obtain optimal outcomes on a consistent basis. A plastic surgeon must consider the appropriate timing of the reoperation based on urgency and wound-healing physiology. Hematoma and infection are two common reasons for reoperation that often do not allow the luxury of observation, so the surgeon is forced to treat these complications in a timely fashion. However, complications such as asymmetry, wound-healing difficulties, and overvigorous scarring allow the surgeon to delay a secondary procedure until other variables are optimized and controlled.

Potenti all y Al ter ed Phy sici an–Patient Rel atio nship

There is no doubt that reoperation adds some degree of strain to the physician–patient relationship, regardless of whether the impetus to return to the operating room is patient- or surgeon-driven. Suffici t time should be spent assessing the precise reason for reoperation and counseling the patient. An unexpected complication changes a patient’s feelings toward both the plastic surgeon and the prospect of future surgery. Reestablishing trust and confide ce is a signifi ant hurdle; secondary surgery should not be undertaken hastily unless it is prompted by emergent circumstances.

Goals of Reo pera tio n

A satisfactory reoperative result is a result of diligent preoperative planning, technical precision, and, equally importantly, prudent management of patient expectations. With the exception of urgent indications for surgery, suffici t time should be allotted for patient counseling and education. The realistic goals and potential complications should clearly be explained to the patient regardless of his or her level of interest or perceived understanding. Further, plastic surgeons should temper their anticipated outcome in light of more challenging operative conditions and potentially uncontrollable variables inevitably associated with reoperative surgery. Thus effective communication with the patient regarding goals, limitations, expectations, and potential complications of the future reoperation are critical to ensure its success. Appropriate informed consent should also be completed for a patient to avoid further dissatisfaction.

K23345_Pu_c05_Reoperations_r4_st_0045-0050.indd 47

4/2/2015 1:15:12 PM

48

Part I 

General Principles

Box 5-1  Common Sequelae of Hematomas7-9 Infection Capsular contraction (breast augmentation) Poor cosmesis Skin necrosis Blindness (retrobulbar hematoma)

Timing

Acute bleeding causing hypotension or necrotizing infection warrants immediate reoperation as a lifesaving measure. A postoperative hematoma should be removed as soon as possible after surgery (in general, within 24 hours) to avoid its sequelae8 (Box 5-1). A seroma should also be drained promptly to avoid infection.10 Most plastic surgeons understand that a less-than-optimal scar is best treated after a period of maturation. It becomes more of a quandary when problems fall somewhere in the spectrum between urgent and completely elective, which is more commonly the issue. Th s decision should be a physician-guided choice based on the patient’s expectations and a precise understanding of the mechanics of wound healing and tissue inflammation. Table 5-1 summarizes the appropriate timing for reoperation to correct a cosmetic deformity in the most commonly performed plastic surgery procedures.

Scar r ing

Scarring is a complex sequence of defi ed visible and histologic stages occurring over the course of approximately 1 year. The maturation and remodeling phase, which begins as early as 3 weeks postinjury, is an intricate period of microscopic processes that generally lead to predictable macroscopic changes. A detailed understanding of scar formation and wound healing will allow the plastic surgeon to provide reassurance during periods of change and to select the optimal timing for revision. Much of the patient’s stress that is induced by the thought of reoperation stems from the possibility of an extra scar; this is a valid fear, particularly in cosmetically sensitive areas such as the face and breast. Although many secondary procedures access the surgical site through a prior incision, some secondary procedures require new incisions through virgin skin. For example, most patients undergoing an augmentation mammaplasty performed through an axillary incision will require an additional periareolar or inframammary incision, because the axillary incision is difficult to use in secondary surgery to treat capsular contracture necessitating capsulectomy. For this reason, the possibility of additional scarring should always be discussed with the patient before reoperation.

Al ter ed Anat omy

Regardless of the type of dissection employed and the plastic surgeon’s technical skill, any violation of virgin tissue planes will result in scar formation. A patient’s genetics will predispose him or her to a certain degree of scarring, and the amount of inflammation induced by the primary surgery will also be a significant factor in determining whether the scar will be a loose film or a thick rind. In either case, tissue planes may be destroyed and local structures are commonly distorted, making the patient more susceptible to further injury and complication.

Chapter 5 

Reoperations in Cosmetic Surgery

Table 5-1  Appropriate Timing for Reoperation to Correct Residual or Other Cosmetic Deformities5-7,9-16 Procedure

Length of Time After Initial Surgery

Blepharoplasty

6 weeks

Rhinoplasty

1 year

Rhytidectomy

3 months

Breast augmentation (implant exchange)

3 months

Breast augmentation (implant replacement after infection)

.3 months

Suction-assisted lipectomy

6 months

Abdominoplasty

6 months

Al ter ed Bl o od Suppl y

Most commonly practiced procedures in plastic surgery were developed based on a defi ed vascular system. When skin, muscle, or composite flaps are elevated, local and regional blood supplies are altered, so these blood supplies must be respected when planning a reoperation. Although the prior elevation of a flap functions as a vascular delay and thus will result in more robust circulation at the flap edges, the incision selected at the primary operation may still preclude the use of alternative approaches. This is of paramount importance when planning reoperative breast surgery. Without a detailed understanding of the approach and pedicle used during the initial operation, a well-intended but poorly planned reoperation may result in catastrophic full-thickness nipple-areolar necrosis.

Al ter ed Tiss ue Chara cter is tics

Previous surgery inevitably creates scarring, which alters the quality of normal tissue; as a result, previously operated tissues respond less predictably than normal tissues. Th s is a signifi ant concern in the rhinoplasty patient whose revision includes a secondary dissection of the tip cartilage, because the normal delicate supporting structures around the tip cartilage are lost and the cartilage itself is softened. The same changes also occur in skin, fat, muscle, and bone. For example, when the skin has been previously undermined, it loses some of its pliability and elasticity, reducing its movement. In addition, the tissue has usually been denervated after previous surgical dissection, which clearly has a destructive effect on the tissue components.

Financi al Consid era tio ns

The fi ancial responsibility for an unanticipated reoperation is yet another barrier to physician–patient understanding and communication. Many patients are fi ancially stretched to afford the primary operation; unplanned reoperation charges to achieve the desired or satisfactory outcome can add signifi ant stress and anxiety. For this reason, most plastic surgeons have defi ed policies regarding revision surgery, for both urgent and elective indications. Although there is no single correct solution or course of action, the plastic surgeon should provide a full disclosure before the initial operation regarding a patient’s fi ancial responsibility for any potential reoperations.

49

50

Part I 

General Principles

Pearls for Success • Reoperative plastic surgery has many physical and emotional facets that collectively alter the physician–patient relationship. • Plastic surgeons need to understand all potential complications associated with cosmetic procedures and their appropriate management. • Plastic surgeons should be fully aware of the limitations of plastic surgery for each patient. • Surgeons should ask for appropriate advice and help when reoperative plastic surgery becomes more complicated.

Refer ences 1. Grotting JC. What is reoperative plastic surgery? In Grotting JC, ed. Reoperative Aesthetic & Reconstructive Plastic Surgery, ed 2. St Louis: Quality Medical Publishing, 2006. 2. Goldwyn RM. The surgeon. In Grotting JC, ed. Reoperative Aesthetic & Reconstructive Plastic Surgery, ed 2. St Louis: Quality Medical Publishing, 2006. 3. Grotting JC. The patient. In Grotting JC, ed. Reoperative Aesthetic & Reconstructive Plastic Surgery, ed 2. St Louis: Quality Medical Publishing, 2006. 4. Sarwer DB, Baker AW, Infi ld AL. Psychological considerations in reoperative plastic surgery patients. In Grotting JC, ed. Reoperative Aesthetic & Reconstructive Plastic Surgery, ed 2. St Louis: Quality Medical Publishing, 2006. 5. Hammond DC, Hidalgo D, Slavin S, et al. Revising the unsatisfactory breast augmentation. Plast Reconstr Surg 104:277-283, 1999. 6. Spear SL, Evans KK. Complications and secondary corrections after breast reduction and mastopexy. In Spear SL, Willey SC, Robb GL, et al, eds. Surgery of the Breast: Principles and Art, ed 3. Philadelphia: Wolters Kluwer/ Lippincott Williams & Wilkins, 2010. 7. Handel N. Managing complications of augmentation mammaplasty. In Spear SL, Willey SC, Robb GL, et al, eds. Surgery of the Breast: Principles and Art, ed 3. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins, 2010. 8. Mulliken JB, Healey NA. Pathogenesis of skin flap necrosis from an underlying hematoma. Plast Reconstr Surg 63:540-545, 1979. 9. Mejia JD, Egro FM, Nahai F. Visual loss after blepharoplasty: incidence, management, and preventive measures. Aesthet Surg J 31:21-29, 2011. 10. Capella JF. Special problems in reoperative body contouring. In Nahai F, ed. The Art of Aesthetic Surgery: Principles & Techniques, ed 2. St Louis: Quality Medical Publishing, 2011. 11. Lelli GJ Jr, Lisman RD. Blepharoplasty complications. Plast Reconstr Surg 125:1007-1017, 2010. 12. Cochran CS, Landecker A. Prevention and management of rhinoplasty complications. Plast Reconstr Surg 122:60e-67e, 2008. 13. Spear SL, Howard MA, Boehmler JH, et al. The infected or exposed breast implant: management and treatment strategies. Plast Reconstr Surg 113:1634-1644, 2004. 14. Iverson RE, Pao VS. MOC-PS(SM) CME article: liposuction. Plast Reconstr Surg 121(4 Suppl):1-11,2008. 15. Stewart KJ, Stewart DA, Coghlan B, et al. Complications of 278 consecutive abdominoplasties. J Plast Reconstr Aesthet Surg 59:1152-1155, 2006. 16. Baker TJ, Gordon HL. Complications of rhytidectomy. Plast Reconstr Surg 40:31-39, 1967.

K23345_Pu_c05_Reoperations_r4_st_0045-0050.indd 50

4/2/2015 1:15:12 PM

Part II

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

K23345_Pu_c06p_Skin Hyperpig_r6_cl_0051-0070.indd 51

4/2/2015 1:18:30 PM

K23345_Pu_c06p_Skin Hyperpig_r6_cl_0051-0070.indd 52

4/2/2015 1:18:30 PM

6 Skin Hyperpigmentation in Asians: Classification, Diagnosis, and Treatment

S

Takanobu Mashiko, Kotaro Yoshimura

ymptoms of photoaging, such as wrinkling and hyperpigmentation, vary signifi antly among races. Skin hyperpigmentation generally results from the excessive deposition of melanosomes, which are the melanin-containing organelles in the epidermis and/or dermis. In Asians, melanosomes are larger and more likely to produce eumelanin, a substance generated in the absence of cysteine, which physically protects the skin from ultraviolet rays, thus reducing photoaging. Skin inflammation also activates melanocytes and induces skin hyperpigmentation in Asians. Therefore the most frequent dermatologic complaints from Asian patients are hyperpigmented skin lesions. In whites, by contrast, melanosomes are much smaller than those in Asians and are more likely to produce reddish-yellow pheomelanin than brownish-black eumelanin.1 Pheomelanin, which is produced by the addition of cysteine to dopaquinone, allows ultraviolet rays to reach the dermis and generates reactive oxygen species in response to these UV rays. Thus photoaged skin in whites is frequently characterized by malignant changes and dermal damage, including wrinkles, solar elastosis, and telangiectasia. An appropriate therapeutic strategy based on the correct diagnosis is essential for treating hyperpigmentation. Although the correct treatment strategy cannot be determined without the correct diagnosis, plastic surgeons are generally unfamiliar with differential diagnosis of hyperpigmented skin lesions. In addition, the best treatment may vary among patients with the same diagnosis, depending on the lifestyle of each patient. Therefore, to accurately optimize a personalized therapeutic strategy for each patient, we need suffici t information about treatment options, the differential diagnosis of hyperpigmented lesions, and the physiological nature of each hyperpigmentation.

Pathophysiology of Hyperpigmented Lesions Mech anis m of Skin Hyper pigment atio n

Epidermal pigmentation is determined by the degree of melanin deposits, which are governed by the balance between the production and discharge of melanin in the epidermis. Epidermal melanin is produced by epidermal melanocytes in the basal epidermal layer, which are transferred to keratinocytes and then

53

54

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

Discharge h Retinoids i  Aging corticosteroids

Production h  Genetic factors:   Inflammation   UV radiation i Hydroquinone

Melanin Melanocytes

Fig. 6-1  Melanin metabolism in the epidermis. Melanin deposits in the epidermis are controlled by the balance between melanogenesis by epidermal melanocytes and melanin discharge by epidermal turnover.

discharged through epidermal keratinocyte turnover. Epidermal melanosis (hyperpigmentation), which represents a local increase of epidermal melanin, can be induced by an increase in melanin production (through UV irradiation, inflammation, genetic disease, and so on), and/or a decrease in melanin discharge induced by a decrease of epidermal turnover. Many factors affect melanin metabolism (Fig. 6-1). For example, aging decelerates epidermal turnover and melanin discharge, making the skin appear more yellowish. Ultraviolet radiation and inflammation promote melanin production, yielding a more bronzed skin tone. Tretinoin (all-trans retinoic acid [RA]) accelerates epidermal turnover and melanin discharge, whereas hydroquinone (HQ) suppresses melanin production in melanocytes. Dermal hyperpigmentation results from either of two mechanisms: dermal melanosis (melanin incontinence) or dermal melanocytosis. Repeated epidermal inflammation damages the basement membrane and results in melanin incontinence into the dermis. Macrophages phagocytize the melanosomes and are deposited as melanophages in the upper epidermis. The dermal melanophages are not discharged by epidermal turnover and remain as dermal melanosis. Melanocytosis refers to ectopic localization and/or an increase of melanocytes. Dermal melanocytosis is observed in genetic conditions such as nevus of Ota and acquired dermal melanocytosis (ADM).

Hyper pigment atio n in Asians

Asians have not only darker skin with eumelanin, but also a much higher risk of persistent erythema and hyperpigmentation after any skin inflammation (postinflammatory hyperpigmentation [PIH]) than whites (Table 6-1). Thus even subtle inflammation associated with daily life, such as eczema or rubbing the face, easily increases eumelanin production in epidermal melanocytes and consequently results in PIH. In addition, therapeutic procedures that lead to inflammation, such as chemical peeling or laser irradiation, can induce PIH in Asians. Notably, hyperpigmentation in Asians is induced or worsened by daily inflammation, such as allergic reactions, UV irradiation exposure, and friction.

Chapter 6 

Skin Hyperpigmentation in Asians: Classifi ation, Diagnosis, and Treatment

Table 6-1  Comparison of Skin Pigmentation in Asians and Whites Asians

Whites

Many

Few

Few

Many

Class II to V

Class I to II

PIH

Common (frequently)

Rare

Common symptoms by photoaging

Hyperpigmentation

Wrinkles, telangiectasia, and malignancy

Common hyperpigmentation

Melasma, ADM, solar lentigines, and PIH3

Ephelides, warts

Actinic keratosis4,5

Fewer

Greater

Eumelanin Pheomelanin Fitzpatrick skin types

2

A numerical classifi ation for the response of different types of skin to UV light. ADM, Acquired dermal melanocytosis; PIH, postinflammatory hyperpigmentation.

Table 6-2  Pigment Depth Determination Parameters Epidermal Pigment

Dermal Pigment

Combination Pigment

Color

Light brown (occasionally yellowish or reddish)

Gray or black (occasionally bluish)

Dark brown or grayish brown

Margin

Clear

Unclear

Clear

Category and Diagnosis of Skin Hyperpigmentation How t o Dia gnos e Accurate diagnosis of a hyperpigmented lesion requires careful macroscopic inspection for five features: color, margin, surface condition, shape, and distribution (localization). After clinical inspection, the surgeon can determine the depth of pigment and the diagnosis without histologic examination (Table 6-2). Epidermal pigment appears light brown (occasionally yellowish or reddish) with a clear margin (demarcation), whereas dermal pigment appears gray or black (occasionally bluish) with an unclear margin. Hyperpigmentation with both epidermal and dermal pigments is a mixture of light brown and gray or black; thus it appears dark brown or grayish brown with a clear margin. Hyperkeratosis in solar lentigines or seborrheic keratosis can be detected by carefully inspecting the surface condition. Some hyperpigmented lesions, such as ephelides and melasma, have a characteristic form, margin, location, and distribution. Melasma and symmetrical facial PIH are frequently confused and can be discriminated by the margin; melasma has a clear demarcation of part of its margin but not the entire margin, whereas PIH always shows an unclearly demarcated margin.

Ma jo r Hyper pigmented Les io ns

Based on histologic features, we classify hyperpigmented lesions into seven categories (Table 6-3).6 Category I lesions have excessive hyperkeratosis. Categories II and III have epidermal pigmentation, and the

55

56

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

epidermal melanogenesis is only temporarily upregulated in category II but permanently upregulated in category III. Categories IV, V, and VI all have both epidermal and dermal hyperpigmentation. Categories IV and V have dermal melanosis (pigmentary incontinence) with (V) or without (IV) activated epidermal melanocytes, whereas category VI has ectopic dermal melanocytosis. Category VII has dermal melanocytosis alone. The major hyperpigmented lesions are described in Table 6-3.

Table 6-3  Seven-Category Classifi ation for Hyperpigmented Lesions Category

Pathologic Features

Morbidities

Comments

I

Melanosis with hyperkeratosis

Seborrheic keratosis Lichen pilaris*

Hyperkeratosis is marked, and the lesion is clinically protruded.

II

Reactive epidermal melanosis

Postinflammatory hyperpigmentation Sunburn

Epidermal melanocytes were temporarily activated by external factors.

III

Epidermal melanosis

Solar lentigines* Pigmented nipple-areola complex Ephelides Nevus spilus Lichen pilaris* Lentigo simplex Melasma/chloasma*

Genetic alterations in epidermal melanocytes lead to enhanced melanin production. Histologic fi dings are similar to those of Category II lesions.

IV

Reactive epidermal melanosis and dermal melanosis

Pigmented external genitalia Friction melanosis Rippled hyperpigmentation after atopic dermatitis Pigmented contact dermatitis

Repeated inflammation activates epidermal melanocytes and damages the basement membrane, resulting in pigmentary incontinence; thus the lesions present epidermal hyperpigmentation and melanophages in the upper dermis.

V

Epidermal melanosis and dermal melanosis

Solar lentigines* Melasma* (dermal melasma) Erythromelanosis follicularis faciei et colli Pigmentation petaloides actinica

Genetic alterations in epidermal melanocytes lead to enhanced melanin production, and melanin deposits are observed in the epidermis and upper dermis (pigmentary incontinence). The histological fi dings are similar to those of Category IV lesions.

VI

Epidermal melanosis and ectopic dermal melanocytosis

Acquired dermal melanocytosis Periorbital hyperpigmentation

Enhanced melanin production by epidermal melanocytes. Dermal melanocytosis is observed in the upper dermis.

VII

Dermal melanocytosis

Nevus of Ota Blue nevus Mongolian spots

Dermal melanocytes are scattered throughout the dermis.

From Kurita M, Kato H, Yoshimura K. A therapeutic strategy based on histological assessment of hyperpigmented skin lesions in Asians. J Plast Reconstr Aesth Surg 62:955-963, 2009. *Morbidities classifi d into two categories.

Chapter 6 

Skin Hyperpigmentation in Asians: Classifi ation, Diagnosis, and Treatment

Solar Lentigines (Category III or V) and Seborrheic Keratosis (Category I) Solar lentigines (Fig. 6-2, A) are the most common epidermal melanosis on areas of skin normally exposed to UV rays, such as the face and dorsum of the hand and forearm. Seborrheic keratosis (Fig. 6-2, B) is a protruded lesion with excessive hyperkeratosis and can develop from solar lentigines. These lesions are light to dark brown and have a clear margin. The underlying dermis is frequently damaged and thinner than normal. Because of their hyperkeratotic surface, topical treatments such as topical HQ and chemical peeling are not very effective.

Postinflammatory Hyperpigmentation From Single (Category II) or Repeated (Category IV) Inflammatory Events

PIH is induced by the temporary upregulation of epidermal melanogenesis that occurs after inflammatory responses. We divide PIH into two types: PIH from a single inflammatory event (PIH-S) (Fig. 6-3) and PIH from repeated multiple inflammatory events (PIH-M) (Fig. 6-4). An inflammatory response results in the release of inflammatory mediators, which activate epidermal melanocytes. PIH-S usually disappears over time through epidermal turnover, which occurs more quickly on the face than on the limbs or trunk. Some PIH-S after ablative injury persists for a long time, because the injury most likely reduced the number of epidermal stem cells, and melanin discharge has been permanently affected. On the other hand, with PIH-M, the basement membrane of the epidermis has been damaged by repeated inflammation, resulting in lower epidermal melanin and deposit of melanophages into the upper dermis (also called pigmentary incontinence). Thus PIH-M not only has epidermal hyperpigmentation but also melanosis in the upper dermis. PIH-M includes pigmented contact dermatitis (Riehl’s melanosis) (Fig. 6-4, A), rippled hyperpigmentation in atopic dermatitis (Fig. 6-4, B), and friction melanosis (Fig. 6-4, C).

A

B

Fig. 6-2  Hyperpigmented lesions with hyperkeratosis.

A, Solar lentigines (senile lentigines). B, Seborrheic keratosis (verruca vulgaris).

Fig. 6-3  Epidermal hyperpigmentation. PIH-S induced by a single inflammatory event (abrasive wound).

57

58

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

A

B

C

Fig. 6-4  Hyperpigmentation with both epidermal and dermal melanosis (pigmentary incontinence). A, Pigmented con-

tact dermatitis (Riehl’s melanosis). B, Dirty neck (rippled hyperpigmentation after atopic dermatitis). C, Friction melanosis.

Ephelides, Nevus Spilus, and Lentigo Simplex (All Category III) Ephelides (Fig. 6-5, A) is a genetic lesion that is characterized by epidermal melanocytes with enhanced melanin production. These lesions are more common in whites than Asians. Small round spots, which are flat and brown or red, usually emerge in the teenage years, are distributed symmetrically on the nose and cheek, and fade or enlarge at later stages. Nevus spilus (Fig. 6-5, B) and lentigo simplex are clinically different from ephelides, but they are almost identical to ephelides histologically. A nevus spilus (also known as a café-au-lait macule) is a congenital benign solitary lesion that may appear on any part of the body. The most common form of lentigo is lentigo simplex, which involves the presence of a single or multiple round lesions that are present at birth or occur at any age. These three epidermal hyperpigmented lesions—nevus spilus, lentigo simplex, and ephiledes— are light brown, have a clear margin, and exhibit a high rate of recurrence after treatment. Although these lesions can be removed or improved by both retinoic acid and hydroquinone (RA-HQ) therapy and Qswitched laser therapy, they frequently recur within several months or years.

Melasma/Chloasma (Category III, but rarely Category V) Acquired symmetrical epidermal melanosis is known as melasma (Fig. 6-6, A), which may be related to the alteration of the female sex hormone profiles. The symptoms of melasma are generally found on the malar prominence and upper cheek and are less frequently found on the forehead and upper lip. Melasma has a clear margin on at least one side, although the other side frequently has an unclear margin such as a gradient. As previously mentioned, symmetrical PIH (called false melasma or pseudomelasma) (Fig. 6-6, B) has a similar appearance and is frequently misdiagnosed as melasma. A critical difference between melasma and symmetrical PIH is that symmetrical PIH always has an unclear margin. Daily friction on the face can induce symmetrical PIH; the friction results from a physical stimulus such as removing makeup, scrubbing the face, and facial massage.

Acquired Dermal Melanocytosis (Category VI) Acquired dermal melanocytosis (ADM) (Fig. 6-7) generally presents as multiple round grayish-brown or grayish-blue macules with an unclear margin. These lesions occur symmetrically on the malar prominence, nasal ala, and/or temple. Other phenotypes include a solitary macule on the eyelids or cheek, symmetrical

Chapter 6 

Skin Hyperpigmentation in Asians: Classifi ation, Diagnosis, and Treatment

A

B

Fig. 6-5  Epidermal hyperpigmentation. A, Ephelides. B, Nevus spilus.

A

B

Fig. 6-6  Melasma and pseudomelasma. A, Melasma with a partially clear margin. The eyelids are not hyperpigmented in melasma. B, PIH induced by daily friction of the face. PIH usually has an unclear margin.

Fig. 6-7  Hyperpigmentation with dermal melanocytosis.

ADM usually presents with multiple small grayish-brown macules with an unclear margin.

Fig. 6-8  Nevus of Ota is bluish-gray and can be easily treated by multiple sessions of Q-switched laser alone.

macules on the nasal root, and symmetrical periorbital hyperpigmentation. ADM onset usually occurs in the individual’s twenties, and ADM is frequently seen in Asian women. Histologic examination reveals active melanocytes in the upper dermis as well as upregulated epidermal melanogenesis.

Nevus of Ota, Blue Nevus, and Mongolian Spots (Category VII) These lesions are indicative of congenital deep dermal melanocytosis, in which active melanocytes are distributed throughout the entire dermis. Nevus of Ota (Fig. 6-8) presents as a blue or gray patch on the face within the area of the ophthalmic and maxillary branches of the trigeminal nerve. These lesions may also involve ocular and oral mucosa.

59

60

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

Treatment Methods Topical Retino ic Acid−H yd r o quino ne Therap y Retinoids and Hydroquinone for Skin Bleaching

Retinoids, which are natural or synthetic derivatives of vitamin A, act through specific uclear receptor pathways. A natural isoform of RAs and the most biologically active retinoid is all-trans RA, also known as tretinoin. The serum levels of retinol (vitamin A) and RA are millimolar and nanomolar, respectively. Topical RA easily induces skin-reactive dermatitis without an allergy to this retinoid. RA was fi st introduced more than 30 years ago as a prescription for acne vulgaris,7 and since then its antiaging properties have been recognized. RA promotes the discharge of melanin granules in the epidermis by accelerating epidermal turnover in a direct manner and indirectly promoting epidermal growth (Fig. 6-9). The indirect effect of promoting epidermal growth was found to be mediated by heparin-binding epidermal growth factor, which is secreted by suprabasal keratinocytes. Thus RA has a specific effect as a discharger of epidermal melanin, and this function cannot be performed by other exfoliating procedures such as alpha-hydroxy acid peeling or microdermabrasion. Patients who receive RA treatment gradually develop tolerance to RA, probably because cytoplasmic retinoid acid−binding protein type 2 is increased. Thus we use topical RA for a maximum of 2 months, and then, if needed, treatment is restarted after more than 1 month and preferably more than 2 months. HQ reduces melanin production by tyrosinase inactivation and melanocyte cytotoxicity. Although this compound is the most reliable and effective inhibitor of epidermal melanogenesis and is not dangerous if used at the proper dosage, HQ always causes primary irritant—usually not allergic—dermatitis when applied at high doses. In the 1970s, Kligman and Willis8 fi st proposed a topical depigmenting formula that combined RA, HQ, and a corticosteroid. Since then, a widely accepted treatment for whites involves the application of RA on the whole face and HQ on the pigmented area or the use of a triple-mixed cream containing RA, HQ, and corticosteroids. Improvement of hyperpigmentation is variable in Asian patients; however, RA and HQ induce irritating dermatitis and consequently PIH. Therefore we propose a new bleaching protocol for Asians that involved the aggressive use of RA only on the pigmented area and HQ on the entire face without the use of corticosteroids; this strategy has proved very effective for the removal of any kind of epidermal hyperpigmentation.9 We did not include the use of corticosteroids, because these mitigate irritating dermatitis but decelerate epidermal turnover, leading to a higher risk of PIH. A

B

Fig. 6-9  Histologic change by aggressive RA-HQ therapy. A, Before treatment. B, Hyperplasia and depigmentation of the epidermis is apparent 2 weeks after treatment.

Chapter 6 

Skin Hyperpigmentation in Asians: Classifi ation, Diagnosis, and Treatment

RA-HQ Bleaching Protocol Our bleaching protocol consists of two phases: bleaching and healing (Fig. 6-10). In the bleaching phase, epidermal melanin discharge is aggressively accelerated by application of topical RA, and melanin production is suppressed by topical HQ. In the absence of HQ, bleaching would ultimately fail, because inflammation after RA increases melanin production and off ets its depigmentation effects. The bleaching phase lasts until hyperpigmentation is suffici tly improved or up to 8 weeks. Beyond 8 weeks, tolerance to RA is established, and further application would not continue to be helpful. In the healing phase, topical RA is discontinued, and only HQ is applied with great care not to induce new PIH. Th s phase lasts until the erythema disappears, which usually occurs at approximately 4 weeks. Thus one session of the RA-HQ therapy requires a total of 6 to 12 weeks (Table 6-4). Tretinoin (RA) Hydroquinone (HQ) (Bleaching phase) Start

(Healing phase)

Disappearance of pigmentation (2-8 weeks)

1-2 months

1st session

Disappearance of erythema (6-12 weeks)

1-2 months

2nd session

3rd session

Fig. 6-10  Protocol for aggressive RA-HQ therapy. RA and HQ are used in the bleaching phase. RA is aggressively used

only on the hyperpigmented spots, whereas HQ is applied all over the face. After hyperpigmentation is substantially improved (usually 2 to 6 weeks), RA is discontinued and HQ is applied alone (healing phase). If necessary, another round of treatment is conducted after an interval of more than 4 weeks.

Table 6-4  Retinoic Acid−Hydroquinone Bleaching Protocol Medicinal Effect

Applied Area

Application Period

Tretinoin (RA)

Accelerates epidermal turnover and melanin discharge in the epidermis when applied aggressively

Hyperpigmented areas only

Bleaching phase only, 2 to 8 weeks

HQ

Reduces production of melanin in the epidermis and dermis

Wide area including the surrounding skin, such as the entire face

Bleaching and healing phases, 6 to 12 weeks in total HQ is also used after RA-HQ treatment as maintenance

HQ, Hydroquinone; RA, retinoic acid. In the bleaching phase, 0.1% to 0.4% RA and HQ are applied twice daily. Typically, patients should be carefully monitored at 1, 2, 4, 6, and 8 weeks, and the appropriate instructions for the use of RA and HQ are provided at each visit. In the healing phase, only HQ is applied twice daily for 4 weeks.

61

62

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

In the bleaching phase, the aggressive use of RA is performed by applying 0.1% to 0.4% RA aqueous gel (original preparation) twice daily or commercially available 0.1% Retin-A gel several times a day. With aggressive treatment, RA must be carefully applied only on hyperpigmented areas with a tiny cotton applicator to avoid unnecessary erythema and subsequent PIH on the surrounding intact skin. Concurrently, HQ should be widely applied on the entire face to avoid possible PIH. During this aggressive treatment period, transient adverse skin effects—such as erythema, scaling, and irritation—may be observed. The so-called retinoid dermatitis generally reflects therapeutic performance; thus it is a clinical indicator of a working dose. If the dermatitis is too severe or not intense enough, the dose and frequency of the topical RA can be adjusted. Areas that are sensitive to topical RA include the lips and eyelids, although the trunk and limbs are not sensitive to this treatment. UV irradiation should be minimal throughout RA-HQ therapy. Patients should be carefully monitored, and the acceleration of epidermal turnover should be confi med during the fi st 2 weeks of treatment. Otherwise, maximal bleaching performance is not frequently attained. Having no skin reaction during the initial period only leads to the patient’s achieving tolerance to RA; further acceleration of epidermal turnover cannot be expected even after elevating the daily dose. Physicians usually see these patients at 1, 2, 4, 6, and 8 weeks of treatment, and the appropriate instructions for the use of RA and HQ are provided at each visit, depending on the current skin conditions. If the clinical result is insuffici t and another course of treatment is recommended, the treatment can be performed after 2 months to enable the loss of RA tolerance.

Q-Swit ched La ser Therap y

Physical Theory of Pigment Removal Laser therapy for melanin pigment is based on selective photothermolysis, in which an optimal effect on the targeted tissue and a minimal adverse effect on the surrounding tissue are achieved by selecting a specific wavelength, pulse duration, and fluence of laser irradiation. Melanin is generally targeted with a wavelength between 500 and 1100 nm (Fig. 6-11). Q-switched lasers (ruby, alexandrite, or neodymium-doped yttrium aluminum garnet [Nd:YAG]) use minimal pulse duration (nanoseconds) to minimize thermal

Hemoglobin Melanin Nd:YAG

Water

Absorption

Alexandrite Ruby

300

400

500

600

700

800

900 1000 1500 2000 3000

5000

7500 10000

Wavelength (nm)

Fig. 6-11  Relationship between laser wavelength and absorption by each targeting chromophore. To target melanin, wavelengths of 500 to 1100 nm are used. These include ruby, alexandrite, and Nd:YAG lasers. The Q-switch system with a pulse length of nanometers is used to avoid any thermal damage to the surrounding tissue.

Chapter 6 

Skin Hyperpigmentation in Asians: Classifi ation, Diagnosis, and Treatment

63

damage to the tissue. Fluence is measured in Joules per square centimeter (J/cm2); a low fluence is suffici t for epidermal pigmentation, whereas a higher fluence is needed for dermal pigment. Therefore a ­Q-switched Nd:YAG laser is suffici t for solar lentigines (senile lentigines) with hyperkeratosis, but a ­Q-switched ruby (QSR) laser is preferable for ADM, although the QSR laser more frequently induces PIH. If the irradiation is strong and repeated with a short interval, such as 2 weeks, hypopigmentation will result.

Treatment Protocol A lidocaine patch or cream is used 1 to 2 hours before irradiation for surface anesthesia. For dermal melanocytosis on the palpebral (eyelid) area, local lidocaine injection is recommended. We routinely use a QSR laser (694.5 nm) with a spot size of 5 mm, pulse duration of 20 ns, and 2 Hz repeat rate. QSR and alexandrite (755 nm) lasers show high absorbance by melanin and can be applied to both epidermal and dermal pigments, whereas the Nd:YAG laser (1064 nm) is not very effective for dermal hyperpigmentation. When laser therapy is applied to epidermal pigment, an immediate whitening phenomenon that reflects the vacuolization of superfic al pigment is a good indication of epidermal destruction at the level of the basement membrane, and this effect is typically followed by complete replacement with new epidermis within 1 week. On the other hand, an immediate whitening phenomenon is not observed when dermal pigments are irradiated; however, the pigment will be gradually removed during the next 2 months. Topical antibiotic ointment is applied twice a day until the eschar comes off, although an eschar may not develop if the pigment is localized only in the dermis. HQ application is started 1 week after the laser irradiation to reduce the PIH, which usually emerges 3 to 4 weeks after laser treatment.

Abl ative La ser Therap y (CO2 Ga s La ser, Er biu m-Doped Yt tr ium Al uminum Gar net [Er:YAG] La ser)

An ablative laser with a long wavelength (targeting water) is necessary to treat projected hyperpigmented lesions, such as seborrheic keratosis (verruca senilis) and lichen pilaris. We prefer the CO2 laser with a scanner (skin drilling mode). The CO2 laser produces a small beam (0.1 to 0.2 mm diameter) of infrared light with a wavelength of 10,600 nm, and the scanner system provides a controlled homogenous laser distribution to a precise area, such as a circular area of 0.6 to 1.2 mm diameter. Water, which composes most biologic tissues, absorbs this wavelength very well; thus this laser can be used for any type of nonselective incision, ablation, coagulation, or transpiration. A CO2 laser is also very useful for treating small skin tumors, such as nevocellular nevus, xanthoma, and syringoma, with minimal burn to the surrounding intact tissue. Application of a surface anesthetic is recommended to reduce pain during treatment. Careful ablation to the accurate depth, which depends on the target lesion, is important to avoid unnecessary injury, which could lead to persistent erythema and PIH in Asians. The only special care needed is to cover the ablated area with a covering ointment; the wound generally heals within 1 week.

Oral Med ica tio ns

Tranexamic acid suppresses the production of prostaglandin through its antiplasmin activity. Its daily use (750 mg) for several months is known to have a benefic al effect in reducing melasma, although the underlying mechanisms of the depigmenting effect remain unclear. Vitamins C and E are antioxidants that scavenge free radicals and reactive oxygen species and may protect the skin from inflammation and melanosis; these oral medications show subtle clinical effects but can be benefic al when combined with other therapies.

K23345_Pu_c06p_Skin Hyperpig_r6_cl_0051-0070.indd 63

4/2/2015 1:18:36 PM

64

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

Therapeutic Strategy Based on the categorization (Category I to VII) of the pigmented skin lesions (see Table 6-4), we recommend a combined therapeutic strategy (Table 6-5) using RA-HQ therapy, QSR laser therapy, and CO2 laser therapy to cover the entire range of skin hyperpigmentation6 (Fig. 6-12). Epidermal melanogenesis can be treated by RA-HQ therapy if no hyperkeratosis is present. Excessive hyperkeratosis of seborrheic keratosis can be treated only by CO2 laser, whereas hyperkeratosis of solar lentigines can be removed by Q-switched lasers. Dermal pigmentation, either melanosis or melanocytosis, can be treated only by Q-switched lasers, although two or three sessions of such treatment at an interval of 2 months may be needed. If any epidermal hyperpigmentation coexists with dermal pigmentation, removal of epidermal pigmentation by RA-HQ therapy before laser treatment is recommended to maximize the effects on the removal of dermal pigmentation and to minimize the risk of PIH after laser treatment. Category I lesions can be effectively treated with CO2 laser ablation. RA-HQ therapy does not work well for Category I lesions and some of the solar lentigines with hyperkeratosis, because the thickened horny layer prevents percutaneous absorption of topical ointment. Categories II and III hyperpigmentation can be treated with topical RA-HQ therapy, except for solar lentigines with hyperkeratosis, which is preferably treated by QSR laser followed by RA-HQ therapy for possible PIH. After Q-switched laser irradiation for solar lentigines, a thin crust comes off the face or extremities after 1 or 2 weeks, respectively; therefore it is recommended to begin HQ therapy 1 to 2 weeks after the Q-switched laser therapy to prevent possible PIH. The RA-HQ treatment must usually be performed two or three times to eliminate melasma.10 Supplemental use of oral tranexamic acid (750 mg per day) facilitates elimination. Melasma patients frequently experience PIH by induction of occasional or daily subtle inflammation; thus appropriate education regarding daily skin care and choice of cosmetics is critical for successful treatment and posttherapy maintenance. PIH-S does not recur after RA-HQ treatment; however, ephelides, nevus spilus, and lentigo simplex tend to reappear after either RA-HQ or Q-switched laser treatment. Topical HQ application for posttherapy maintenance may delay this recurrence.

Table 6-5  Therapeutic Options for Hyperpigmentation Method

Target Depth

Instructions

RA-HQ

Epidermis

RA-HQ is effective if no hyperkeratosis is present. The face is most sensitive to this treatment, whereas the trunk and limbs are relatively insensitive.

Q-switched laser

Epidermis and dermis

An interval of 2 months is generally recommended for repeated sessions to avoid depigmentation or melanin incontinence. If any epidermal hyperpigmentation coexists with dermal pigmentation, RA-HQ therapy as a prelaser treatment is recommended to maximize the effects on the removal of dermal pigmentation by Q-switched laser and to minimize postlaser PIH.

CO2 laser

Epidermis and dermis

CO2 laser is quite useful when excessive hyperkeratosis is present. As for tiny pigmentation (,5 mm), dermal lesions such as nevocellular nevus is also a good indication.

PIH, Postinflammatory hyperpigmentation; RA-HQ, retinoic acid–hydroquinone.

Chapter 6 

65

Skin Hyperpigmentation in Asians: Classifi ation, Diagnosis, and Treatment

Category I

CO2 laser

II

RA-HQ

III SL

ML

Other

QSR

RA-HQ

RA-HQ

RA-HQ

RA-HQ

IV

V

VI

VII

RA-HQ

RA-HQ

RA-HQ

QSR

QSR

QSR

QSR

RA-HQ

RA-HQ

RA-HQ

QSR

QSR

RA-HQ

RA-HQ

QSR

Fig. 6-12  Our therapeutic strategy for pigmented lesions is summarized. We proposed the treatment protocol for each

category (I to VII). Category III lesions are divided into three subclasses: SL, ML, and others. SL frequently has a thicker horny layer; therefore this hyperpigmentation is initially treated with a QSR laser followed by RA-HQ therapy for postlaser PIH. ML sometimes requires two or three courses of RA-HQ therapy. Lesions in Categories IV to VI require combination protocols using a QSR laser and RA-HQ therapy, whereas Category VII can be treated with a QSR laser alone. (ML, Melasma; QSR, Q-switched ruby; RA-HQ, retinoic acid–hydroquinone; SL, solar lentigenes.)

Category IV hyperpigmentation, such as PIH-M, involves both epidermal and dermal melanosis with a damaged basement membrane; thus it should be treated with a combination of RA-HQ therapy and Qswitched laser therapy.6 Signifi ant improvement can usually be achieved after one or two treatment sessions. Solar lentigines in category V, however, require a strong irradiation by the Q-switched laser followed by RA-HQ therapy to remove the remaining pigmentation and PIH. Dermal melasma in category V can be treated the same as that in category IV. In categories IV to VI, the sole use of Q-switched laser therapy results in a high frequency of PIH or depigmentation, because the overlying epidermal melanosis serves as competing chromophores and obstructs the laser irradiation to the dermal pigmentation. In addition, considerable inflammation in the epidermis induces severe PIH, especially in patients with darker colored skin. Repeated Q-switched laser irradiation within a short interval may lead to depigmentation. RA-HQ therapy before Q-switched laser therapy is quite helpful to overcome both of these issues. RA-HQ can also be used after Q-switched laser treatment to remove postlaser PIH. For category VI lesions (dermal melanocytosis), the use of the combination of RA-HQ therapy and Qswitched laser therapy usually needs to be repeated two to four times10 (see Fig. 6-12), although one Qswitched laser session may be enough to treat the lesions in categories IV and V (dermal melanosis).6 Th overall treatment plan for category VI hyperpigmentation requires several months to complete, but recurrence of pigmentation does not occur. Category VII involves dermal melanocytosis throughout the dermis without epidermal hyperpigmentation. Therefore Q-switched laser therapy alone works well to remove the dermal pigment with a low risk of postlaser PIH, although several sessions with an interval of more than 8 weeks are needed to remove the pigmentation completely.

66

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

Results

A

B

C

Fig. 6-13 Th s 40-year-old Japanese woman presented with solar lentigines and melasma on her right cheek 11 (Fig. 6-13, A). The solar lentigines were first treated with a QSR laser, but 4 weeks later, PIH appeared at the original position (Fig. 6-13, B). Bleaching treatment with 0.1% RA and HQ ointment was performed for 4 weeks. Th s treatment was followed by healing treatment with HQ alone for 4 weeks. The PIH was completely eliminated, and the melasma was also improved at 8 weeks (Fig. 6-13, C).

A

B

Fig. 6-14 Th s 49-year-old Japanese woman presented with ADM10 (Fig. 6-14, A). She had spotty pigmentations on her cheeks, lateral forehead, and nasal alae. After three sessions of QSR laser and RA-HQ therapies over 32 weeks, the pigmentation was almost completely cleared, and the yellowish color of the surrounding skin changed to a pinkish tone (Fig. 6-14, B).

Chapter 6 

A

Skin Hyperpigmentation in Asians: Classifi ation, Diagnosis, and Treatment

B

D

C

E

Fig. 6-15 Th s 56-year-old Japanese woman had pigmented contact dermatitis caused by cosmetics.6 Dark gray macules were distributed symmetrically on a wide area of her face (Fig. 6-15, A). At 8 weeks, pigmentation was reduced, with slight erythema soon after topical bleaching treatment with 0.1% and 0.4% RA and 5% HQ; however, the macules still had a grayish color (Fig. 6-15, B). QSR irradiation was performed at 8 weeks to reduce dermal melanosis, and RA-HQ therapy was performed again 4 weeks later. The patient’s results are shown at 20 weeks (Fig. 6-15, C). Histologic fi dings at baseline showed that the dermoepidermal junction was severely damaged, and a number of melanosomes were found in the upper dermis (Fig. 6-15, D). Histologic fi dings at 8 weeks showed that epidermal pigmentation was signifi antly improved, although the dermal melanocytosis had not changed (Fig. 6-15, E).

67

68

Part II 

A

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

B

D

C

E

Fig. 6-16 When this 26-year-old Japanese woman was initially seen, her nipple-areola complex had dark brown hyperpigmentation12 (Fig. 6-16, A). Two weeks after beginning a bleaching treatment with 0.2% RA and 5% HQ, the hyperpigmentation had improved (Fig. 6-16, B). Some erythema was observed. Treatment was continued for 8 weeks, consisting of 4 weeks of treatment with 0.2% tretinoin and 5% HQ together, followed by 4 weeks of treatment with 5% HQ alone (Fig. 6-16, C). An initial histologic examination revealed epidermal pigmentation (Fig. 6-16, D), which was highly reduced after 2 weeks (Fig. 6-16, E). After all treatment was completed, pigmentation improved and no PIH was observed.

Discussion The treatment strategy of hyperpigmentation should be theoretically constructed with an accurate diagnosis, which can be achieved by careful clinical inspection of the five features of pigmented lesions: color, margin, surface condition, shape, and distribution (localization). Appropriate training is needed to obtain the accurate diagnosis, and our categorization of skin hyperpigmentation is helpful to understand the pathohistology of each lesion type. Asians have a high risk of PIH, and any therapeutic procedure that induces inflammation should be avoided or performed carefully. Our treatment protocol is based on the localization of pigments. Epidermal melanin is removed by topical RA-HQ therapy, whereas dermal pigments are removed by Q-switched laser therapy. Because a high dose of RA is critical for the effici t removal of epidermal melanin, it is recommended that patients use a 0.4% RA aqueous gel formulation and change the application frequency to achieve the appropriate skin

Chapter 6 

Skin Hyperpigmentation in Asians: Classifi ation, Diagnosis, and Treatment

69

reactions. When treating lesions with both epidermal and dermal pigments, the RA-HQ therapy is also important as a pretreatment of Q-switched laser therapy. There are some distinct advantages in our protocol: (1) epidermal hyperpigmentation can be treated more effici tly than any other protocol by the aggressive but effici t use of RA; (2) PIH, the most signifi ant complication in Asians, can be easily managed through the use of RA-HQ therapy; and (3) our protocol involves a systematic treatment algorithm based on the localization of pigments. The most common complication of RA-HQ therapy is retinoid dermatitis, although it is unavoidable with the aggressive use of RA. The typical symptoms of retinoid dermatitis include erythema, scaling, and irritation. Patients may complain about the symptoms of RA, but physicians have to properly educate patients to understand the unavoidable conditions for the efficient removal of epidermal pigments and to manage the adverse effects appropriately. If the dermatitis is too severe, the frequency of topical RA should be temporarily decreased and should increase again immediately after achieving the appropriate reactions. If the skin reaction extends beyond the targeted hyperpigmented area, the patient should be well instructed again to apply RA only on the targeted area and to avoid spreading it when applying HQ and sunscreen. Many cases of hyperpigmentation in Asians are derived from or worsened by PIH, which is the most prominent difference in the cause of pigmented lesions between Asians and whites. In most Asians, symmetrical PIH can be induced by daily friction through removing makeup, scrubbing the face, and facial massage, and the projected areas are more likely to have inflammation from the physical stimulus. Th s symmetrical condition is frequently misdiagnosed as melasma. Persistent and repeated inflammation leads not only to epidermal hyperpigmentation but also to melanin incontinence (melanin deposits on the upper dermis), which is a very difficult condition to treat. However, a combination of topical RA-HQ therapy and Q-switched laser therapy is very useful to treat skin lesions with both epidermal and dermal pigmentation. Prelaser RA-HQ therapy can maximize the clearance of dermal pigmentation by Q-switched lasers and minimize the risk of PIH. After successful treatment of hyperpigmentation through RA-HQ and/or Q-switched laser therapy, ongoing HQ application is recommended to maintain an aesthetically satisfactory condition. There is no known time limitation on HQ application.

Pearls for Success • The theoretical design of a therapeutic strategy based on an accurate diagnosis is signifi ant for treating skin hyperpigmentation. • Asians have darker skin that protects them from UV-induced damage, such as skin cancer, telangiectasia, and wrinkles; however, Asians have a high risk of PIH, which leads to a variety of hyperpigmented lesions throughout the body. • Topical RA-HQ therapy reduces epidermal pigmentation by accelerating epidermal turnover (upregulation of output) and reducing epidermal melanogenesis (downregulation of input), although this treatment also induces irritant dermatitis. • Q-switched laser treatment is the best method for clearing dermal pigmentation, either melanosis or melanocytosis. Th s therapy is also the best tool for solar lentigines; however, the use of this laser treatment for other epidermal pigmentation lesions should be considered carefully because of its ability to induce PIH or depigmentation. • Th CO2 laser is the best tool for treating excessive hyperkeratosis, such as seborrheic keratosis (verruca senilis), as well as a mole (nevocellular nevus).

K23345_Pu_c06p_Skin Hyperpig_r6_cl_0051-0070.indd 69

4/2/2015 1:18:39 PM

70

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

Refer ences 1. Ito S; IFPCS. The IFPCS presidential lecture: a chemist’s view of melanogenesis. Pigment Cell Res 16:230-236, 2003. 2. Fitzpatrick TB. Soleil et peau. J Med Esthet 2:330-334, 1975. 3. Davis EC, Callender VD. Postinflammatory hyperpigmentation: a review of the epidemiology, clinical features, and treatment options in skin of color. J Clin Aesthet Dermatol 3:20-31, 2010. 4. Davis SA, Narahari S, Feldman SR, et al. Top dermatologic conditions in patients of color: an analysis of nationally representative data. J Drugs Dermatol 11:466-473, 2012. 5. Henderson MD, Abboud J, Cogan CM, et al. Skin-of-color epidemiology: a report of the most common skin conditions by race. Pediatr Dermatol 29:584-589, 2012. 6. Kurita M, Kato H, Yoshimura K. A therapeutic strategy based on histological assessment of hyperpigmented skin lesions in Asians. J Plast Reconstr Aesth Surg 62:955-963, 2009. 7. Kligman AM, Fulton JE Jr, Plewig G. Topical vitamin A acid in acne vulgaris. Arch Dermatol 99:469-476, 1969. 8. Kligman AM, Willis I. A new formula for depigmenting human skin. Arch Dermatol 111:40-48, 1975. 9. Yoshimura K, Harii K, Aoyama T, et al. Experience with a strong bleaching treatment for skin hyperpigmentation in Orientals. Plast Reconstr Surg 105:1097-1108; discussion 1109-1110, 2000. 10. Yoshimura K, Sato K, Aiba-Kojima E, et al. Repeated treatment protocols for melasma and acquired dermal melanocytosis. Dermatol Surg 32:365-371, 2006. 11. Sato K, Matsumoto D, Iizuka F, Aiba-Kojima E, Machino C, Suga H, Watanabe-Ono A, Inoue K, Gonda K, Yoshimura K. A clinical trial of topical bleaching treatment with nanoscale tretinoin particles and hydroquinone for hyperpigmented skin lesions. Dermatol Surg 33:937-944, 2007. 12. Yoshimura K, Momosawa A, Watanabe A, et al. Cosmetic color improvement of the nipple-areola complex by optimal use of tretinoin and hydroquinone. Dermatol Surg 28:1153-1157;discussion 1158, 2002.

K23345_Pu_c06p_Skin Hyperpig_r6_cl_0051-0070.indd 70

4/2/2015 1:18:39 PM

7 Treatment for Acne and Acne Scars

A

Takanobu Mashiko, Kotaro Yoshimura

cne vulgaris has multiple causes, including increased sebum production (activated sebaceous gland), obstruction of sebum discharge by follicular hypercornifi ation (keratotic plug formation), colonization with Propionibacterium acnes, and lymphocytic and neutrophilic inflammatory responses.1 Among these causes, androgenic effects, such as abnormal cornifi ation and activated sebaceous glands, seem to be signifi ant. Acne occurs most commonly during adolescence, because levels of male hormone, such as testosterone and dihydrotestosterone (DHT), are elevated at that stage. Acne scars are like facial pores and striae distensae (stretch marks) in that they are one of the most diffi ult targets in cosmetic dermatology. Acne scars can be classifi d into four types according to surface appearance: ice pick scars, boxcar scars, rolling scars, and hypertrophic scars.2 To achieve the best results, the surgeon should use or combine a variety of treatment options, depending on the type of acne scar.

Pathophysiology of Acne Scars in Asians Acne scars can occur as a result of damage to the skin during the healing of active acne. Repeated or prolonged inflammation of hair follicles results in hypertrophied or atrophied dermal cicatrix with surface irregularities, which occasionally accompany erythema and/or postinflammatory hyperpigmentation (PIH). Inadequate response in wound healing induces diminished deposition of collagen and the formation of atrophic (ice pick, boxcar, and rolling) scars, whereas overexuberant remodeling of the matrix leads to a raised nodule of fibrotic tissue and forms hypertrophic scars.3 Acne generally diminishes by the age of 20. However, some patients carry this condition well into their thirties, forties, and beyond. Acne occasionally spreads across a wide area of the face, neck, chest, back, shoulders, and upper arms. When acne occurs chronically or recurrently in Asian patients, the persistent erythema, scarring (surface irregularities), and PIH is further disfigu ing. Physicians need to perform antisymptomatic treatments to improve the patient’s current condition as well as manage the cyclic recurrence of acne and maintain good skin and psychological conditions.

71

72

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

Androgen

Keratotic plug Sebum

Stress

Occlusion

Acne Infection

Fig. 7-1  Vicious cycle in acne formation. Androgenic signals are deeply related to comedogenesis and sebum discharge,

and the signal level is readily increased by the patient’s psychological stress. It is important to stop this spiral to prevent recurrence of the acne.

When sebum mixes with dead cells in the cornifi d layer and clogs the pores, acne results, and P. acnes can grow in this mixture. If the infected mixture leaks into the surrounding tissue, it can cause a pustule with swelling and erythema. To make matters worse, severe acne causes psychological stress for the patient, which can easily exacerbate acne by further elevating adrenal and androgenic hormones in a vicious cycle that increases the risk of acne scarring after healing (Fig. 7-1).

Treatment Strategy for Acne The grading scale for overall severity by Allen and Smith (Investigators’ Global Assessment scale)4 has become a standard for the assessment of acne (Table 7-1). Acne usually starts with microcomedones arising from proliferation-retention hyperkeratosis in the infundibulum of hair follicles and develops into open and closed comedones. Sebum discharge is then blocked, and inflammatory acne appears after P. acnes colonizes. The infected acne papules can further develop into pustules and nodules, frequently accompanied by erythema and seborrheic dermatitis. Treatment for acne can be divided roughly into two approaches: antisymptomatic (curative) treatments and inhibitory (preventive) ones. Antisymptomatic treatments are widely used in daily dermatological and cosmetic practice, and include a variety of chemical peelings, laser treatments, cleansing, antibiotics, and topical or oral vitamins. On the other hand, inhibitory treatments, such as retinoids (which also have antisymptomatic effects) and antiandrogenic therapies, are considered an essential approach to inhibit the new development of acne and to stop its cyclic recurrence.5 Optimized protocols specific for Asians should be established, because hormonal actions, serum hormone levels, and hormonal side effects in Asian patients differ markedly from those in white individuals. Generally, acne is a persistent condition, so the keys to successful management are to provide both curative and preventive treatments to break out of the vicious spiral of recurring acne and psychological stress. A treatment strategy depends on the condition and severity of the acne and the patient’s acceptance of adverse effects (Table 7-2). The skin condition is evaluated not only for the severity of acne but also for other relevant factors such as sebum secretion, seborrheic dermatitis, skin dryness, treatment history, menstrual irregularities, and scarring.

Chapter 7 

73

Treatment for Acne and Acne Scars

Table 7-1  Overall Inflammatory Acne Severity Scale Grade

Definition

1

Clear, no inflammatory lesions

2

One or two inflammatory lesions

3

Th ee to five inflammatory lesions

4

Six to nine inflammatory lesions over a wide area of the face

5

Moderate number of inflammatory lesions, some large, over a wide area of the face, with increasing erythema

6

Papules and pustules with larger inflamed lesions over much of the face, with pronounced erythema

7

Large papules and pustules with pronounced erythema over most of the face

Modifi d from Allen BS, Smith JG Jr. Various parameters for grading acne vulgaris. Arch Dermatol 118:23-25, 1982.

Table 7-2  Treatment Strategy According to the Severity of Acne Severe (Grade 6 or 7)

Moderate (Grade 3 to 5)

Mild (Grade 1 or 2)

Treatment strategy

Inhibitory treatments required to stop cyclic recurrence of acne

Combination of modalities with limited adverse effects recommended

Much safer agents indicated

Primary treatment options

Oral spironolactone (for females only) Oral isotretinoin (for both males and females)

Topical retinoids Chemical peeling Benzoyl peroxide

Topical agents containing vitamin C, alpha-hydroxy acid, or salicylic acid

Adjunctive treatment options

Oral contraceptives Topical tretinoin CO2 laser

Antibiotics CO2 laser

Vitamins B2, B6, C, and E

If there are signs of androgenic influences, such as oily skin (sebum discharge), seborrheic dermatitis, and menstrual irregularity, it is recommended that antiandrogenic modalities be proposed. For females with the most severe, resistant, or widespread acne (grade 6 or 7), we recommend an oral combination of spironolactone and isotretinoin if patients are willing to accept the possible side effects; spironolactone strongly reduces androgenic effects, and isotretinoin removes keratotic plugs. The combination of spironolactone and isotretinoin is the most powerful combination among the antiandrogenic options. Oral contraceptives can be combined to regulate menstrual cycles, to avoid possible pregnancy, and to reduce androgenic effects. For males, oral isotretinoin is the strongest modality, because oral spironolactone cannot be used in men. If a patient has a reason for wanting a good appearance in the short term, the removal of keratin plugs of inflammatory papules or cystic nodules by CO2 laser may be the best option. Isotretinoin is not recommended for patients concerned about side effects on their facial appearance, whereas spironolactone is not recommended for patients concerned about menstrual irregularities.

K23345_Pu_c07_Treat for Acne_r5_st_0071-0084.indd 73

4/2/2015 1:32:41 PM

74

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

Treatment Modalities for Active Acne Topical Retino ids

Retinoids, which are chemical analogs of vitamin A, play an important role in regulating physiologic functions of the skin. In addition to natural retinoids, such as retinoic acid, thousands of synthetic retinoids have been developed. The application of topical retinoids for acne was fi st described by Kligman et al in 1969.6 Topical retinoids, such as tretinoin and adapalene, are useful tools to treat acne in all patients, including Asians, because topical retinoids reduce the amount of sebum and remove keratotic plugs of pores (Fig. 7-2). Topical retinoid therapy is efficacious for mild-to-moderate cases.

Treatment Protocol We start with 0.05% to 0.1% tretinoin (all-trans retinoic acid) gel once per day and adjust the application frequency and concentration according to adverse skin reactions such as scaling and erythema. Patients gradually develop tolerance to retinoids over time, so the dose can be increased. It usually takes 4 to 12 weeks to reduce comedonal and inflammatory lesions. After clinical improvement, continued therapy over several months is strongly recommended to reduce recurrence.7 Adapalene is a synthetic retinoid that is thought to offer comparable efficacy to tretinoin but less irritation.8

Oral Retino ids

Isotretinoin (13-cis retinoic acid), a geometric isoform of tretinoin, can be obtained as an oral tablet (see Fig. 7-2). Oral isotretinoin, also known as Roaccutane, reduces sebum secretion from the sebaceous glands and removes keratotic plugs occluding hair follicles. In addition, oral isotretinoin treatment reduces inflammation and infection of the hair follicle, although it always induces some degree of retinoid dermatitis, such as scaling, erythema, and dryness. Oral isotretinoin is a systemic therapy that is highly effective in severe, persisting, and widespread cases. It is also a useful option for females who are allergic to antiandrogenic therapies and male patients with severe acne.

COOH atRA 5 tretinoin

13cisRA 5 isotretinoin COOH

H3C

O

COOH

Adapalene

Fig. 7-2  Chemical structures of retinoids. Tretinoin and isotretinoin are natural retinoids, whereas adapalene is a synthetic retinoid.

Chapter 7 

75

Treatment for Acne and Acne Scars

Treatment Protocol Oral isotretinoin is initiated at a dose of 10 to 20 mg per day, depending on the severity of the acne, and the daily dose is adjusted to a maximum within the range of tolerable adverse effects such as angular cheilitis. The acne may worsen slightly during the fi st week, but it improves signifi antly in following weeks, when the dosage can be reduced gradually. The usual course of treatment with oral tretinoin alone is about 2 to 4 months, but we frequently use oral isotretinoin combined with an antiandrogenic therapy for a short period, such as 4 weeks (see the next section, “Antiadrogenic Therapy”). Major adverse effects of oral isotretinoin include scaling, erythema, cheilitis, and severe dryness of the facial skin and mucosa; nasal bleeding, liver damage, and depression have also been reported. Isotretinoin is not recommended for patients concerned about side effects on their facial appearance. Also, keloid formation related to oral isotretinoin in conjunction with dermabrasion was reported throughout the 1980s and 1990s, although a recent study did not indicate a signifi ant correlation between isotretinoin and hypertrophic scarring or keloid scarring.9 Furthermore, isotretinoin can cause birth defects if taken by a pregnant woman, so strict birth control measures, such as concomitant use of oral contraceptives, are mandatory for young females.

Anti and r o genic Therap y

Androgens are secreted by the testis in men and by the adrenal gland and ovary in women; secretion is controlled by the upstream hypothalamic pituitary system. Testosterone is the main circulating form of androgen and is converted to the most active form, DHT, by 5alpha-reductase (type II), an enzyme present in the sebaceous glands (Fig. 7-3). Measuring both serum total testosterone and free testosterone in Japanese patients with severe acne, we found that total and free testosterone were not signifi antly higher in these patients than in the control patients. However, blocking of androgenic signals with a competitive inhibitor improved acne in almost all patients,5 suggesting that the androgen signal is likely important in inducing acne and that androgen receptor expression may be a more important determinant of androgen signaling than the ligand concentration in serum. Thus androgens undoubtedly play an important role in the etiology of acne, and an antiandrogenic therapy, especially oral spironolactone, is defin tely a strong tool against acne in Asian females.

Estrogen

GnRH

Gonadotropin

DHEA

Androstenedione

Ketoconazole

Gonads

Testosterone 5alpha-reductase DHT

Finasteride Dutasteride Cyproterone Spironolactone Flutamide

Androgen receptor

Fig. 7-3  Working mechanism of antiandrogenic agents. Spironolactone and other competitive inhibitors inhibit testosterone and DHT binding to nuclear androgen receptors, whereas 5alpha-reductase inhibitors block the conversion of testosterone to DHT. (DHEA, Dehydroepiandrosterone; DHT, dihydrotestosterone; GnRH, gonadotropin-releasing hormone.)

76

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

Oral Contraceptives Oral contraceptives, which contain estrogen and progesterone, inhibit the production of gonadotropins by negative feedback. Suppression of the luteinizing hormone and the follicle-stimulating hormone results in decreased secretion of testosterone by the ovary. Additionally, estrogen increases the serum level of sex hormone-binding globulin, resulting in greater inactivation of testosterone by capturing free testosterone. Thus oral contraceptives may indirectly have antiandrogenic effects. Although their efficacy is relatively mild and not consistent among patients, oral contraceptives are safer than other antiandrogenic treatments. Oral contraceptives may only show therapeutic effects on acne in patients with high serum testosterone levels. Spironolactone Spironolactone, an established diuretic agent, also shows a strong antiandrogenic effect as a competitive inhibitor of the androgen receptor (see Fig. 7-3). Flutamide and cyproterone acetate, other competitive inhibitors of the androgen receptor, induce liver dysfunction much more frequently in Asians than whites; thus flutamide and cyproterone are not typically acceptable for treating acne in Asians. Finasteride and dutasteride, inhibitors of 5alpha-reductase, are available for the treatment of androgenic alopecia and prostate hyperplasia, but are less effective for acne (see Fig. 7-3). Therefore spironolactone is the safest and most effective antiandrogenic agent for acne in Asian females. Oral spironolactone is very effective for treating acne in Asian females, especially in cases with promoted sebum discharge, such as Asian females with severe seborrheic dermatitis. Although spironolactone does not have exfoliating effects on keratotic plugs, it strongly suppresses sebum discharge and new comedogenesis in almost all patients. Therefore oral spironolactone is a strong tool for treating persistent, recurrent, severe, or widespread types of acne. Although spironolactone does not induce any adverse effects in the skin, menstrual irregularities occur very frequently at doses greater than 150 mg per day. Birth control is needed, because blocking of androgen signals can result in a pseudohermaphrodite condition in male babies. Additionally, spironolactone cannot be used in male patients because of its low efficacy in acne and the potential risk of gynecomastia. A high dose of oral spironolactone can cause allergic effects, such as drug eruptions, in 2% to 3% of Japanese patients.5

Treatment Protocol Oral spironolactone is administered at an initial dose of 200 mg per day (Fig. 7-4). In its usual course after treatment for acne, sebum secretion decreases dramatically during the first 2 weeks and comedogenesis stops by 1 month. After it is confi med that no acne appears over the next month at a dose of 200 mg per day, the daily dose of oral spironolactone can be reduced by 50 mg per day per month until the end of the treatment, tapering to avoid any rebound in acne.5 In cases that do not respond well to the initial dose, the daily dose of oral spironolactone can be raised to 300 mg per day, which works most of the time, even in severe cases. Menstrual irregularities are common, and compensatory hormonal injection (intramuscular depot injection of estrogen and progesterone) is recommended every 3 to 4 months to induce menstrual bleeding, which is seen 10 to 14 days after the injection, and to renew the endometrium in the uterus.

Chapter 7 

Treatment for Acne and Acne Scars

77

Estrogen 1 progesterone injection

200 mg 150 mg 100 mg 50 mg 8 to 12 weeks

4 weeks

4 weeks

4 weeks

Fig. 7-4  Treatment protocol for oral spironolactone. The dose, started at 200 mg per day, is reduced step by step after confi ming improvement and the absence of comedogenesis, and the therapy is usually fin shed within several months. Antisymptomatic therapies can be combined. A depot injection of estrogen and progesterone is performed at 3 to 4 months to restart the menstrual cycle.

Chemical Peeling

Chemical peeling is a skin resurfacing procedure using a chemical cauterant or escharotic agent that induces a chemical burn, followed by a wound-healing process. Chemical peeling is an antisymptomatic therapy good for mild acne such as numerous comedones. Keratotic plugs can be removed by a very superficial chemical peeling using alpha-hydroxy acid solution (pH 1.0 to 2.5) for 1 to 4 minutes, followed by neutralization. Peeling that is too weak will fail to achieve proper exfoliation, whereas peeling that is too strong can induce a deeper wound (epidermal erosion), leading to delayed wound healing, long-lasting erythema, and PIH in Asians. A weaker solution (pH 3.0 to 4.0) may also be helpful as a daily cosmetic lotion applied by patients themselves.

Antibio tics

Oral antibiotics are an antisymptomatic therapy for infectious acne. Antibiotics appropriate for P. acnes, such as tetracycline, doxycycline, and minocycline, are used. Topical antibiotic creams or lotions are also available. An antibiotic therapy alone is typically not strong enough; thus it is used in conjunction with other therapies.

Car bon Dio xid e La ser Dr illing

For inflammatory acne, such as pustules and nodular or cystic acne, direct drainage by creating a pinhole with a CO2 laser can be very effective at reducing inflammation and infection. Oral antibiotics are also recommended in combination with this type of direct drainage. We prefer the CO2 laser with a scanner in skin drilling mode or hair transplantation mode. The scanner system provides a controlled, homogeneous laser distribution to a precise area, such as a circular area; for severe acne, a pinhole of 0.6 to 0.9 mm diameter is appropriate to allow pus discharge. The wound will heal in a few days, and the inflammation will disappear within a week or two.

K23345_Pu_c07_Treat for Acne_r5_st_0071-0084.indd 77

4/2/2015 1:32:42 PM

78

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

Classification of and Treatment Strategies for Acne Scars In less fortunate acne patients, severe and repeated inflammatory responses can result in permanent, disfigu ing scars. Complaints by Asian acne scar patients include surface irregularities of scar tissue, persisting erythema, and PIH. Clinical features and treatment for different types of scars are shown in Table 7-3. For surface irregularities, there is a simple and standard classifi ation system that categorizes acne scars into four types2 (Fig. 7-5). 1. Ice pick scar. A narrow (,2 mm) and deep indentation, as if it was pierced by an ice pick. An ice pick scar is most often found on the cheeks and nose. 2. Boxcar scar. A round depression with a sharp and vertical edge, resembling the scar caused by chicken pox. Boxcar scars can be subdivided into shallow (0.1 to 0.5 mm) and deep (.0.5 mm), and they usually occur on the temple, forehead, and cheeks. 3. Rolling scar. An abnormal fibrous anchoring of the dermis to the subcutis leads to a rolling scar, a scar with a wavelike, rolling, or undulating appearance that is several millimeters wide. A rolling scar is most commonly found on the forehead and cheeks. 4. Hypertrophic scar (keloid). A normal-colored, thickened, or reddish keloid scar. A hypertrophic scar (keloid) is caused by a wider wound, and it is more commonly seen on the jaw, chest, and back.

Table 7-3  Morphological Classifi ation of Acne Scars Type of Scar

Clinical Features

Treatment

Ice pick

Narrow (,2 mm), deep, sharply marginated epithelial tracts that extend vertically to the deep dermis or subcutaneous tissue.

Topical retinoids   → TCA peeling Punch excision

Boxcar (shallow)

Vertically shallow round to oval depressions with sharply demarcated vertical edges, similar to varicella scars. Wider at the surface than ice pick scars. Do not taper to a point at the base.

Topical retinoids   → CO2 laser ablation Fractional laser

Boxcar (deep)

Vertically deep round to oval depressions with sharply demarcated vertical edges, similar to varicella scars. Wider at the surface than ice pick scars. Do not taper to a point at the base.

Punch excision Fractional laser

Rolling

Dermal tethering of otherwise relatively normal-appearing skin and usually wider than 5 mm. Abnormal fibrous anchoring of the dermis to the subcutis leads to superfic al shadowing and a rolling appearance to the overlying skin.

Subcision Filler injection Fractional laser

Hypertrophic

Typically pink, raised, and fi m, with thick hyalinized collagen bundles that remain within the borders of the original site of the injury. The histology is similar to that of other dermal scars.

Topical and injected steroids Pulsed dye laser TCA

Adapted from Jacob CI, Dover JS, Kaminer MS. Acne scarring: a classifi ation system and review of treatment options. J Am Acad Dermatol 45:109-117, 2001. TCA, Trichloroacetic acid.

Chapter 7 

Ice pick

Boxcar

79

Treatment for Acne and Acne Scars

Rolling

Hypertrophic

Fig. 7-5  Four subtypes of acne scar irregularity.

The skin irregularities of acne scars are one of the most challenging targets in cosmetic dermatology. No treatment procedure is perfect for such surface irregularities, and multiple procedures are frequently combined to seek maximum improvement. The appropriate treatment strategy can be designed according to the type and severity of the patient’s acne scars and the patient’s willingness to accept the side effects and downtime associated with each treatment modality. Basically, treating an acne scar means improving the surface appearance by replacing a conspicuous scar with a less conspicuous new scar. It is important that active acne has cleared before starting treatment for acne scars. Deep ice pick scars can be treated well using the trichloroacetic acid chemical reconstruction of skin scars (TCA CROSS) method (see the Chemical Peeling section later in this chapter), although the procedure is technically demanding. Shallow boxcar scars may be treated by a skin resurfacing treatment such as dermabrasion; however, deeper boxcar scars need full-thickness scar remodeling, and a punch excision with suturing provides a better scar if the boxcar scar is less than 2 mm. Generally, ice pick scars do not respond as well as boxcar and rolling scars to fractional laser resurfacing. For rolling scars, treatment from the surface typically has minimal effects on subdermal fibrous structures; subcision is one way to radically change the surface structure, and filler injection may also work in some cases. Hypertrophic scars can be reduced in thickness and softened by repeated injection of triamcinolone, although it may induce telangiectasia.

Treatment Modalities for Acne Scars Topical Retino ids

Topical retinoids biologically renew the epidermis by accelerating epidermal turnover, activating remodeling of the dermal matrix, and promoting vascularization in the dermis. Aggressive use of tretinoin can promote wound healing, and when used in combination with other deep-skin–resurfacing procedures, it can augment the effects of each procedure. To induce such a skin reaction, retinoids must be used aggressively until signifi ant scaling and erythema is maintained during the treatment.

Sur gical Dermabra sio n

Dermabrasion with a motor surgical grinder mechanically removes the upper layers of skin. For acne scars, abrasion should be done deep into the reticular dermis, until blood oozing is seen. Antibiotic ointment should be applied until reepithelialization, which is completed between days 5 and 14. PIH is frequently

K23345_Pu_c07_Treat for Acne_r5_st_0071-0084.indd 79

4/2/2015 1:32:42 PM

80

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

seen 2 to 4 weeks after the abrasion, but it can be treated with topical tretinoin and hydroquinone. The downtime for this procedure is the longest of the treatment modalities, but substantial remodeling can be expected after the signifi ant removal of skin. A fi al evaluation of the result should be performed at 3 months. Microdermabrasion is not a good option for such a deep resurfacing.

La ser Abra sio n (CO2 La ser, Er biu m:YAG La ser)

Laser resurfacing has been used for skin tightening and rejuvenation in whites. Removing portions of the dermis with an ablative laser may be effective, but it induces some dermal burning and carries a high risk of PIH in Asians.

Chemical Peeling

Deep chemical peeling using glycolic acid, phenol, or TCA can damage the skin to the reticular dermis, inducing dermal remodeling. However, it is not easy to control the depth of peeling in acne scars, and it can also induce adverse effects such as long-persisting erythema and PIH in Asians. For ice pick scars, 100% (weight/volume) TCA can be used successfully to reduce the depth; it is generally referred to as the CROSS (chemical reconstruction of skin scars) technique.10 Using a small-tip applicator, such as a wooden toothpick or a small needle, you place the TCA focally into the base of each individual scar with great care to avoid damaging the surrounding intact skin. Th s results in red, swollen, and crusted skin that peels over a few weeks. Collagen formation is stimulated, skin texture is improved, and deep and indented scars are lifted up. The treatment is usually repeated several times at 2-week intervals.

Fra ctio nal La ser Res ur f a cing

A nonablative fractional laser delivers a series of microscopic laser spots and can be used not only for skin rejuvenation but also for acne scars.11 Fractional ablative CO2 lasers are available, but they induce PIH more frequently in Asians.12 While remodeling scarred skin, fractionated injury stimulates new collagen to plump the skin. Th ee or four sessions, spaced about 3 to 4 weeks apart, achieve optimal improvements, which are usually visible in approximately 3 months with gradual improvement for up to 1 year. Usually, mild swelling subsides within 3 days, and redness fades within 5 to 7 days. Fractional laser treatment is appropriate for all atrophic types of acne scars.

Fillers

Substances that add volume to the skin or subcutis, such as hyaluronic acid, can be used alone or in combination with the other procedures to smoothen surface irregularities. To maintain the effects of absorbable substances, you need to reinject the lesions at regular intervals.

Punch Excis io n

For isolated ice pick and boxcar scars, a small punch excision (1.5 mm diameter) of the entire skin, followed by a single 7-0 nylon closure, readily repairs each individual scar. The scars should be small and isolated; otherwise, the closed scar may leave some irregularity.

Subcis io n

Subcision, a subcutaneous incision with a needle first described in 1995,13 is useful to release the skin from an adhesive contracture. Separate the fibrous cords beneath the skin that cause rolling scars by using a tribeveled hypodermic needle or 18-gauge needle, and then smooth the skin. Using subcutaneous local

Chapter 7 

Treatment for Acne and Acne Scars

anesthesia, insert the needle at the periphery of the scarred area, turning the needle just below the dermalsubcutaneous junction and parallel to the skin, and gently sweep the tethering fibrous bands. Rolling scars on the chin and upper lip may require more than one subcision session for a satisfactory result.

Ster oid Injectio n

For hypertrophic scars or keloids, multiple triamcinolone injections (10 to 40 mg/ml) work well. Monthly injections can reduce the thickness and soften the scar. However, repeated steroid injections may induce persisting telangiectasia, which can be treated with a long-pulsed dye laser.

Topical Tr etino in and Hyd r o quino ne Therap y, and Puls ed Dye La sers

Common complaints in Asian acne scar patients are not only surface irregularities but also color changes such as erythema and PIH. Erythema in acne scars is generally related to recurrent acne, and inhibitory treatments for acne are expected to reduce erythema over time. A pulsed dye laser can be an option if the erythema persists even after the complete healing of acne. PIH associated with acne can be readily treated with topical hydroquinone or a combination of tretinoin and hydroquinone, as shown in Chapter 6. The combination of topical tretinoin and hydroquinone is also frequently used for 1 to 2 weeks as a primer before resurfacing procedures for acne scars.

Results

A

B

Fig. 7-6 Th s 23-year-old Japanese man presented with severe and widespread Grade 6 acne on his whole face (Fig. 7-6, A). Because oral spironolactone is not recommended for men because of possible side effects such as gynecomastia, oral isotretinoin therapy was utilized. Sebum secretion and new acne development was gradually decreased, and after 20 weeks of oral isotretinoin, the acne greatly improved (Fig. 7-6, B). Topical tretinoin was then used to prevent recurrence of the acne.

81

82

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

A

B

Fig. 7-7 Th s 28-year-old Japanese woman presented with severe Grade 7 acne and excessive sebum discharge, which did not improve with repeated alpha-hydroxy acid peeling and oral antibiotics5 (Fig. 7-7, A). After 4 months of treatment with oral spironolactone, she showed great improvement (Fig. 7-7, B). If the patient can accept side effects, the most powerful combination—spironolactone and isotretinoin—would be the best option. Oral contraceptives can be combined to regulate menstrual cycles, to avoid possible pregnancy, and to reduce androgenic effects.

A

B

C

Fig. 7-8 Th s 31-year-old Japanese man presented with atrophic scars on his cheeks. He had severe acne during his twenties, and then developed ice pick and deep boxcar scars (Fig. 7-8, A). If active acne were still newly formed, a preventive treatment for acne should be applied fi st. In this case, no active acne was observed; therefore the TCA CROSS procedure was used. TCA-treated scars turned white with surrounding erythema (Fig. 7-8, B). CO2 laser ablation would be an alternative, and topical tretinoin as a pretreatment would enhance healing after treatment. The surface irregularity was improved at 2 months (Fig. 7-8, C).

Chapter 7 

Treatment for Acne and Acne Scars

83

Discussion The treatment strategy for acne is determined by the severity of the acne and patient’s acceptance of adverse effects. For the most severe cases in Asian females, oral spironolactone is primarily recommended, even though menstrual irregularities occur and a depot injection of estrogen and progesterone is recommended to reset the irregularity every 3 to 4 months. For Asian males with the most severe acne, oral isotretinoin is the fi st choice, although adverse symptoms in the face that are derived from retinoid dermatitis, such as dryness and scaling, are also seen. These two inhibitory treatments are the most powerful treatments for acne, and can be done together in Asian females as the strongest combination when the patients prefer. Topical retinoids, oral contraceptives, chemical peeling, and antibiotics are effective in some cases for patients with relatively mild acne, and all treatment options can be combined together if needed to obtain the synergistic effect. Oral contraceptives are also useful to avoid possible pregnancy when using oral spironolactone or isotretinoin. After obtaining acceptable conditions, medical cosmeceuticals containing vitamin C and/or alpha-hydroxy acids can be used as posttreatment maintenance to prevent the recurrence of acne. The treatment strategy of acne scars should be determined by the type of scars and the anticipated compliance of the patient; patient compliance is important because patients need to complete multiple treatment sessions over several months. Aggressive treatments frequently induce PIH, and therapy consisting of retinoic acid and hydroquinone plays an important role both before and after treatment to enhance wound healing and treat PIH.

Pearls for Success Acne Treatment • Treatment options for acne should be chosen depending on the patient’s skin condition, hormonal features, and severity of acne as well as the patient’s willingness to accept adverse effects. • Both curative and preventive treatments for acne should be considered. • Inhibitory treatments, such as oral retinoids and antiandrogenic therapy, are strongly recommended for treating widespread persisting acne with a vicious spiral. • Oral spironolactone is the safest and most effective antiandrogenic therapy for Asian females with acne. Acne Scar Treatment • Treatment options for the treatment of acne scars should be chosen depending on the type and severity of the acne scars and the patient’s willingness to accept adverse effects. • Because Asians frequently develop PIH, it is very important to use topical retinoids with hydroquinone before and after any resurfacing procedures when treating acne scars. • The TCA CROSS technique is useful for treating deep ice pick scars. • Surgical procedures, such as punch excision, seem to be the best option for treating deep ice pick or boxcar acne scars. • Fractional laser resurfacing can be applied to atrophic acne scars.

K23345_Pu_c07_Treat for Acne_r5_st_0071-0084.indd 83

4/2/2015 1:32:44 PM

84

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

Refer ences 1. Goulden V, Stables GI, Cunliffe WJ. Prevalence of facial acne in adults. J Am Acad Dermatol 41:577-580, 1999. 2. Jacob CI, Dover JS, Kaminer MS. Acne scarring: a classifi ation system and review of treatment options. J Am Acad Dermatol 45:109-117, 2001. 3. Chivot M, Pawin H, Beylot C; GROUPE EXPERTS ACNE. [Acne scars: epidemiology, physiopathology, clinical features and treatment] Ann Dermatol Venereol 133:813-824, 2006. 4. Allen BS, Smith JG Jr. Various parameters for grading acne vulgaris. Arch Dermatol 118:23-25, 1982. 5. Sato K, Matsumoto D, Iizuka F, Aiba-Kojima E, Watanabe-Ono A, Suga H, Inoue K, Gonda K, Yoshimura K. Anti-androgenic therapy using oral spironolactone for acne vulgaris in Asians. Aesthetic Plast Surg 30:689-694, 2006. 6. Kligman AM, Fulton JE Jr, Plewig G. Topical vitamin A acid in acne vulgaris. Arch Dermatol 99:469-476, 1969. 7. Th boutot DM, Shalita AR, Yamauchi PS, et al. Adapalene gel, 0.1%, as maintenance therapy for acne vulgaris: a randomized, controlled, investigator-blind follow-up of a recent combination study. Arch Dermatol 142:597-602, 2006. 8. Bershad S. Developments in topical retinoid therapy for acne. Semin Cutan Med Surg 20:154-161, 2001. 9. Bagatin E, dos Santos Guadanhim LR, Yarak S, et al. Dermabrasion for acne scars during treatment with oral isotretinoin. Dermatol Surg 36:483-489, 2010. 10. Fabbrocini G, Cacciapuoti S, Fardella N, et al. CROSS technique: chemical reconstruction of skin scars method. Dermatol Ther 21(Suppl 3):S29-S32, 2008. 11. Chan NP, Ho SG, Yeung CK, et al. The use of non-ablative fractional resurfacing in Asian acne scar patients. Lasers Surg Med 42:710-715, 2010. 12. Chan NP, Ho SG, Yeung CK, et al. Fractional ablative carbon dioxide laser resurfacing for skin rejuvenation and acne scars in Asians. Lasers Surg Med 42:615-623, 2010. 13. Orentreich DS, Orentreich N. Subcutaneous incisionless (subcision) surgery for the correction of depressed scars and wrinkles. Dermatol Surg 21:543-549, 1995.

K23345_Pu_c07_Treat for Acne_r5_st_0071-0084.indd 84

4/2/2015 1:32:44 PM

8 Laser Skin Resurfacing

T

Cheng-Jen Chang

here   are numerous resources and advanced techniques for face lifting, blepharoplasty, and chemical peeling to restore signs of aging (wrinkles, skin atrophy, and surface irregularities) and actinic damage (hyperpigmentation, dermal thickening, hyperkeratosis, and loss of elasticity).1-6 Advances in laser technology have resulted in the development of lasers that can precisely remove thin layers of skin with minimal thermal damage to the surrounding tissue. Laser skin resurfacing refers to the use of char-free laser energy to precisely ablate or vaporize skin in very thin layers, with a high level of control and without affecting deeper layers of dermis. These lasers rely on rapid pulsing or scanning of the laser beam, producing more predictable and reproducible effects; therefore they are ideal for skin resurfacing. In this chapter, further insights on the effects of various lasers, laser resurfacing techniques, postoperative care, and management of complications during and after laser resurfacing are discussed.

Relevant Equipment and Techniques Before performing laser resurfacing treatment, surgeons and staff using lasers must be very familiar with each machine’s distinctive physiology, routinely check the equipment, and be aware of the laser’s safety mechanisms (Fig. 8-1).

Fig. 8-1  Eyewear with stainless-steel or impermeable eye shields for protection.

85

86

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

Table 8-1  Ablative and Nonablative Lasers for Resurfacing Treatment Wavelength (nm)

Laser Generation

Pulse Energy

Pulse Duration (msec)

SilkTouch/ Feather Touch CO2

10600

Spiral pattern

1400 mJ

800-900

Optomechanical flashscanner plus CW

UltraPulse CO2

10600

Collimated beam

500 mJ

950

3-10 Hz lays down 81 spots in 0.4 sec

SurgiPulse CO2

10600

Reshape Gaussian beam to minimize beam skirts

400 mJ

600

Can be used in conjunction with scanner and FiberLase

Fractional CO2

10600

Pixel

80-100 mJ

150-3000

120/1300 mm spot with maximal scan area of 14 3 14 mm)

Er:YAG

2940

Spot size 4 mm

0.5-1.5J/cm2

5-20

Can be used in conjunction with scanner in area of 20 3 20 mm (250-450 mm spot)

Nd:YAG

1320

Spot size 10 mm

16-20 J/cm2

200-350

Combine with CSC*

Nd:YAG

1064

Spot size 1.518 mm

40-150 J/cm2

250

Combine with CSC*

Fraxel

1540

Microscopic laser spots

6-25 mJ

—

30-50 mm spot of MTZ† with area of 10 3 10 mm

Laser Type

Notes

Ablative Laser

Nonablative Laser

CSC, Cryogen cooling system; CW, continuous wave; MTZ, microthermal zone. *Can be combined with cryogen coolant before, during, and after laser application, allowing laser light to pass through the upper layers to shrink the sebaceous glands and stimulate fibroblasts to produce new collagen. Th s enables greater thermal stimulation of the dermal fibroblasts within the papillary dermis and the midreticular dermis, while cooling the epidermis and protecting it from direct thermal injury. †Can penetrate 20% of MTZ by fractional microbeams causing laser injury to promote new collagen production and resultant skin rejuvenation. Th s leaves 80% of nonablated skin surface areas to facilitate faster healing with less risk of complications.

Studies have shown favorable clinical results with high-energy ultrapulsed and scanned continuous-wave CO2 lasers for the removal of upper skin layers in areas with wrinkles or blemishes. In particular, the ablative fractional CO2 and pulsed Er:YAG lasers, as well as the nonablative CoolTouch YAG lasers, have yielded good results and minimized complications.7-13 As shown in Table 8-1, ablative and nonablative lasers offer diversity in strength and area coverage. The beam from ablative lasers, such as the 10,600 nm wavelength CO2 lasers and the 2940 nm wavelength Er:YAG laser, can be absorbed efficiently by superficial (water-containing) cutaneous tissue. Such lasers have computer-controlled precision; therefore they can emit the ideal beam pattern to allow uniform and rapid treatment, consistent results, reduced user errors, and significantly less thermal damage. The ablative laser’s precision control for tissue ablation and less residual thermal damage result in faster reepithelialization, dermal remodeling induced by new collagen formation, and an improved side-effect profile. Studies have shown that the erbium laser produces less heat than the CO2 laser and has a shorter recovery time.14 In contrast to ablative laser rejuvenation procedures, nonablative laser rejuvenation procedures induce a dermal-healing response without notable injury to the epidermis. Improving the appearance of the skin without injuring the epidermis is a hallmark of nonablative skin rejuvenation. A subthreshold laser-induced

Chapter 8 

87

Laser Skin Resurfacing

injury to the dermis and/or the dermal vasculature theoretically results in a wound-repair response, fibroblast stimulation, and collagen reformation. The main nonablative laser rejuvenation modalities involve the application of midinfrared lasers. Certain visible light lasers, such as pulsed dye lasers, have been shown to induce dermal remodeling in patients with lighter skin tones; thus the affi ty of such lasers for melanin limits their use in darker-skinned patients. Laser energy in the near-infrared and midinfrared ranges of the spectrum is weakly attracted to melanin; thus, if these areas are properly bypassed, patients with all skin types can be treated with laser energy with reduced risk. Also, by extending the wavelength of the selected laser to the infrared and midinfrared areas, the surgeon can achieve deeper energy penetration and deliver laser energy to the dermis. Theoretically, heat-induced dermal injury eventually results in the activation of dermal fibroblasts and leads to collagen remodeling and induction of a healing response. In a study by Trelles et al,15 a 1064 nm Nd:YAG laser using 28 to 33 J/cm2 in conjunction with a 10 msec aftercooling delay, achieved a penetration depth of 150 to 350 mm, while the precooling was applied in 20 to 30 msec and had postcooling of 30 msec. Treating the skin fractionally with patterns of microscopic microthermal zones (MTZ) has also resulted in a unique wound-healing process. Th s is aided by the fact that each laser spot is surrounded by healthy tissue. Many of the stem cells and melanocytes in the papillary dermis are spared. On the other hand, although only 15% to 30% of the epidermis is affected during treatment under an MTZ pattern, the entire skin is affected in the wound-healing response. One kind of mediator of wound healing is a type of protein called a heat shock protein that helps in the repair process.16,17

Indications for Laser Resurfacing Determining whether to treat a patient is an important decision. It is essential to completely comprehend both the indications and contraindications of treating patients (Boxes 8-1 and 8-2). Ideal patients have fi e

Box 8-1  Indications for Laser Resurfacing • Actinic cheilitis • Actinic keratosis • Adenoma sebaceum • Dermatosis papulosa nigra • Epidermal nevi

• Rhinophyma • Rhytids • Scars • Sebaceous hyperplasia

Box 8-2  Contraindications to Laser Resurfacing • Active herpes simplex infection • Psychoneurosis • History of hypertrophic or keloid scar • Use of isotretinoin (Accutane) in the previous 12 months • Unrealistic expectations • Noncompliant patient

• Solar lentigines • Syringoma • Trichoepithelioma • Xanthelasma

88

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

wrinkles, full-face acne scars, or photoaging. Photoaging in Asians commonly consists of problems of pigmentation, skin tone (pore size, skin texture), fi e lines, or skin laxity. When determining whether a patient is a candidate for surgical face lifting, the surgeon should keep in mind that patients with facial wrinkles are not good candidates if they have medical contraindications or if they have had too many previous face lifts

Preoperative Assessment Based on Fitzpatrick’s skin types,6 coloration, skin thickness, and age, there are some guidelines for surgeons regarding the selection of Asian patients for laser skin resurfacing. To assist in determining whether a patient is a candidate for laser resurfacing, the surgeon should ask the patient about previous skin problems, such as scars, texture changes, or pigmentary changes. Previous sun exposure with resultant skin damage should be evaluated, and patients should be advised to limit their sun exposure after the procedure. Patients should be asked about any history of hypertrophic scarring or keloid formation. Patients with a history of postinflammatory hyperpigmentation (PIH) and/or hypertrophic scars or keloids should have a small area tested preoperatively. Although the use of isotretinoin is still controversial, any patient who has taken Accutane for up to 6 to 12 months before surgery should not have laser skin resurfacing, because reepithelialization is compromised and scarring is more prevalent in these patients. Finally, any pathologic condition such as scars, keratoses, rosacea, acne, or dyschromias, or a high suspicion of skin cancer, should be diagnosed and treated before the patient undergoes laser resurfacing. Preparation for laser resurfacing is another very important component for laser care. Most plastic surgeons perform laser resurfacing on Asian patients without preparing their skin. However, our suggestion for some Asian patients with keratosis, severe lentigenes, or dark skin color (Fitzpatrick’s skin types) is to have a 2- to 3-week regimen of skin care using glycolic acid or intense pulsed light before the procedure. The advantages of this approach are twofold: it encourages the patient to participate in the process, and it assesses the patient’s motivation and cooperative ability to follow instructions.

Anesthesia Most laser resurfacing procedures are performed in the office ith a topical or local anesthesic (nerve block or fi ld block) and sedation analgesia.18 The use of eutectic mixture of local anesthetics (EMLA) cream (lidocaine 2.5% and prilocaine 2.5%) satisfactorily anesthetizes the skin for most laser resurfacing of small areas (Fig. 8-2). The surgeon must wait long enough—a minimum of 45 minutes to 1 hour—for the cream to take effect. An intradermal injection of lidocaine with epinephrine can be used as a local anesthesic for 45 minutes to 3 hours. The pain of injection can be lessened by buffering the lidocaine with 1 ml of sodium bicarbonate (1 mEq/ml) to each 10 ml of lidocaine. Th ough a small amount of anesthetic solution placed around the nerve that supplies the area, anesthesia by nerve block provides the benefit of anesthesia to a larger area. Usually, to block the entire distribution of the nerve, 1 to 2 ml of lidocaine with epinephrine can be infiltrated around the nerve at its exit from the bony foramen. Excellent anesthesia of the forehead, nose, chin, and midface can be achieved by bilateral blocking of the supraorbital, supratrochlear, infratrochlear, infraorbital, external nasal, nasopalatine, and mental nerves (Fig. 8-3). The lateral temporal area, lateral zygoma, and the area involving the lateral cheek and oral commissure can be easily anesthetized by local infiltration.

Chapter 8 

89

Laser Skin Resurfacing

Fig. 8-2  EMLA cream anesthetizes the skin for laser resurfacing of most small areas. (EMLA, Eutectic mixture of local anesthetics.)

V1

Fig. 8-3  Anesthesia of the forehead, nose, chin, and midface can be achieved by bilateral blocking of the supraorbital, supratrochlear, infratrochlear, infraorbital, external nasal, nasopalatine, and mental nerves. (Cranial nerve V, the trigeminal nerve: V1, ophthalmic; V2, maxillary; V3, mandibular.)

V2

V3

Surgical Technique Abl ative La ser Res ur f a cing Ablative laser resurfacing has replaced chemical peeling and dermabrasion as the procedure of choice for skin resurfacing. Because the pulses of laser resurfacing are shorter than the thermal relaxation time of tissue (695 msec), all heat is dissipated during vaporization; thus laser resurfacing has very little risk of thermal damage in subsequent passes until smooth upper dermal contour can be achieved. The depth through the epidermis and into the papillary or reticular dermis can be readily observed by the color change in the tissue and the shrinkage of the collagen. These two benefits—physical smoothing of the surface irregularities, and heat shrinkage in type I collagen from laser thermal damage—cause immediate and long-lasting results. A neophyte plastic surgeon should initially perform ablative laser resurfacing on regional areas such as the perioral or periorbital areas by following the guideline of facial units (Fig. 8-4). Full-face laser resurfacing should only be performed by skillful plastic surgeons. Patients who would have undergone traditional external subciliary skin/muscle lower blepharoplasty with an external scar and the risk of ectropion, can instead undergo the transconjunctival approach combined with laser resurfacing of the lower eyelids and crow’s-feet. Such combined procedures are safer, resulting in smooth, tight, and rejuvenated eyelids with little risk of ectropion. Full-face resurfacing can be used for photoaging, acne scars, and multiple superficial fi e wrinkles. Th s procedure is ideal for Asian patients for whom face lift is not an option. However, the complications of dyspigmentation and scarring exist with full-face resurfacing and should be avoided. The sequence of ablative laser resurfacing is fairly standardized. Before anesthesia is induced, the rhytids or targets for treatment are marked. For thicker or deeper lesions, a weak epinephrine solution with a

90

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

1 2

3

4

5 6

8

7

Fig. 8-4  Facial guideline for laser skin resurfacing from forehead (zone 1), periorbits (zones 2 and 3), preauricles (zones 4 and 5), cheeks (zones 6 and 7), nose (zone 8), upper lip (zone 9), chin (zone 10), and neck (zone 11).

9

10 11

A

B

Fig. 8-5  A, Passes are placed adjacent to each other to minimize overlap. B, Dessicated debris is removed with wet gauze after treatment.

concentration of less than 1:200,000 is used so that severe vasoconstriction will not obliterate the color indicators of depth. When superfic al laser abrasion of the marked areas is completed, the desiccated char is gently but thoroughly wiped away with a moist saline gauze pad. Because excess water will absorb the laser energy, the treated surface is dry, and two to four subsequent passes have to be made to remove the rhytid shoulders, or the high points of lesions, furrows, or scars. The surgeon gradually decreases the power of the laser to feather the edges of the regular areas to prevent a sharp line of demarcation. The thickness of the patient’s skin, as noted in the preoperative evaluation, must be kept in mind in the variation in zonal areas, with fewer passes in the thin eyelid skin and more passes to the thick, photoaged cheeks. The endpoint of a gray opalescent appearance signals that the resurfacing has reached the epidermal junction, with an average depth of 60 mm. A uniform gray-white response of the papillary dermis is seen at an average depth of 70 to 130 mm, and a white-yellow appearance heralds reaching the superfic al reticular dermis with a depth of 155 to 315 mm. It is better to stop at this point to avoid the risk of scarring as a result of having removed excessively deep tissue on the first treatment (Fig. 8-5). Reassessment and further treatment can proceed on the same area in 2 to 3 months.

Chapter 8 

Laser Skin Resurfacing

Postoperative Care Postoperative wound care consists of either open or closed wound care with the use of ice or cold pack compresses. A topical ointment such as bacitracin or Vaseline or an occlusive, semipermeable dressing can be applied to keep the treated area moist and to aid in reepithelialization. The patient should only have minimal pain if the artific al dressing is left i tact for 7 to 10 days. Active herpes should be treated vigorously with both oral and topical acyclovir (Zovirax). Infections should be cultured and treated with appropriate antibiotics. Swelling should subside after 3 or 4 days with the application of an ice or cold pack, but patients may need systemic steroids if swelling persists. The area will be pink for 2 to 3 months for most patients and for as long as 6 months for some patients, and the skin may have a sensation of excessive tightness between the third and eighth weeks after treatment. To prevent PIH, Asian patients with type III skin color should routinely be treated with hydroquinone both before and immediately after reepithelialization. To aggressively prevent the formation of keloids, surgeons should proactively look for any sign of hypertrophic scars or keloids and use intralesional steroids to treat any areas with persistent texture change, fi mness, or pain.

Management of Complications The complications with laser skin resurfacing can be divided into mild, moderate, and severe categories. Mild complications include edema, erythema, milia formation, acne exacerbations, pruritus, burning sensation, eczema, and allergic dermatitis. Moderate complications are transient PIH, hypopigmentation, limited bacterial or fungal infection (candidiasis), local herpes simplex reactivation, and telangiectasia. The most severe complications include disseminated infection, hypertrophic scarring, and ectropion formation.19-21 In our previous studies, we observed that Asian patients had skin reddening (erythema), dyspigmentation (hypopigmentation, hyperpigmentation) for weeks or even months after treatment, and there were some cases of scarring. To ensure good results and avoid complications, the surgeon must understand the importance of laser-­ tissue interactions. We have developed a model for the ex vivo study of human skin to determine the depths of tissue ablation (z) and zones of thermal damage (x, y) of CO2 laser tissue ablation produced with different powers in a single pulse, but with no more than 30 watts. These findings may be attributable to the changes of thermal conductivity and diffusivity after the high-power effects of tissue coagulation, and carbonization. The study consisted of a single pulse with durations of 0.25, 0.5, and 1.0 seconds at 5, 10, 15, 20, 25, and 30 watts. The histologic changes are shown in Fig. 8-6, and the parameters and results are shown in Fig. 8-7.

A

B

C

Fig. 8-6  A, Section of skin after one pulse (0.5 sec) with 20 watts. B, Section of skin after one pulse (0.5 sec) with 25 watts. C, Section of skin after one pulse (0.5 sec) with 30 watts.

91

92

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

200

A

180 160 140 0.25 s

120 mm 100

0.5 s

80

1.0 s

60 40 20 0

5

10

20

30

40

50

Watts

B

600 500 400 0.25 s mm

300

0.5 s 1.0 s

200 100 0 5

10

20

30

40

50

Watts

Fig. 8-7  A, Depth of tissue ablation of the incident power exposure per pulse in human skin. B, Zone of thermal damage of the incident power exposure per pulse in human skin.

New laser systems allow even more precise ablation without excessive thermal damage. To minimize altered dermal-stromal tissue resulting in scarring and unwanted pigmentary chancres, certain (parts of) skin structures need to remain intact to allow for repopulation with melanocytes and keratinocytes. Pans of the follicular and the appendageal apparatus will function as a reservoir for reseeding. Extensive ablation and heat deposition could reach into the deeper layers of the reticular dermis with irreparable effects. However, some thermal damage is necessary to account for the tissue (collagen) shrinkage that is thought to be partially responsible for the clinical improvement observed.

Results CO2 laser skin resurfacing for rhytids can be achieved through two mechanisms: ablation of surface irregularities and collagen shrinkage as a result of controlled heat deposition. Collagen shrinkage as a result of controlled heat deposition leads to skin tightening, which can be most easily demonstrated in the

K23345_Pu_c08_Laser Skin_r5_cl_0085-0096.indd 92

4/2/2015 1:35:22 PM

Chapter 8 

93

Laser Skin Resurfacing

periorbital region on the infraorbital skin. Both the Sharplan SilkTouch and Coherent UltraPulse lasers have proved effective for the treatment of facial rhytids and can be used safely with proper training and experience. After performing laser resurfacing, we analyzed 47 patients in three separate clinical sessions at 3, 6, and 12 months. Results are shown in Fig. 8-8, and the major complications that we observed are noted in Table 8-2. At the 3-month stage of posttreatment observation, all 47 patients experienced minor complications of burning discomfort, edema, erythemas, pruritus, and skin tightness. Among the major complications, hyperpigmentation was recorded in 34% of the patients, although only 2% of patients had ectropion, herpes simplex virus, and scarring, respectively. Milia was noted in 17% of patients, and infection was recorded in 4.2% of patients. At the fi al observation session at 12 months, all major and minor complications had subsided and eventually completely resolved.

A

B

Fig. 8-8 Th s 30-year-old woman shown in Fig. 8-8, A had facial acne scars. Fig. 8-8, B shows that signifi ant improvement is evident after three treatments with a Fraxel laser (8 mJ/MTZ, 2000 MTZ).

Table 8-2  Major Complications in 47 Patients Using Laser Resurfacing for Rhytids Patients Showing Complications After 3 Months (% of total)

Patients Showing Complications After 6 Months (% of total)

16 (34)

0

0

Milia

8 (17)

0

0

Infection

2 (4.2)

0

0

Ectropion

1 (2)

1 (2.1)

0

Herpes simplex virus

1 (2)

0

0

Scarring

1 (2)

1 (2.1)

0

Type

Hyperpigmentation

Patients Showing Complications After 12 Months (% of total)

94

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

Discussion With proper execution, laser resurfacing is effective and has many potential benefits. It is less operatordependent, has little intraoperative and postoperative bleeding, and has less risk of infection. The use of the pulse laser allows easier control and means that thermal damage is predictable for collagen shrinkage. Because laser resurfacing provides accurate treatment, its postoperative care is simple, with little need for wound care; therefore laser resurfacing can be combined with other methods and surgical procedures.

Pearls for Success • Laser resurfacing is not without risks and disadvantages: ȤȤ Laser resurfacing is operator-dependent and has a steep initial learning curve. ȤȤ Specialized and expensive equipment is needed. ȤȤ The setup to get laser resurfacing established requires specialized staff training. ȤȤ The laser is potentially hazardous. ȤȤ There are potential complications and risks with laser resurfacing; therefore safety regulations and precautions must be followed closely. • Nonablative and ablative resurfacing lasers can precisely remove thin layers of skin. • Thorough clinical observation and analysis of the patient’s skin type must be conducted and diagnosed to properly determine not only the method of laser resurfacing treatment but also whether the patient’s current skin condition is suitable for resurfacing treatment. • If the pretreatment analysis shows any infection, such as acne, herpes simplex virus, or other conditions, these must be treated before laser skin resurfacing is performed to clear the infection and to avoid potential postoperative complications. • If hypertrophic scarring or scarring incidence such as keloid formation is noted in the pretreatment assessment, the surgeon must consider whether laser resurfacing will obtain the optimal result. • Patients with moderate to severe rhytids may see enhanced results with surgical or ablative skintightening procedures for facial rejuvenation treatment. • Long-term follow-up is essential to effectively evaluate the long-term safety record of new treatment modalities. • Nonablative laser treatments have not yet replaced the proven skin resurfacing techniques or standard surgical procedures for facial rejuvenation.

Refer ences 1. Baker TJ, Gordon HL. Chemical face peeling: an adjunct to surgical facelifting. South Med J 56:412-414, 1963. 2. Weiss JS, Ellis CN, Headington JT, et al. Topical tretinoin improves photoaged skin. A double-blind vehiclecontrolled study. JAMA 259:527-532, 1988. 3. Elson M. The utilization of glycolic acid in photoaging. Cosmet Dermatol 5:12-15, 1992. 4. Brodland DG, Cullimore KC, Roenigk RK, et al. Depths of chemexfoliation induced by various concentrations and application techniques of trichloroacetic acid in a porcine model. J Dermatol Surg Oncol 15:967-971, 1989. 5. David LM, Lask GP, Glassberg E, et al. Laser abrasion for cosmetic and medical treatment of facial actinic damage. Cutis 43:583-587, 1989. 6. Fitzpatrick RE. Use of the ultrapulse CO2 laser for dermatology including facial resurfacing. Lasers Surg Med 15:50, 1995.

K23345_Pu_c08_Laser Skin_r5_cl_0085-0096.indd 94

4/2/2015 1:35:22 PM

Chapter 8 

Laser Skin Resurfacing

95

7. Chernoff G, Slatkine M, Zair E, et al. SilkTouch: a new technology for skin resurfacing in aesthetic surgery. J Clin Laser Med Surg 13:97-100, 1995. 8. Fulton JE Jr. Dermabrasion, chemabrasion and laser abrasion. Historical perspectives, modern dermabrasion techniques, and future trends. Dermatol Surg 22:619-628, 1996. 9. Waldorf HA, Kauvar AN, Geronemus RG. Skin resurfacing of fi e to deep rhytides using a char-free carbon dioxide laser in 47 patients. Dermatol Surg 21:940-946, 1995. 10. Lowe NJ, Lask G, Griffin ME, et al. Skin resurfacing with the Ultrapulse carbon dioxide laser. Observations on 100 patients. Dermatol Surg 21:1025-1029, 1995. 11. Cotton J, Hood AF, Gorin R, et al. Histologic evaluation of preauricular and postauricular human skin after highenergy, short-pulse carbon dioxide laser. Arch Dermatol 132:425-428, 1996. 12. Chang CJ. Combining the CO2 laser and endoscope to remove soft issue masses from the forehead area. Photomed Laser Surg 23:509-512, 2005. 13. Li YH, Chen JZ, Wei HC, et al. A Chinese experience of fractional ultrapulsed CO2 laser for skin rejuvenation. J Cosmet Laser Ther 12:250-255, 2010. 14. Cole RP, Widdowson D, Moore JC. Outcome of erbium:yttrium aluminium garnet laser resurfacing treatments. Lasers Med Sci 23:427-433, 2008. 15. Trelles MA, Alvarez X, Martín-Vázquez MJ, et al. Assessment of the efficacy of nonablative long-pulsed 1064-nm Nd:YAG laser treatment of wrinkles compared at 2, 4, and 6 months. Facial Plast Surg 21:145-153, 2005. 16. Manstein D, Herron GS, Sink RK, et al. Fractional photothermolysis: a new concept for cutaneous remodeling using microscopic patterns of thermal injury. Lasers Surg Med 34:426-438, 2004. 17. Chan NP, Ho SG, Yeung CK, et al. The use of non-ablative fractional resurfacing in Asian acne scar patients. Lasers Surg Med 42:710-715, 2010. 18. Airan LE, Hruza G. Current lasers in skin resurfacing. Facial Plast Surg Clin North Am 13:127-139, 2005. 19. Fitzpatrick RE. Fractional resurfacing. Expert Rev Dermatol 5:269-291, 2010. 20. Bernstein LJ, Kauvar AN, Grossman M, et al. The short- and long-term side effects of carbon dioxide laser resurfacing. Dermatol Surg 23:519-525, 1997. 21. Tanzi EL, Alster TS. Side effects and complications of variable-pulsed erbium:yttrium-aluminum-garnet laser skin resurfacing: extended experience with 50 patients. Plast Reconstr Surg 111:15 24-1529; discussion 1530-1532, 2003.

K23345_Pu_c08_Laser Skin_r5_cl_0085-0096.indd 95

4/2/2015 1:35:23 PM

K23345_Pu_c08_Laser Skin_r5_cl_0085-0096.indd 96

4/2/2015 1:35:23 PM

9 Soft Tissue Fillers for Facial Rejuvenation

W

David S. Kung

hen   the new millennium began, the most popular procedures within the specialty of facial rejuvenation included the use of injectable substances to address the effects of aging. Although American and European women and men continue to lead the demand for aesthetic plastic surgery and minimally invasive procedures, such as facial dermal fillers, demand across Asia is escalating at an unprecedented rate. Whereas the physical attributes associated with beauty may vary among cultures, a number of commonalities exist. Th s chapter serves as a general primer on fillers and addresses the relevant features of the Asian population where applicable.

Today’s Dermal Fillers Dermal fillers have been called liquid face lifts for their virtually immediate rejuvenating results. The natural effects of aging, combined with sun exposure, smoking, and other damaging environmental conditions, result in visible deficie cies in the face, particularly decreased volume related to the depletion of subcutaneous fat and the loss of dermal collagen. The mirror reflects contour changes, deep creases, lines, sagging skin, hollow cheeks, and thinning lips. Today’s demand for minimally invasive procedures makes dermal fillers among the fastest-growing segment of the facial rejuvenation market. The reduced risks, recovery time, and expense of dermal fillers compared with traditional surgery have perpetuated exponential interest in dermal fillers as a preferred treatment choice. Th s is best illustrated by the number of patients who have particular fillers in mind when they arrange a physician consult. The popularity of dermal fillers worldwide is on a steep growth curve, led by the United States. According to the American Society for Aesthetic Plastic Surgery (ASAPS), 83% of all cosmetic procedures were nonsurgical in 2012. Hyaluronic acid-based fillers were the second most popular nonsurgical procedure, with a staggering 1,423,705 treatments performed. In total, cosmetic minimally invasive procedures increased more than 10% in 2012 over 2011,with approximately 8.5 million procedures being performed.1 Some of today’s most commonly used dermal fillers are listed in Box 9-1.2 Preferred treatments, filler materials, and injection techniques are then outlined in detail by facial section.

97

98

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

Fillers and Pr oper ties

Natural fillers can be derived from animals or humans. Although their effects are not permanent, natural fillers are typically well tolerated, except by individuals who may have allergic reactions to the source. Synthetic fillers contain no biologic compounds. Volumizing effects are well documented, but they may not be as well tolerated as naturally derived material. Naturally derived and synthetic fillers for facial rejuvenation are outlined in Table 9-1.

Box 9-1  Fillers: Temporary, Semipermanent, and Permanent Temporary Fillers • Less durable and enduring • Biodegradable • Bovine collagen ȤȤ Zyderm, Zyplast • Human collagen ȤȤ CosmoDerm, CosmoPlast • Hyaluronic acids ȤȤ Captique, Hylaform, Juvéderm, Juvéderm Ultra, Juvéderm Ultra Plus, Perlane, Restylane

Semipermanent Fillers • Slowly biodegradable • Polylactic acid ȤȤ Sculptra (formerly New-Fill) • Calcium hydroxylapatite ȤȤ Radiesse Permanent Fillers • Nonbiodegradable • Polymethylmethacrylate ȤȤ Artefil , Artecoll • Liquid silicone ȤȤ AdatoSil 5000, Silikon 1000

From Barrett-Hill F. Dermal Fillers: An Overview, 2006. Available at http://www.beautymagonline.com/beauty-articles/994dermal-fillers-3.

Table 9-1  Dermal Fillers and Their Properties Filler

Duration

Source/Composition

Allergy Testing

Advantages

Disadvantages

Naturally Derived Fillers Bovine collagen (Zyderm, Zyplast)

3-18 mo

Fibrillar collagen derived from cattle

Required

—

Up to 5% of patients may have hypersensitivity

Human-derived collagen (CosmoDerm, CosmoPlast)

3-18 mo

Human-derived collagen in phosphate-buffered physiologic saline

Not required

Virtually no risk of hypersensitivity

—

Hyaluronic acids (Hylaform, Juvéderm, Perlane, Restylane)

3-18 mo

Collagen-derived polysaccharide from animal (such as Hylaform; avian) and nonanimal (such as Restylane; streptococcal bacterial fermentation) sources

Not required

Ease of injection, effects can be reversed

—

Chapter 9 

99

Soft Tissue Fillers for Facial Rejuvenation

Filler

Duration

Source/Composition

Allergy Testing

Advantages

Disadvantages

Autologous collagen (Autologen)

Up to 12 mo

Recipient’s own skin

Not required

Provides ultimate compatibility, with 3 square inches of harvested skin yielding 1 cc of 3.5% collagen

Preparation time is up to 4 weeks

“Recycled” skin (Cymetra)

3-6 mo

Micronized human freezedried cadaveric dermis

Not required

Can be processed as sheets for additional indications

Thi k, viscous material that requires larger-gauge needles to inject local or regional anesthetic

Sculptra (formerly New-Fill)

2 yr or more

Thermoplastic aliphatic polyester comprised of poly-L-lactic acid diluted in suspension of sterile water

Not required

Biocompatible, biodegradable, immunologically inert, stimulates collagen formation

Results appear over time. Series of up to four treatments 4 weeks apart

Radiesse

Up to 2 yr

Microspheres of calcium hydroxyapatite suspended in an aqueous gel carrier

Not required

Serves as lattice for body to form scaffolding for tissue infiltration resulting in semipermanent eff ct

Results can be diffi ult to reverse

Hydrogel polymers (Aquamid, Argiform, Bio-Alcamid, Interfall)

2 yr or more

Polyacrylamide and polyalkylimide gels mixed in sterile water

Not required

Holds 300-400 times its weight in water; nonbiodegradable; no migration; immediate permanent results

Reported infection risk

Liquid silicone (AdatoSil 5000, Silikon 1000)

Permanent

Purifi d polydimethylsiloxane

Not required

Permanent filler option

Only FDA-approved for treatment of detached retinas; requires series of 2-5 injections 4 weeks apart; migration and sensitivity reported

Hybrid technologies (Artefill)

Permanent

Polymethylmethacrylate microspheres suspended in bovine collagen

Required

Long-lasting eff ct

Migration and foreign-body reaction

Synthetic Fillers

K23345_Pu_c09_Soft Tis Fills_r7_cl_0097-0116.indd 99

4/7/2015 8:41:59 AM

100

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

Contraind ica tio ns

Contraindications to dermal fillers for facial rejuvenation include the following: • History of severe allergy or anaphylaxis • Bleeding disorders • Hypersensitivity to one of the components in the product preparation. For example, a patient who has an allergic reaction to avian products or eggs should avoid products such as hylan-B gel (Hylaform). A patient with sensitivity to gram-positive bacteria should not be injected with hyaluronic acid products derived from bacterial fermentation. A skin test must be performed before the injection of fillers derived from bovine sources. • Other relative contraindications include the recent use of aspirin, NSAIDs, or herbal supplements that affect coagulation and hemostasis.

Preoperative Assessment Patient-C enter ed Appr oa ch

“I just don’t want to look tired anymore.” Th s common patient statement reveals the importance of a patient-centered approach to aesthetic plastic surgery, and particularly soft issue fillers. The majority of patients who seek out my professional advice for aesthetic augmentation do not want to alter their facial characteristics; rather, they simply want some rejuvenation, a refreshed appearance. They have noticed that their cheeks have hollowed, their eyes make them look perpetually tired, and their pronounced smile lines and deep forehead creases make them look older when they look in the mirror. Although they may not articulate it, what patients are looking for is the correction of volume loss. However, what a patient thinks and desires is the most important element of an initial patient treatment plan; therefore listening to the patient is the critical fi st step for the surgeon in the consultation and evaluation process.

Eval uatio n

After attaining an understanding of the patient’s expectations and goals, the surgeon should explain the evaluation process, including the different systems used to analyze the bony structure and the soft tissue status of the face. The surgeon’s taking time to explain the evaluation process will contribute to patient understanding and trust; this is particularly true when the surgeon recommends a treatment plan that is supported by accepted standards of observation and an analysis based on facts. Additional factors evaluated include the patient’s age, sex, skin condition, and any underlying medical condition and/or medication that may predispose the patient to complications. The surgeon must conduct a comprehensive bone and soft tissue evaluation, including both radiographic and physical examinations of the upper, middle, and lower face (Fig. 9-1), to attain an accurate understanding of the causes and effects, and an ability to address deficie cies at their source. For example, a congenital defect will not be corrected by any type of dermal filler. Conducting a radiographic examination of the patient’s bone structure will also provide the surgeon with insight into what changes have occurred or are likely to occur as a result of aging, because soft tissue changes will occur after skeletal changes.

Chapter 9 

Soft Tissue Fillers for Facial Rejuvenation

Fig. 9-1  The face is divided into horizontal thirds and vertical fi hs to illustrate the value of the whole-face perspective and the golden ratio as evaluation tools. Symmetry and deficie cies are easier to recognize by using anatomic landmarks as a guide.

Understanding the common skeletal differences in Asian patients helps in the approach to augmentation with facial dermal fillers in this population. The skeletal differences among Asians and the subsequent augmentation approaches are as follows: • Higher degree of lip protrusion. Lip augmentation is not in high demand among Asians, presumably as a result of the combination of cultural preferences and the common anatomic fi ding of lip protrusion in this population. • Lower angle of nasal inclination. A flatter nasal bridge and bones, particularly common among Korean adults, make this area a common site for augmentation. • Flatter midface. Asians have less volume in the infraorbital region; therefore malar and infraorbital filler placement can have dramatic results in these patients. • Narrower eyelid fold. Because of the lower double eyelid folds of Asians, the upper eyelids are a common filler site among these patients. However, this region is very delicate and prone to overcorrection. • Less-prominent chin protrusion. Dermal fillers for chin augmentation can be an appropriate option for Asian patients.

Pertinent Facial Anatomy Anatomic landmarks are useful standard reference points for evaluating the face and for providing procedural accuracy and effectiveness. These landmarks provide parameters for physical measurements and for understanding how appearances change, for example, as a result of aging. The facial skeleton is a frame on which the soft issue of the face provides form and function (Fig. 9-2). In response to muscle contraction (Fig. 9-3), the soft tissues facilitate eating, facial expression, breathing, and speech. Skeletal form, muscle activity, and soft tissue volume collectively determine facial aesthetics.

101

102

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

Frontal bone Glabella Supraorbital process Temporal bone Nasal bone Zygomatic bone

Maxilla

Nasal spine

Ramus

Alveolar process

Angle of jaw

Mandible Mental tuberosity

Fig. 9-2  The anterior features of the skull and facial bones, including the anatomic landmarks important to dermal filler procedures.

Occipitofrontalis

Temporalis Corrugator

Procerus

Orbicularis oculi

Nasalis Levator labii superioris

Levator labii superior alaeque nasi

Zygomaticus minor Orbicularis oris

Zygomaticus major

Risorius

Buccinator Depressor anguli oris Depressor labii inferioris

Mentalis Platysma

Fig. 9-3  The muscles of facial expression.

K23345_Pu_c09_Soft Tis Fills_r6_cl_0097-0116.indd 102

4/2/2015 1:43:45 PM

Chapter 9 

Soft Tissue Fillers for Facial Rejuvenation

103

Common Facial Areas for Dermal Fillers: Preferred Treatments, Products, Cautions, and Insights The guiding principle in medicine, “Treat like with like,” generally applies to dermal fillers. The composition of the facial area to be augmented will, in most cases, determine the type of filler material that should be used. Bony areas such as the forehead, temples, and upper nose are better suited for treatment with the calcium-derived hydroxylapatite microspheres found in Radiesse. Likewise, deficie cies in soft tissue areas are best augmented with softer, collagen-derived fillers such as the hyaluronic acids. Heavier fillers such as Radiesse have to be injected into the deeper, subdermal layers to avoid visible lumps, bumps, and irregularities, particularly in areas with limited or no soft issue. Lighter fillers, such as the hyaluronic acids, can be injected more superfic ally. Patients should return two or three times a year for regular maintenance of areas treated with a dermal filler.

Upper Fa ce Forehead

Horizontal Rhytids Fillers injected into supraorbital and glabellar rhytids will sit virtually on bone and will need to support thick overlying skin. These horizontal rhytids respond well to more volumizing fillers such as Radiesse. Vertical Rhytids Vertical rhytids are caused when the corrugator muscles used in facial expression pull horizontally between the eyebrows, resulting in dynamic and static lines. Dynamic lines, caused by muscle function, can only be eliminated by surgery or treatment with botulinum toxin A. If static lines resulting in a depressed area persist, the use of filler is appropriate to compensate for the lack of volume.

Temple Hollows Deficie cies in the temple area are most commonly caused by atrophy of the temporalis muscle. Many types of filler can be effective in this region. Effective choices include Radiesse, hyaluronic aids, and autologous implantation. Sculptra is an appropriate choice when signifi ant volume replacement is necessary. The procedure should not result in the brows being pushed down. Sometimes the brow complex is also filled, which can cause extra skin to be lifted off the upper lids.

Periorbital Region Upper Eyelids Volume deficie cy can readily be corrected by autologous collagen injection into the superfic al middermis. The use of softer and lighter filler materials, such as hyaluronic acids, is also an option. Injections placed too superfic ally risk lumps, bumps, and other irregularities, and excess skin is a surgical problem. Lower Eyelids Th tear trough is a depression centered over the medial inferior orbital rim. Hyaluronic acids, particularly Restylane, are the preferred choice for superfic al volume loss in this area. For greater defic ts, deep plane injection just above the bone is necessary. The filler can be placed under the arcus marginalis, in combination with surgery to raise it and reduce or eliminate the tear trough. The lower eyelid is among the most unforgiving areas to treat; therefore performing a procedure in this region requires not only skilled technique but also the appropriate filler material. Complications and unsightly results are often seen with the use of heavier, more permanent fillers injected in a superfic al plane.

K23345_Pu_c09_Soft Tis Fills_r6_cl_0097-0116.indd 103

4/2/2015 1:43:46 PM

104

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

Nasal Tip and Bridge Fillers to reshape the nose are commonly used to restore the nasal bridge, elevate the tip, correct asymmetries, or fill in depressions. Radiesse is an effective filler choice, because it can be placed directly over the bone. Conversely, hyaluronic acids are preferred for augmentation of the nasal tip and to correct asymmetries.

Mid f a ce

Malar Region A common area for rejuvenation is the malar region, because patients often express a desire to have higher cheekbones or to fill the hollow cheeks that occur with time. The malar region includes the outer upper cheek; the hollow zygomatic arch, where the cheekbones attach to the skull; the submalar region, which presents a chiseled appearance when the cheekbones are high; and the midcheek area, or buccal region, where aging causes sallow or hollow cheeks. Although distinct in structure, these areas often appear to blend together. Cheek volume restoration can be accomplished with hyaluronic acids or with a more permanent poly-L-lactic acid such as Sculptra. Volume restoration with medical-grade liquid silicone injection has been reported as a permanent filler option for restoring cheek volume. Because liquid silicone injection is permanent, overcorrection, among other serious issues, is a concern.

Lower Fa ce

Nasolabial Folds Nasolabial folds are dynamic vertical lines that appear with age, because the fatty tissue of the cheek deflates and the ligaments around the mouth and chin relax and begin to loosen and sag. Nasolabial folds cannot be eliminated completely. The rhytids appear deeper when the cheek folds over in the nasolabial region between the nose and mouth, and similarly in the labial area between the lips and chin. Hyaluronic acids are often used in this area. One approach is to work “top down” by using filler in the malar region fi st, then providing support with additional filler in the area of the nasolabial folds. The choice of filler product will be determined by the severity of the rhytids. Restylane or Juvéderm, for example, are best for shallow lines and folds. Deeper lines may require a more full-bodied material, such as Perlane or Juvéderm Ultra Plus. Layering of these products is often an effective treatment plan.

Labiomental Rhytids Labiomental rhytids or marionette lines respond well to heavier hyaluronic acids, such as Perlane or Juvéderm Ultra Plus. These products will be more effective and long-lasting when they support the heavier tissue and strong muscle action in this area. Because these lines feather outward and upward to the inner cheek and corners of the mouth, blending the product throughout this area will result in a more natural appearance.

K23345_Pu_c09_Soft Tis Fills_r6_cl_0097-0116.indd 104

4/2/2015 1:43:46 PM

Chapter 9 

Soft Tissue Fillers for Facial Rejuvenation

Perioral Lines Perioral lines are fi e vertical lines that appear with age around the lips and mouth. These lines occur because the sphincter muscle of the mouth contracts multiple times an hour for speech and expression.3 Th lighter hyaluronic acids, injected superfic ally, are effective for treating the fi er lines and thinner skin around the lips and mouth, as is a collagen such as porcine-derived Evolence. For thicker skin, a thicker hyaluronic acid is warranted. Treatment of multiple, deeper perioral rhytids may include combination therapy, including the injection of botulinum toxin A, followed by filler injections.

Prejowl Sulci and Masseteric Hypertrophy The prejowl sulci are regions of contour depression that separate soft tissues over the body of the mandible from the symphysis or chin. Deeper placement of a filler such as Radiesse directly over bone is very effective in re-creating a smooth mandibular border. Masseteric hypertrophy is not so much a soft issue deficiency as muscle overgrowth as a result of repeated use. Therefore botulinum toxin A treatment would be effective in improving contour in patients with masseteric hypertrophy.

Lip Augmentation Aging often lengthens the upper lip, resulting in lip thinning and vermilion inversion (Fig. 9-4). Because full lips are considered a sign of youth and beauty in many cultures, lip augmentation is popular among younger patients as well as individuals in their forties, fi ies, and sixties. Although traditional Asian performing arts depict beautiful women with thin and painted lips, modern Asian women commonly seek lip augmentation, similar to women in Western cultures. Filler treatments in the lip area most often involve adding fullness to the body of the lip and/or enhancing the vermilion border. Lip shape, length, volume, and lower lip support should be considered when augmenting or restoring the lips, in addition to skin texture and the balance of the upper to lower lip.

Left

Right

Fig. 9-4  Changes in the lip area associated with aging. Lengthening of the upper lip (patient’s left side) is associated with lip thinning and vermilion inversion, in contrast to the patient’s youthful right side.

105

106

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

The very nature of the vermilion makes restoration and augmentation particularly challenging. The fact that the skin is very thin is complicated by the concentrated presence of blood vessels, which causes the red appearance of the lips. Filler applied too superfic ally here will risk visible irregularities. Because the makeup of this soft tissue area is primarily collagen, collagen fillers are a traditional choice. However, collagen fillers have been widely replaced by hyaluronic acids because of the associated complications with collagen such as signifi ant bruising. Other effective choices include human and artific al dermis implants. My patients have had excellent results when I perform lip augmentation through the injection of synthetic fillers, such as Radiesse, combined with the new technique of microthreading with a blunt-tipped cannula. The use of a blunt-tipped cannula, rather than a traditional needle, for implantation has been shown to result in signifi antly less bruising. In addition, a blunt-tipped cannula allows better control of the fl w and amount of product placed. Th s is particularly important for the lips, where spreading of the filler is undesirable. Using a blunt-tipped instrument expands the choices for safe, effective filler materials in thinskin, soft tissue areas such as the lips.

Other Lip Filler Treatments Philtral Columns A more defi ed, younger appearance can be produced by injections into the philtral columns, the vertical anatomic landmarks from each nostril to the high point of each side of the upper lip. Small injections of hyaluronic acids are the preferred treatment. Cupid’s Bow Lip augmentation and restorative procedures may include enhancing or re-creating the Cupid’s bow, the natural arch of the upper lip, which is described as resembling the symmetrical low-to-high curves of the mythical Cupid’s bow. Th s can be effectively achieved by properly injecting filler deep into the dermis and adequately massaging it to avoid lumps and bumps. Hyaluronic acids are the preferred method of treatment. Asymmetry Correction Asymmetry of the lip may be corrected with filler, sometimes in combination with botulinum toxin A. For example, in the patient with an uneven smile when one side rises higher, botulinum toxin A can lower the elevation. Then the filler can soften the associated nasolabial fold.

Anesthetic Infil tra tio n of a Lo cal Anes the tic

Recent advancements in filler products are changing the practice regarding the use of an anesthetic before and during dermal filler procedures. Several products now incorporate a local anesthetic such as lidocaine, which in many instances can replace separate injections for infiltration of a numbing agent. The use of these filler products can simultaneously provide the advantages of increased patient comfort and simplify the procedure. Anesthetic-inclusive products eliminate the need for multiple needle sticks before most filler procedures and generally provide an effective, well-tolerated numbing effect. A topical anesthetic may still be applied, using a cream, paste, spray, dressing, or patch, to numb the initial injection site.

K23345_Pu_c09_Soft Tis Fills_r6_cl_0097-0116.indd 106

4/2/2015 1:43:46 PM

Chapter 9 

Soft Tissue Fillers for Facial Rejuvenation

Upper

Lower

Fig. 9-5  Insertion and injection of a nerve block for upper and lower lip enhancement with fillers. A topical anesthetic can be placed at the depth of the anterior maxillary and mandibular vestibule. Then 2% lidocaine with epinephrine 1:100,000 is injected into a submucosal plane between the mucosa and periosteum in four or five locations in both the upper and lower lips.

Ner ve Bl o cks

Until recently, nerve blocks were a common anesthetic option for dermal fillers in most facial areas. For example, a nerve block is a traditional and effective choice to enhance the nasolabial folds and cheek areas. Blocking the infraorbital nerve, with access either through the skin or inside the mouth, will numb the entire lower central face, including the upper lip and nose. With filler products that combine numbing agents now available, nerve blocks can be reserved for anatomic areas that are extremely sensitive, or areas that are not suitable for fillers available with a numbing agent. One example is the lip area (Fig. 9-5). Critically important to creating an effective nerve block is targeting the appropriate nerve and therefore the conduction of that nerve. The primary advantage of a nerve block over an infiltration technique is that one injection will numb the entire area that the nerve supplies, producing more profound and larger areas of effect. For example, blocking the mental nerve will affect the entire middle-lip and lower-lip areas with fewer injections—typically with two injections rather than four.

Injection Techniques There are several techniques to discuss regarding the administration of dermal fillers (Fig. 9-6). Th eading, serial puncture, fanning, and crosshatching are all well-known techniques. Less common are the very effective pyramidal and reverse pyramidal techniques. Another way to administer dermal fillers is with the use of a blunt-tipped cannula through a new technique called microthreading. Although particular anatomic sites will lend themselves more to one specific echnique, physician preference is often the key deciding factor. The size of the insertion needle is primarily determined by the viscosity of the filler. The smallest needle that can effectively deliver the product should be selected. The angle of injection depends on the depth of the defect and the anatomic location. For example, deeper defects will generally require more obtuse angles of insertion, 45 degrees or greater. Superfic al defects into the mid-dermis will require an insertion angle of 30 to 45 degrees. Keeping the anatomy in mind, the surgeon can perform each technique variation in multiple planes.

107

108

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

A

B

E C

D 1

3

2

5 4 7 9 6 8

Fig. 9-6  Techniques to administer dermal fillers. A, Serial puncture. B, Linear threading. C, Fanning. D, Crosshatching. E, Pyramidal.

Linear Thr ead ing

With linear threading, the surgeon injects the filler in a tunneling manner beneath the defect area at the appropriate depth for the filler type and anatomic area. The product is injected while the needle is withdrawn rather than as the needle is introduced. Common areas for the use of threading include the lips and nasolabial folds.

Ser ial Punctur e

A less frequently used technique, serial puncture consists of injecting a series of close boluses along the length of the treatment area. Th s technique can leave irregularities, such as small bumps; therefore a smooth line of insertion may be preferred, particularly when placing the filler superfic ally. Serial puncture is best for deep injections, such as around the eyes, because any such irregularities will not be problematic. Combining the threading technique with serial puncture is known as serial threading.

Fanning

Fanning uses the threading technique, with multiple threads injected radially by changing the direction of filler insertion without withdrawing the injection needle.

Cr oss hat ching

Crosshatching forms a grid with multiple threads injected perpendicular to each other. Th s technique is excellent for larger fill areas with extensive volume loss, and for facial shaping.

K23345_Pu_c09_Soft Tis Fills_r6_cl_0097-0116.indd 108

4/2/2015 1:43:46 PM

Chapter 9 

Soft Tissue Fillers for Facial Rejuvenation

Fig. 9-7  Blunt-tipped cannulas used in the microthreading technique.

Pyramid al

A less well-known technique, pyramidal injection is a deep and perpendicular injection in which the amount of filler is injected in a pyramid or cone shape. As filler is injected, a broader base is formed for support at the base. The closer to the skin, the less filler is injected. Th s technique works well for filling hollow areas, such as at the temple or the base of the nose. A reverse pyramid technique—less filler at the bottom, with gradually more filler injected toward the skin surface—is effective for depressed areas; for example, to correct a scar or for deep nasolabial folds.

Micr othr ead ing

Microthreading is a new technique in which a needle is replaced with a blunt-tipped cannula (Fig. 9-7). I have found that microthreading allows safer use of longer-lasting, heavier fillers, such as Radiesse, when they would otherwise be avoided. Hyaluronic acids are the accepted filler choice in soft tissue areas where superfic al injection is required, such as the lips. A blunt-tipped cannula allows placement of fi e threads of filler for improved control of the amount of product deposited; thus microthreading is important in an area such as the lips, where spreading too much filler risks an unwanted, overcorrected result. Microthreading also reduces the amount of swelling and bruising associated with needle injections in the lips and other highly sensitive facial areas.

Postoperative Care Proper postoperative care is essential for the patient who has had a dermal filler administered through one of these injection techniques. The patient should do as follows: • Avoid strenuous physical activity for 24 hours. • Use acetaminophen as directed for pain relief; prescription pain medication is not routine. • Apply cold compresses to control pain and swelling. • Avoid massaging or manipulating the treated areas for at least 24 hours, because the filler position can be disturbed. • Treat bruised areas with warm compresses. • Use natural antibruising supplements such as Arnica montana.

109

110

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

Results In the majority of the patients presented here, filler materials included 1% lidocaine; therefore additional local anesthetics were not required, except where indicated.

A

B

3 5 Serial puncture sites

C

n 5 Pyramidal injection sites

– – – 5 Linear threading sites

Fig. 9-8 Th s 38-year-old woman was bothered by the appearance of her sunken eyes and hollowing around the temples. She showed deep supraorbital and temporal hollowing and left eyelid ptosis (Fig. 9-8, A and B). The upper eyelid ptosis of her left eye was surgically corrected. A total of 4.5 cc of Radiesse was injected in the temple, nasolabial, and infraorbital regions. In the supraorbital areas, 1.6 cc of Juvéderm was injected. The techniques performed by region were as follows: • Infraorbital: Deep pyramidal injections with linear threading. A total of 1.5 cc of Radiesse was injected above the infraorbital rim and the body of the zygoma. • Nasolabial: Linear threading. A total of 1.5 cc of Radiesse was placed in the nasolabial region. • Temporal: Deep pyramidal injections. A total of 1.5 cc of Radiesse was placed in the temporal fossa. • Supraorbital: Deep serial puncture with linear threading. A total of 1.6 cc of Juvéderm was placed deep into the orbital septum. At 3 months after the procedure (Fig. 9-8, C), improved balance is shown in her upper eyelids, and volume increase is evident in her supraorbital and temporal hollow areas.

Chapter 9 

Soft Tissue Fillers for Facial Rejuvenation

A

B

3 5 Serial puncture sites

C

n 5 Pyramidal injection sites

– – – 5 Linear threading sites

Fig. 9-9 Th s 46-year-old woman requested periorbital and midface rejuvenation. She showed loss of volume in the infraorbital and malar regions, with noticeable nasojugal and nasalabial folds (Fig. 9-9, A and B). The techniques and fillers used by region were as follows: • Malar: Th ough pyramidal injections, a total of 1.5 cc of Radiesse was placed above the body of the zygoma. A total of 1 cc of Restylane was placed in a subcutaneous plane through linear threading and the crosshatching technique. • Infraorbital rim: A total of 1 cc of Restylane was placed above the infraorbital rim through serial pyramidal injection and threading. • Nasolabial: A total of 1.5 cc of Radiesse was placed through superior pyramidal volumizing and inferior linear threading. The postoperative photograph at 10 weeks (Fig. 9-9, C) shows the replenishment of volume in her infraorbital, malar, and nasolabial regions, with decreased visibility of her nasojugal and nasolabial folds.

111

112

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

A

B

C

D

n 5 Pyramidal injection sites

– – – 5 Linear threading sites

Fig. 9-10 Th s 38-year-old woman presented complaining of her undersized chin. She showed genial retrusion with normal occlusion (Fig. 9-10, A and C). Radiesse (1.5 cc) was injected in a pyramidal fashion directly above the chin at the pogonion, and then superfic al linear threading was performed in the subcutaneous plane. Her well-balanced lower face is shown 3 months after the injections (Fig. 9-10, B and D).

Chapter 9 

Soft Tissue Fillers for Facial Rejuvenation

A

B

C

D

3 5 Serial puncture sites

– – – 5 Linear threading sites

# 5 Fanning and crosshatching

Fig. 9-11 Th s 50-year-old woman was bothered by the appearance of her deep-set eyes and indistinct supratarsal folds. She showed volume loss, supraorbital hollowing, and no dominant double eyelid crease (Fig. 9-11, A and C). Restylane was injected in the upper and lower eyelids and the glabellar region. The techniques and fillers that were used by region were as follows: • Upper lid: A total of 2 cc of Restylane was injected through a deep serial puncture at the level of the orbital septum and through light superfic al linear threading below the skin. • Lower lid: A total of 1 cc of Restylane was injected in each lid through linear subcutaneous threading. • Glabella: A total of 0.8 cc of Restylane was injected through subcutaneous crosshatching. At 6 months after the procedure (Fig. 9-11,B and D), she shows natural volume enhancement with the establishment of the one dominant supratarsal fold.

113

114

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

Management of Complications As with any procedure, some adverse effects can be expected with dermal filler procedures, that is, pain, bruising, swelling, and related asymmetry, erythema, and manipulation edema. These would not be unusual within the 2-week postoperative period and will typically resolve themselves without intervention. Dermal filler procedures can also have some complications.

Complica tio ns With Dermal Filler Pr o ced ur es Allergic Reaction

An immediate hypersensitivity reaction can occur with any filler material. Bovine-derived products are often involved, with up to 3% of patients developing a reaction to bovine-derived products, even if they have a normal skin test.3 Lymphedema, or fluid accumulation in the treated area, is a rare but reported reaction.

Eruption Granulomas Over time, nodules and granulomas can form as part of the inflammatory process. Careful excision may be necessary if they do not respond to steroid injections.

Tyndall Effect A blue bump under the skin, the Tyndall effect is a complication that is associated with hyaluronic acid injected too superfic ally. Pointing the needle bevel away from the epithelium offers the best prevention of the Tyndall effect. Hyaluronidase works well to dissolve bumps and overcorrection related to hyaluronic acid fillers. When hyaluronidase is injected, the enzyme breaks up the hyaluronic acid, virtually melting it away. The bump can then be smoothed out through manual massage.

Necrosis Injecting intraarterially can create an occlusion, eliminating blood supply to an area that has received filler. Although necrosis is rare, it is a serious complication and is best avoided through the surgeon’s adequate anatomic knowledge and procedural expertise.

Infections Whether they have an immediate or delayed onset, bacterial and/or viral infections can occur.4,5 A detailed patient history of previous herpes simplex infection should be elicited. The surgeon should practice proper technique to ensure that the risk of infection is minimized.

Other Serious Complications Other serious complications that have been reported from dermal fillers include anaphylaxis, blindness, and death; however, each of these is very rare. Finally, all patients should be aware that subsequent injection treatment for contour correction or additional volume augmentation is necessary with virtually all types of dermal fillers.

Chapter 9 

Soft Tissue Fillers for Facial Rejuvenation

Discussion The development and availability of safe and reproducible tissue-filling agents has fueled a worldwide increase in the utilization of volumizers of the face. With the notion of volume enhancement restoring the appearance of youth, soft tissue fillers, in combination with other injectable treatments such as botulinum toxin A, have taken over the aesthetic landscape. Because of the particular physiology of Asian skin, nonsurgical treatments will remain a permanent fix ure in the aesthetic armamentarium of this population.

Pearls for Success • To use soft tissue fillers for facial rejuvenation, surgeons should know the anatomy very well. • With most injection materials, the best and most natural results are created by fi mly massaging the filler after a defect has been adequately augmented. Spreading the filler with your fi gers and massaging it into place is the equivalent of gently contouring a smooth, desired result that customizes the product to the augmented tissue. • The surgeon should hand a mirror to the patient after completing the procedure on one side. Looking in the mirror halfway through the procedure gives the patient an opportunity to provide feedback, which may be important in guiding the surgeon as he performs the remaining half of the procedure. • To account for the patient’s immediate swelling caused by passing through the tissues, the surgeon would be wise to slightly overcorrect by approximately 5% when injecting into the subdermis. • The surgeon should avoid injecting too superfic ally, particularly in thin-skin areas such as in the upper eyelids and lower-lid tear troughs. Positioning the needle bevel away from the epidermis can help ensure deeper implantation, reducing the risk of lumps, bumps, and other irregularities. • Aspirating the needle before injecting the filler material will minimize the chance of intraarterial injection. • The surgeon’s communicating the importance of postoperative instructions to the patient can make a signifi ant difference.

Refer ences 1. The American Society for Aesthetic and Plastic Surgery (ASAPS). 2012 statistics: a cut above for cosmetic surgery, 2013. Available at www.surgery.org/consumers/plastic-surgery-news-briefs/2012-statistics--cut-cosmeticsurgery-1050547. 2. 2006 Virtual Beauty Corporation. Dermal Fillers: An Overview, 2006. Available at http://www.beautymagonline. com/beauty-articles/994-dermal-fillers-3. 3. Klein AW. Collagen substances. Facial Plast Surg Clin North Am 9:205-218, vii, 2001. 4. Wesley NO. Hydrogel polymers. In Jones D, ed. Injectable Fillers: Principles and Practice. Oxford, United Kingdom: Wiley Blackwell, 2010. 5. Narins RS, Coleman WP III, Rohrich R, et al. 12-month controlled study in the United States of the safety and effi acy of a permanent 2.5% polyacrylamide hydrogel soft- issue filler. Dermatol Surg 36(Suppl 3):1819-1829, 2010.

115

K23345_Pu_c09_Soft Tis Fills_r6_cl_0097-0116.indd 116

4/2/2015 1:43:50 PM

10 Fat Grafting for Facial Contouring

A

Yun Xie, Qingfeng Li, Lee L.Q. Pu

utologous fat grafting, which has been used in plastic and reconstructive surgery for more than two decades, is a technique that can replace the loss of soft tissue and correct cosmetic deformities such as acne pits, temporal concaves, wrinkles of nasolabial folds, hollow cheeks, and even hemifacial atrophy. Autologous fat grafting involves a series of procedures, and techniques vary among surgeons. There is no universal agreement regarding how fat should be harvested, processed, or injected,1-3 and many factors are involved in each surgeon’s decision: Should manual aspiration or machine suction be used for harvesting fat? Centrifugation or only sedimentation? Washing or not washing for processing? How much overcorrection is needed? Although the technique of fat grafting has been reported to be successful, the relatively high percentage—and variable amount—of resorption after fat grafting often results in even less-desirable cosmetic outcomes and the need for additional fat grafting procedures. In this chapter, we introduce our integrated fat grafting technique and report our experience with autologous fat grafting to improve facial contour.

Special Considerations Because the face has an abundant blood supply, fat grafts usually perform well in the face, and only a small amount of fat is usually needed for transplantation.3 As noted in Fig. 10-1, the most common recipient sites in the face can be divided into either movement sites (such as the temporal area, cheek area, mandibular

Fig. 10-1  The most common recipient sites in the

face: 1, Frontal area. 2, Temporal area. 3, Periocular area. 4, Cheek area. 5, Lips. 6, Mandibular area. 7, Chin area.

117

118

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

area, upper part of the periocular area, and lips) or relative rest sites (such as the frontal area, lower part of the periocular area, and chin). Adipose tissue in a relative rest site can usually survive more than that in a movement site; therefore, after each fat injection procedure, the recipient sites should be fully immobilized for approximately 1 week to improve fat graft take and survival. Fat grafts should be injected into two or three layers of the face. The superfic al musculoaponeurotic system (SMAS) layer can be injected with a relatively higher volume of fat if there is reliable support to the superficial layer of the face. The subcutaneous layer, which is the layer that changes the most visibly as soon as the fat is injected, is often treated last to correct the contour deformity of the face. In the frontal area, fat can be injected into the subcutaneous layer, submuscular layer, or periosteal layer.

Indications The indications for the use of autologous fat grafting to improve or correct facial contouring problems depend on the patient and include temporal, cheek, and periocular hollowing; a lean or aging face; facial asymmetry; hemifacial atrophy; or congenital craniofacial deformity. Most of our patients with cosmetic complaints present with a hollowing facial deformity after a traumatic or iatrogenic injury, although some have the typical complaints of facial aging. Asian women, especially those from the southern part of China, often go to plastic surgeons with a strong desire for temple augmentation, because they believe that a “plump” temple symbolizes good luck, whereas a narrow temple may bring bad luck to their husbands. Thus fat grafting for temporal augmentation is a very common procedure in our practice. If cancer patients remain disease free and have no local recurrence for 5 years, they may also be able to have autologous fat transplantation to the tumor-resected area, or a transferred flap for contour improvement.4 In patients with hemifacial atrophy, their soft tissue atrophy usually progressed during adolescence, then stabilized in the atrophic area. Before surgery, it is important to ensure that hemifacial atrophy has stabilized; we recommend at least 2 years of stability. In patients with severe congenital craniofacial defects, such as hemifacial microsomia, who have correctable skeletal abnormalities, their skeletal contour needs to be corrected before improvement of the soft tissue contour is even considered. However, if the soft tissue becomes almost completely atrophic, earlier intervention with fat grafting can improve or prevent further atrophy of the overlying skin and may prevent or lessen subsequent skeletal wasting. We have observed that in patients with facial soft tissue atrophy and overlying skin pigmentation, not only can fat grafting improve facial soft tissue symmetry but it can also improve the pigmentation of the overlying skin.

Preoperative Assessment Patients should be informed about autologous fat transplantation—including its benefits, limitations, and potential complications—as an option for soft tissue augmentation. Before surgery, surgeons should thoroughly discuss autologous fat transplantation with patients to try to ensure maximal results and reliable postoperative compliance. The patient should understand that he or she may require two or three fat injections at intervals of 3 to 6 months. During the initial preoperative visit, various surgical details should be determined, including the extent and thickness of facial recontouring required, the location of available donor sites, and the quantity of fat needed. Standard preoperative photos are taken for each patient during this visit. A three-dimensional imaging scan may nicely illustrate the contour deformity of the face, facilitate postoperative follow-up, and provide a comparison of the outcome both before and after surgery.

Chapter 10 

Fat Grafting for Facial Contouring

Surgical Technique No matter what technique a surgeon may use, the most important factor to achieve better outcomes with autologous fat grafting is the viability of the adipocytes within the fat graft . To maintain more viable adipocytes of fat during surgery (and thus a higher survival rate of grafted fat), we created the “3L and 3M” technique.5 Our 3L and 3M technique consists of low negative pressure for harvesting fat, low speed centrifugation for processing, and low volume (0.1 cc) for each injection. Fat grafts are injected into multiple layers, tunnels, and areas, thus maintaining the greatest viability of adipose tissue. We prefer to use donor sites in the lower part of the body, such as the lower abdomen or thigh. If necessary, repeated fat grafting can be performed after at least 3 months. In some patients with significant contour deformity, two or three consecutive procedures may be required (Fig. 10-2).

E

A

B

C

D

F

Fig. 10-2  A, Marking the injection region. B, Injecting a local anesthetic. C, Incision. D, Subcutaneous layer and submuscular layer. E, The different layers in which the injection can be performed. F, Postoperative massage.

119

120

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

Fig. 10-3  To provide suction with the hand to keep low negative pressure, one must reserve several milliliters in the syringe before pulling back the plunger.

Fig. 10-4  Purifying the fat with a low-speed centrifugation machine. The speed should not exceed 1000 rpm.

A tumescent solution containing 0.08% lidocaine and 1:500,000 of epinephrine is infiltrated into the donor site. A 2.5 mm suction cannula with two holes in the tip is connected with a 50 ml syringe for fat graft harvesting. An appropriate amount of fat is gently aspirated with fi ger pressure on the plunger of the syringe, without using a suction machine, to minimize trauma to the adipose tissue (Fig. 10-3). The harvested tissue is then washed with normal saline solution inside the syringe in sterile conditions to remove lidocaine, oil, and residual red blood cells, and then is spun at low speed (1000 rpm, g force ,100 g) for 2 minutes (Fig. 10-4). After centrifugation, the middle layer of the aspirate—which primarily consists of usable fat parcels—is used for fat injection. The lowest liquid is thrown away, then the middle layer is transferred into the 1 ml or 2 ml syringe through a triple valve, and the rest of the liquid—the upper layer of oil in the 10 ml syringe, which was removed from the centrifugal machine—was also thrown away. The entire procedure is performed within 30 minutes, and the temperature of the lipoaspirates is controlled at 25° C.

Chapter 10 

Fat Grafting for Facial Contouring

121

Fat is injected into multiple tissue areas—within subcutaneous tissue, under the SMAS, and in multiple tissue planes and tunnels—with a syringe connected to a blunt needle that has an external diameter of 2 or 3 mm. Care is taken to inject fat parcels only in small quantities, in one place each time, and radially from distal to proximal. In the buccal area, the needle should be parallel to the facial nerve to avoid direct injury to the nerve. The syringe should be drawn back before each injection to check blood return, with the aim of avoiding hematoma or injection of fat grafts into blood vessels, causing possible fat emboli. In the periorbital area, the surgeon should take extra care to prevent intraarterial injection by using a smaller injection needle. In our practice, we routinely inject 20% to 30% more than the required volume of fat graft in each patient as an overcorrection to compensate for potential absorption after facial recontouring. To ensure a smooth correction, the surgeon can gently massage the patient’s periorbital area with his or her fi ger or palm. In general, the entire procedure takes approximately 60 minutes and is usually performed with one or two assistants. The grafted site of the face should be immobilized with a compression dressing for 1 week. Patients should be instructed to reduce or avoid moving their facial muscles if possible, because these movements could traumatize the newly formed blood vessels around the injected fat grafts. All patients are seen postoperatively at 1 week, 1 month, and 3 months, and standard photos are taken during each visit. These photos are used to compare the facial contour in the injection sites preoperatively and postoperatively. If the volume of the injected area is stable but the outline of the facial contour is not satisfactorily improved 3 months after the fi st injection, a second injection is indicated, usually after 3 to 6 months, to add more volume of fat to the area. We use an integrated fat grafting technique known as the “3Ls and 3Ms” technique rather than Coleman’s technique. In our technique, fat grafts are harvested under low pressure with syringes, processed with lowspeed centrifugation, and then injected into the affected areas of the face with low volume for each pass through multiple tunnels, multiple planes, and multiple points. If necessary, the second injection will be performed 3 to 6 months later.

Postoperative Care Slight bruising and swelling will be seen during the fi st week after surgery. Typically, no obvious scar will be visible during follow-up. Some patients may complain about their appearance in the first month. If a fatty clump still exists after the fi st month, we recommend that the patient massage the site. Sometimes patients complain of swelling in the upper eyelid, which may be caused by the tight compression bandage, which may be loosened to lessen the swelling. Patients may also massage the area if they develop small cysts or minor sclerosis.

K23345_Pu_c10_Fat Graft for Face_r4_cl_117-128.indd 121

4/2/2015 2:34:48 PM

122

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

Results

Preoperative

1 week after first injection

3 months after first injection

7 months after second injection

Fig. 10-5 Th s 30-year-old woman complained about her thin face and temporal concavity, and underwent two autologous fat transplantations, with the second injection occurring 6 months after the fi st one. She achieved the fullness she desired in her buccal and temporal areas.

K23345_Pu_c10_Fat Graft for Face_r4_cl_117-128.indd 122

4/2/2015 2:34:52 PM

Chapter 10 

Preoperative

123

Fat Grafting for Facial Contouring

1 week postoperatively

1 month postoperatively

3 months postoperatively

Fig. 10-6 Th s woman had been treated for a hemangioma with resection and isotope therapy on the left side of her face when she was 20 years old. At age 33 she expressed a desire to address the scar and to improve the concave area beneath the scar. The patient had one autologous fat transplantation session. The buccal area was almost symmetrical as a result, and the scar was to be treated 6 months after the injection. However, augmented fat in the injection site resorbed somewhat during the next 3 months, then stabilized. No further absorption was evident after 3 months, and the injection site on her face remained stable throughout her long-term follow-up.

K23345_Pu_c10_Fat Graft for Face_r4_cl_117-128.indd 123

4/2/2015 2:34:54 PM

124

Part II 

Preoperative

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

After first fat grafting

After second fat grafting

Fig. 10-7 Th s 24-year-old woman had severe hemifacial atrophy on the right side. Her disease had progressed gradually since her childhood but stabilized at age 17. Her disease had been stable for approximately 7 years when she presented to our clinic. She received a total of three subsequent autologous fat transplantations to the right side of her face. Her facial contour on the affected side improved signifi antly with each injection. She had good facial symmetry, with decreased skin pigmentation on the affected side.

K23345_Pu_c10_Fat Graft for Face_r4_cl_117-128.indd 124

4/2/2015 2:34:54 PM

Chapter 10 

Fat Grafting for Facial Contouring

Fig. 10-8 Th s 37-year-old woman with sunken eyes underwent autologous fat transplantation to her upper periorbital area. The fat was aspirated from her abdomen with a 1 mm cannula. Local anesthetic with epinephrine was infiltrated into her periorbital soft issue to create vasoconstriction. A total of 2.5 cc of purifi d fat was injected into the orbital septum of each side of her face with our preferred fat grafting technique; a much smaller cannula was used for fat injection, with 0.1 cc injected in each pass. Only one session of fat injection was needed for this patient. At 1-year follow-up, she looked much younger and was quite pleased with the outcome.

Discussion Grafted autologous fat demonstrably survives after transplantation, although fat grafting is reported in the literature to have unpredictable results. The long-term results are more encouraging, because many of our patients were followed longer than 2 years with well-maintained correction of their soft tissue deficie cies. During follow-up, the perioral area in our patients was found to have more absorption than other facial areas such as the forehead and chin; thus it is evident that the perioral area requires more procedures to improve facial contour. The muscular movements of facial expression and chewing may contribute to less fat graft survival; as a result, patients should be instructed to avoid unnecessary facial movement after fat grafting. Overcorrection should not involve more than 20% to 30% of the volume actually needed; otherwise, lumpiness may occur. On the other hand, the perioral area generally has less fat than other areas, so this friendly environment may make fat graft urvival feasible.6 Autologous fat grafting can be a permanent option for many patients who are looking for cosmetic soft tissue contouring of the face, even if they need additional procedures. Our integrated fat grafting technique has several aspects that are different from Coleman’s technique. Our methods are based not only on fi dings from our previous experiments but also on studies conducted by others. Harvesting fat grafts with a syringe can be performed at low negative pressure by using several milliliters of air or saline solution before aspiration; thus low negative pressure can be generated with hand manipulation to aspirate fat grafts while simultaneously avoiding mechanical trauma to adipocytes. Centrifugation is often necessary to purify fat for transplantation.7,8 In Coleman’s technique, centrifugation at 3000 rpm for 3 minutes is a standard way to process the harvested fat graft 9; however, our previous studies demonstrated that adipocytes within fat grafts have less viability when the speed of centrifugation

125

126

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

is more than 1000 rpm.10 Our preferred centrifugation setting of 1000 rpm for 2 minutes can provide not only a high purity of fat but also more viable adipocytes within the fat grafts Although very rare, fat embolism may develop after fat grafting to the face and may lead to ablepsia, hemiplegia, shock, or even death. Fortunately, the incidence of these complications is extremely low; only two or three cases have been reported every year since the fat grafting technique started to be used widely for facial contouring.11-18 Because there are communicating branches between the internal and external carotid artery systems in the craniofacial area, the increased pressure of fat injection or an arteriovenous shunt will open these communication branches. The fat emboli will enter the internal carotid artery system vessels and cause a fat embolism. The communicating branches, such as the occipital artery–vertebral artery, ascending pharyngeal artery–vertebral artery, or internal maxillary artery–ophthalmic artery, are closed in the normal condition,19 but when the pressure of the external carotid artery system increases, these communicating branches can be opened. All reported fat embolism cases took place shortly after the operation and were without pulmonary embolism; therefore we believe that fat emboli may travel to the embolic site through the communicating branches. To avoid these severe complications, we recommend use of a blunt tip and cannulas of appropriate width for fat injection. The injection itself should be gentle and not forceful, and should be performed only while the syringe is being withdrawn. In addition, the surgeon should look for the tunnel carefully before each injection.

Pearls for Success • Th oughout the entire procedure, it is important to maintain the viability of the adipocytes within the fat grafts • There should be low negative pressure for fat graft arvesting, low speed centrifugation for fat graft processing, and low volume for placement of fat grafts • Fat grafts are injected into multiple tunnels, planes, and areas of the tissue. • Proper immobilization of the recipient area is necessary postoperatively, and suitable massage to the grafted area should be performed if indicated. • If necessary, additional fat grafting can be performed after at least 3 months to achieve the desired results. Two or three additional procedures may be required.

Refer ences 1. Sommer B, Sattler G. Current concepts of fat graft urvival: histology of aspirated adipose tissue and review of the literature. Dermatol Surg 26:1159-1166, 2000. 2. Coleman SR. Structural fat grafting: more than a permanent filler. Plast Reconstr Surg 118(3 Suppl):108S-120S, 2006. 3. Xie Y, Zheng DN, Li QF, Gu B, Liu K, Shen GX, Pu LL. An integrated fat grafting technique for cosmetic facial contouring. J Plast Reconstr Aesthet Surg 63:270-276, 2010. 4. Zheng DN, Li QF, Lei H, Zheng SW, Xie YZ, Xu QH, Pu LL. Autologous fat grafting to the breast for cosmetic enhancement: experience in 66 patients with long-term follow up. J Plast Reconstr Aesthet Surg 61:792-798, 2008. 5. Xie Y, Li Q, Zheng D, Lei H, Pu LL. Correction of hemifacial atrophy with autologous fat transplantation. Ann Plast Surg 59:645-653, 2007. 6. Ergün SS, Cek DI, Baloğlu H, et al. Why is lip augmentation with autologous fat injection less effective in the vermilion border? Aesthetic Plast Surg 25:350-352, 2001. 7. Coleman SR. Facial recontouring with lipostructure. Clin Plast Surg 24:347-367, 1997. 8. Asken S. Autologous fat transplantation: micro and macro techniques. Am J Cosmet Surg 4:111-1 21, 1987. 9. Lei H, Li QF. Study on influence of centrifugation on fat viability. Chinese J Aesthet Med 14:21-24, 2005.

Chapter 10 

Fat Grafting for Facial Contouring

127

10. Xie Y, Zheng D, Li Q, Chen Y, Lei H, Pu LL. The effect of centrifugation on viability of fat grafts: n evaluation with the glucose transport test. J Plast Reconstr Aesthet Surg 63:482-487, 2010. 11. Park SH, Sun HJ, Choi KS. Sudden unilateral visual loss after autologous fat injection into the nasolabial fold. Clin Ophthalmol 2:679-683, 2008. 12. Dreizen NG, Framm L. Sudden unilateral visual loss after autologous fat injection into the glabellar area. Am J Ophthalmol 107:85-87, 1989. 13. Teimourian B. Blindness following fat injections. Plast Reconstr Surg 82:361, 1988. 14. Egido JA, Arroyo R, Macros A, Jiménez-Alfaro I. Middle cerebral artery embolism and unilateral visual loss after autologous fat injection into the glabellar area. Stroke 24:615-616, 1993. 15. Lee DH, Yang HN, Kim JC, Shyn KH. Sudden unilateral visual loss and brain infarction after autologous fat injection into nasolabial groove. Br J Ophthalmol 80:1026-1027, 1996. 16. Feinendegen DL, Baumgartner RW, Schroth G, et al. Middle cerebral artery occlusion AND ocular fat embolism after autologous fat injection in the face. J Neurol 245:53-54, 1998. 17. Yoon SS, Chang DI, Chung KC. Acute fatal stroke immediately following autologous fat injection into the face. Neurology 61:1151-1152, 2003. 18. Thaunat O, Thaler F, Loirat P, et al. Cerebral fat embolism induced by facial fat injection. Plast Reconstr Surg 113:2235-2236, 2004. 19. Qin Z, Cao J, Li K, et al. [Maxillofacial vascular malformation associated with abnormal communication between external carotid and cranial arteries] Chinese J Otorhinolaryngology 36:129-131, 2001.

K23345_Pu_c10_Fat Graft for Face_r4_cl_117-128.indd 127

4/2/2015 2:34:54 PM

K23345_Pu_c10_Fat Graft for Face_r4_cl_117-128.indd 128

4/2/2015 2:34:54 PM

11 Total Facial Rejuvenation With Microautologous Fat Transplantation

S

Tsai-Ming Lin

urgeons use face lift (rhytidectomy) to rejuvenate the face by cutting away redundant skin and redraping and tightening the underlying tissues. However, the benefits in proportion to the risks of such a procedure have been challenged for a long time, with some investigators maintaining that the face lift should be replaced with other more simplifi d strategies. The use of botulinum A toxin and soft issue fillers are options favored by many doctors and patients. However, the use of a simple, effective, and rational approach for facial rejuvenation—fat grafting, also called lipofilling, liposculpture, and fat transfer—is gaining in popularity for Asian patients, because of the major downsides to a face lift or the injection of fillers: its cost, signifi ant down time, the relatively short duration of its affects and the need for repeat procedures, and the potential for complications. Fat grafting was introduced by Neüber in 1893.1 Since then, many developments in fat grafting techniques have been proposed to increase the fat survival/retention rate.2-6 Surgeons have investigated numerous innovative methods to perform fat grafting.7-11 In addition to the effect of volume refilling (restoration/ augmentation), recent reports demonstrating the rejuvenating and resurfacing effects of the fat graft n skin texture suggest the existence of, and benefits of, adipose-derived stem cells/stromal vascular fractions in the transplanted fat.12,13 As a result, we have entered an extraordinary era of possibility for autologous fat transfer. In this chapter, the concept of microautologous fat transplantation (MAFT) and its role in total facial rejuvenation for Asian patients are introduced. The instruments and surgical procedures involved in MAFT are described in detail, and several case studies are included to demonstrate the efficacy and safety of this innovative procedure for facial rejuvenation.

129

130

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

Facial Aging and the New Concept of Facial Rejuvenation The aging process occurs throughout every person’s lifetime; no one can escape it. All over the world, in many societies, people are focusing on their health and the pursuit of an attractive appearance and a beautiful body image. Thus the demand for facial rejuvenation is growing, with patients seeking less-invasive procedures with a shorter recovery time. Surgeons are continuously striving to develop techniques that achieve facial harmony, balancing tension on remaining tissues versus volume restoration with an awareness of the effects of tissue atrophy, and focusing on regeneration.

What Is Micr oaut ol o go us Fat Trans pl ant atio n?

Grafted fat does not begin to regain its blood supply until 48 hours after implantation (neovascularization formation)14; this occurs because initially, the infl w of nutrients and outfl w of metabolites through the cell membranes (adipocytes) depends on the physiologic phenomena of direct diffusion and plasmatic imbibition. Carpaneda and Ribeiro9 demonstrated that the central area of transplanted fat will eventually be necrosed, and only approximately 40% of the marginal zone survives at 1.5 6 0.5 mm to the grafted margin. Some studies have shown that many complications after fat grafting, such as absorption, abscess, infection, cyst formation, fibrosis, calcifi ation, ossifi ation, and asymmetry, are related primarily to an implanted parcel that was overlarge.15 According to this theory, the phenomenon of central necrosis induces a chain reaction that leads to many complications and an unpredictable survival/retention of the fat graft. Therefore, as Fournier5 highly recommended, the smallest possible parcel of fat should be transferred. Based on the theory postulated by Carpaneda and Ribeiro9 and by using their mathematic formula, fat volume—in this case, each grafted fat parcel is presumed to be spherically shaped—is calculated by the following formula: the volume of a globe/sphere 5 (4 ∕3)pr3; r 5 the radius of the sphere; and p 5 the ratio of any circle’s circumference to its diameter in Euclidean space. Fig. 11-1demonstrates that the fat volume at a radius of 1, 1.5, and 2 mm is 4.2, 14.1, and 33.5 mm3, respectively. I have concluded further that the injecting frequency of 1 cc of grafted fat as a sphere 1 mm in radius was calculated by 1000 mm3 (1 cc) divided by 4.2 mm3, yielding 240, and that a sphere 2 mm in radius was calculated by 1000 mm3 (1 cc) divided by 33.5 mm3, yielding 30. Therefore the injection frequency of each 1 cc (1000 mm 3) of grafted fat was more accurately set between the two yields of 30 and 240 to achieve a higher survival rate by avoiding the formation of central necrosis. Fig. 11-2shows the size of a fat parcel in proportion to a sphere at a volume of 1 cc, 1∕10 cc, 1∕30 cc, 1∕60 cc, 1∕90 cc, 1∕120 cc, 1∕150 cc, 1∕180 cc, and 1∕240 cc. The difference in the sizes of these fat parcels is readily apparent.

What Micr oaut ol o go us Fat Trans pl ant atio n Empha sizes # Radius # 2 mm and How It1 mm Wor ks

Anr 5Innovative Delivery of Microautologous Fat Transplantation 1.0 mm: volumeInstrument of the sphere is (for ∕ )p(1.0) 5 4.2 mm 4

3

3

3

1.5 mm: volume of the sphere is (4∕3)p(1.5)3 5 14.1 mm3 Thrr 5 multiple orientations volume adjustable microinjection device (MOVAMID) kit is a surgical combination 5 2.0 mm: volume of the sphere is (4∕3)p(2.0)3 5 33.5 mm3

set for autologous fat transplantation or biocompatible filler injections (Fig. 11-3).The of the Fig. 11-1  The fat volume at acentral radius offeature 1, 1.5, and Total Injection Frequency MOVAMID kit is the MAFT-Gun (Fig. 11-4), which provides an innovative operating system to deliver 2 mm is shown. The total injection frequency per 1 cc a 3 Radius of 1 cc 1 1(1000 mm 1 1 ) 1 1 (1000 mm3) of fat is 240, 70, and 30, respectively. ∕ 60 , ∕ 90 , ∕ 120 , ∕ 150 , ∕ 180 , or ∕ 240 cc per injection to meet the needs of surgeons fat graft with aVolume flex bleofvolume of (mm) Sphere (mm3) Fat Grafting performing fat grafting in different areas of the body.16 Ease of use and ergonomic characteristics, such as 1.0  4.2 1000/4.2 5 240 the ability to freely change the aperture position of the injection needle, make this state-of-the-art device 16 1.5 14.1 a valuable tool for fat grafting. 1000/14.1 5 70 2.0

33.5

1000/33.5 5 30

Chapter 11 

Total Facial Rejuvenation With Microautologous Fat Transplantation

1

∕10 cc

1 cc

Fig. 11-2  The size ratios of spheres at 1 cc, ∕10 cc, ∕30 cc, ∕60 cc, ∕90 cc, ∕120 cc, ∕150 cc, ∕180 cc, and 1∕240 cc are shown.

1

1

1

1

1

1

1

1

∕120 cc

1

∕30 cc 1

∕150 cc

1

∕60 cc 1

∕180 cc

1

∕90 cc 1

∕240 cc

Fig. 11-3  The MOVAMID kit is a surgical combination set for autologous fat transplantation and biocompatible filler injections, suitable for all parts of the body. (Courtesy of Dermato Plastica Beauty Co., Ltd., Kaohsiung, Taiwan.)

Fig. 11-4  The MAFT-Gun. (Courtesy of Dermato Plastica Beauty Co., Ltd., Kaohsiung, Taiwan.)

What Micr oaut ol o go us Fat Trans pl ant atio n Empha sizes and How It Wor ks

An Innovative Instrument for Delivery of Microautologous Fat Transplantation Th multiple orientations volume adjustable microinjection device (MOVAMID) kit is a surgical combination set for autologous fat transplantation or biocompatible filler injections (Fig. 11-3).The central feature of the MOVAMID kit is the MAFT-Gun (Fig. 11-4),which provides an innovative operating system to deliver a fat graft with a flex ble volume of 1∕60, 1∕90, 1∕120, 1∕150, 1∕180, or 1∕240 cc per injection to meet the needs of surgeons performing fat grafting in different areas of the body.16 Ease of use and ergonomic characteristics, such as the ability to freely change the aperture position of the injection needle, make this state-of-the-art device a valuable tool for fat grafting.16

131

132

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

The transmitting system of the MAFT-Gun is designed to deliver a minimum injection volume of 1∕240 cc per parcel (from 1∕60 cc to 1∕240 cc) by pulling the trigger.17 With the microdelivery mechanism, the radius of each injected droplet/bolus is between 1 and 2 mm by pulling the trigger, the dimension that has been documented in studies as essential to decrease the potential for central necrosis after fat grafting.9 The survival/ retention rate can be improved when each droplet is transplanted in such a small volume (1∕60 to 1∕240 cc), and there should be less potential for central necrosis, the main cause of morbidities after fat grafting.

Precise, Accurate, and Consistent Placement of Small Fat Parcels Coleman18 has emphasized that each parcel must be between 1∕30 and 1∕50 cc per injection in difficult sites such as the periorbital area. Many types of ratchet guns were used clinically for decades in fat grafting. However, the minimum delivery volume per triggering was only 1∕10 cc, which was accurate but not low enough to match the requirement of Coleman’s concept.18 The underlying subcutaneous tissue, where fat grafting is primarily placed, has strong, fibrous septa with tough fascia and ligaments in between. Traditionally, when surgeons used a cannula to push tiny fat parcels, they often encountered resistance from the tissue; thus they had to use more injection pressure than necessary. Therefore a larger fat parcel was delivered, and this larger volume was impossible to aspirate out. A consistent volume of each tiny fat parcel per injection is essential to avoid transplantation of a large parcel that will subsequently lead to morbidity. The low volume of each parcel (ranging from 1∕60 cc to 1∕240 cc) must be predetermined by switching the adjustable dial and consistently maintaining it through the triggering of the MAFT-Gun. With this device, the surgeon can maneuver easily, expending much less effort throughout the procedure.

Avoiding Excess Swelling and Protracted Down Time To transplant miniature fat parcels with an injection cannula, the surgeon must use a tunneling maneuver—with to-and-fro or back-and-forth movements—to loosen the subcutaneous tissues and simultaneously place the tiny fat parcels. However, such a maneuver unavoidably creates signifi ant tissue trauma and necessitates a longer recovery time for the patient, because of postoperative swelling and ecchymosis. If the strong and tough adherent subcutaneous tissue is not loosened by this maneuver, many larger or huge fat droplets can be dislodged through abrupt overinjection when the tissue resistance is suddenly lost. With the microcontrolling system of the MAFT-Gun, a predetermined injection volume of each parcel is secured by a selection on the six-grade adjustable dial—for example, the 240 setting means that each parcel will trigger at 1∕240 cc, and so on—with uniform control throughout the procedure. A steady, precise, and consistent volume is therefore transmitted by each pull of the trigger, regardless of the strength exerted by the surgeon or the speed of injection. For decades in traditional fat grafting, patients developed severe bruises and hematomas in the fi st 2 weeks after fat grafting. They were frustrated by having a monsterlike or beat-up appearance and avoided any outings or social gatherings during this stage of recovery. Studies have reported that some persistent swelling remained up to 16 weeks.19 With the MAFT-Gun, the tunneling movement is unnecessary and avoidable, because the fat can easily be delivered by pulling the trigger while withdrawing the instrument. Therefore the downtime or recovery after fat transplantation may be shortened. As seen in Fig. 11-5,only mild swelling and ecchymosis results from the procedure.

Chapter 11 

Total Facial Rejuvenation With Microautologous Fat Transplantation

A

B

C

D

Fig. 11-5  A and B, Th s 67-year-old woman had fat grafting performed through the traditional technique. She is shown

with preoperative markings and in the postoperative period. C and D, Th s 63-year-old woman underwent microautologous fat transplantation with a MAFT-Gun. She is shown with preoperative markings and 2 days after surgery.

Alternative to Overgrafting Two depressions (a and b) are illustrated in Fig. 11-6,A, as analogous to two soft issue deficie cies. Frequently, as Fig. 11-6,B shows, the surgeon overinjects two large fat parcels (1 and 2) in the sunken areas when performing augmentation. Then the surgeon vigorously massages the surface to reshape it evenly and smoothly (Fig. 11-6,C). However, after massage and manipulation, the fat parcels tend to form a confluent mass (large yellow mass outlined in Fig. 11-6,C). Although the surface of the skin will look smooth and flat postoperatively for days to weeks, the unavoidable central necrosis (dark brown zone) and the remolding processes, including absorption and fibrosis, continue and evolve (Fig. 11-6, D). Eventually, the skin develops an irregularity, and an uneven surface appears over the grafted area, presenting a potential morbidity. The parcel delivered by a MAFT-Gun can be adjusted according to the variable characteristics of the areas to be grafted and the different droplet sizes selected. Therefore the structural fat graft is fully achieved through MAFT, not only in the filling effect, but also by obviating the need for overinjection and its related complications (Fig. 11-7).

133

134

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

A

B a

b 1

C

2

D

Fig. 11-6  A and B, Fat grafting with overcorrection. C and D, With vigorous massage, the graft ake evolves over several weeks.

1 1 1 1

∕30 cc

∕60 cc

∕120 cc

∕240 cc

Fig. 11-7  A higher filling effect can be achieved by MAFT, because minute parcels of fat can be injected.

High Performance Clear markings with 360 degree multirange adjustability of the instrument provide precise control of the injection direction. With this innovation, a surgeon can change the pinhole of a cannula freely, comfortably, and accurately as needed. Th s multiorientation design reduces the effort needed by the surgeon and increases the smoothness of his or her performance. With its simple pulling maneuver, the user-friendly trigger system enables the predetermined volume of each parcel to be delivered precisely. Moreover, rightor left- andedness can be set in advance in each handpiece.

Indications The aging face is characterized by soft issue loss, ptosis, and atrophy. The MAFT technique can be used to achieve both recontouring and rejuvenating effects. The areas of the aging face on which MAFT can be performed include the forehead, sunken temporal area, sunken upper eye, nasojugal groove, lid-cheek junction, midcheek furrow, dorsum of the nose, cheek, nasolabial groove, marionette lines, upper and lower lip, chin, jawline, and prejaw depression. In addition, MAFT can be performed on some other parts

K23345_Pu_c11_Total Fac Rejuv Fat Trans_r6_dc_129-148.indd 134

4/2/2015 3:55:13 PM

Chapter 11 

Total Facial Rejuvenation With Microautologous Fat Transplantation

of the human body (see the Discussion section). However, if the aging problems of the face involve excess skin or redundancy, some adjunctive procedures, such as blepharoplasty or face lift, an be combined as a necessary treatment strategy.

Preoperative Assessment Preoperative assessment should consist of the following: • Assessing the patient’s general health • Obtaining informed consent from the patient for the anesthetic, operation, and photographs • Marking the recipient areas while the patient is sitting upright • Evaluating the appropriate donor sites • Informing the patient that it may be necessary to perform touchup surgery in some areas to achieve optimal results

Surgical Technique The guidelines for performing MAFT will be discussed according to several categories: harvesting of fat, processing and refi ement of fat, transplantation and perioperative management.20

Har ves ting

Harvesting is the first step for obtaining good-quality fat for processing and refinement (Box 11-1 and Fig. 11-8). Meticulous liposuction without massive damage to the adipocytes/preadipocytes is the main goal. Having a lower aspiration pressure with smaller suction cannulas is preferable to using higher pressure with cannulas larger than 3 mm in diameter.20 Total intravenous anesthesia (TIVA) is optional, and use of a tumescent solution is what I prefer, although some studies discuss the negative effect of the ingredients. Various donor sites are advocated; however, from a regenerative viewpoint, many investigators think that some parts of the body might be preferable to others.

Box 11-1  Harvesting of Fat in MAFT

1. Preferably, all MAFT procedures should be performed with TIVA. 2. Fat is harvested with a blunt-tipped cannula that is smaller than 3 mm in diameter, with various numbers of side holes, as the surgeon prefers. 3. Tumescent solution is infiltrated in donor areas such as the abdomen or thigh. Components of

the tumescent solution are Ringer’s lactate, 2% lidocaine (Xylocaine), and epinephrine, at a ratio of 30:10:0.2 ml. The infiltration volume and the tumescent volume combined are equal to the lipoaspirated volume. 4. Manual liposuction is best performed with a 10 cc Luer-Lok syringe connected to the harvesting cannula. Pressure is maintained by back-pulling to between 2∕10 and 3∕10 cc, at approximately 200 mm Hg, as suggested in the literature. 5. When using a liposuction machine for harvesting, the negative pressure must be kept between 200 and 300 mm Hg.



From Chou CK, Lin TM, Chiou JH, et al. Influential factors in autologous fat transplantation­—focusing on the lumen size of injection needle and the injecting volume. Int Confed Plast Reconstr Aesthet Surg (IPRAS) J 9:25-27, 2012.

135

136

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

Fig. 11-8  Harvesting the fat.

Fig. 11-9  The aspirate was refi ed and processed for 3 minutes at 3000 rpm by centrifugation.

Fig. 11-10  With a MAFT-Gun, an average of 18.5 cc (range 4.0 to 55.5 cc) of refi ed fat was precisely microtransplanted. The purifi d fat was transferred from a 10 cc syringe to a 1 cc Luer-Slip syringe.

Box 11-2  Processing and Refi ement of Fat in MAFT 1. When dealing with lipoaspirate, unnecessary manipulation of the fat must be minimized, and prolonged exposure to ambient air must be avoided. 2. The lipoaspirate contained in syringes is evenly placed in the centrifuge (see Fig. 11-10). 3. The lipoaspirate is centrifuged at 3000 rpm for 3 minutes (keeping the g-force at approximately 1200 g). 4. The lipoaspirate is further refi ed by wicking out the upper oil layer and draining away the lower contents of blood and debris. 5. The purifi d fat is transferred into several 1 cc Luer-Slip syringes. From Chou CK, Lin TM, Chiou JH, et al. Influential factors in autologous fat transplantation—focusing on the lumen size of injection needle and the injecting volume. Int Confed Plast Reconstr Aesthet Surg (IPRAS) J 9:25-27, 2012.

Chapter 11 

Total Facial Rejuvenation With Microautologous Fat Transplantation

137

Pr o cess ing and Refinement

The main purpose of the processing and refi ement step is to purify the harvested fat (lipoaspirate) to a more condensed state by centrifuging the lipoaspirate to separate the blood and tumescent solution from the adipose tissue (Figs. 11-9 and 11-10 and Box 11-2). Ths process must be performed carefully to avoid damage to the cells and to reduce potential contamination. I prefer to centrifuge the lipoaspirate at 3000 rpm for 3 minutes using a table centrifuge, with a g-force of approximately 1200 g.20 After centrifugation, the upper oil fraction, which consists of lipid content released by ruptured or damaged cells (adipocytes or preadipocytes), is wicked away, and then the lower bloody part, which is primarily a tumescent solution mixed with blood and debris from the adipose tissue, is removed. Next the purifi d fat is transferred into several 1 cc Luer-Slip (not Luer-Lok) syringes for transplantation.

Trans pl ant atio n

The actual transplantation of the fat plays a very important role in MAFT. Instruments including a MAFTGun (1 cc for the face and 5 cc for the breasts, buttocks, and other larger areas) and injection cannulas (a blunt-tipped cannula with one side hole is preferred) of different sizes (14-gauge, 16-gauge, and 18-gauge) are required.20 The insertion sites that I typically use are shown in Fig. 11-11,and Fig. 11-12 shows the injection. Box 11-3and Table 11-1list the procedural steps and suggested details for transplantation. The novice surgeon must practice these techniques for a significant period to gain mastery, and the learning curve

A

B

A1

Forehead: A1, A2, B1

A1

B1

B1

A2

A2

C1

C1

E1

M1

Upper sunken eyes: C1 Cheek: F1 Tear trough, lid-cheek junction: F1

E1

N

F1

Temporal fossa: B1

Nose: N

F1

Nasolabial fold, marionette line: M1, J1

M1 J1

Chin, prejaw depression: J1

J1

Earlobe: E1

C

D

A1

A1 B1

A2

A2 C1

F1

N

J1

C1 F1

E1 F1

M1

B1

M1

N E1 M1

J1 J1

Fig. 11-11  Recommended facial insertion sites for MAFT facial rejuvenation.

138

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

Box 11-3  Transplantation in MAFT 1. Choose the predetermined fat volume per triggering (see Table 11-1). 2. Select the facial insertion sites (see Fig. 11-8). 3. Use injection needles with a blunt tip and one side hole: 18-gauge for the face, 16-gauge for the neck and hands, and 14-gauge for the breasts (with 16-gauge for the superfic al/subcutaneous layer).20 4. Load the fat-filled 1 cc syringe and expel the air in the injection cannula by triggering, then insert the cannula tip through a 2 to 3 mm stab wound with a No. 11scalpel. 5. Select the fat output direction (N for upward, S for downward, E for right, and W for left). Usually S is selected for all layers; however, this might change to N for superfic al layers when a tenting effect is required. 6. While withdrawing the MAFT-Gun, the tempo of the triggering must be stable, steady, and rhythmic. 7. Deliver the fat from the deeper, middle, and then superfic al layers, in a fan-shaped manner; a crisscross pattern might be necessary in some recipient areas. 8. Avoid overcorrection by delivering more fat volume than normally required. The endpoint of the MAFT depends on the fullness of the recipient area. From Chou CK, Lin TM, Chiou JH, et al. Influential factors in autologous fat transplantation—focusing on the lumen size of injection needle and the injecting volume. Int Confed Plast Reconstr Aesthet Surg (IPRAS) J 9:25-27, 2012.

Table 11-1  Instrumentation and Volume by Facial Region Fat Parcel per Triggering (cc)

Type of Cannula

Superficial Layer

Insertion Site of Cannula

Crisscross

Average Volume (cc)

1

∕150

A1, A2, B1

As possible

10-25

∕120

1

∕150

B1

—

5-10

1

∕240

1

∕240

C1

—

1-3

1 240

∕

1

∕240

1

∕240

F1

—

0.5-4

1

∕150

1

∕150

1

∕180

N

—

3-8

One

1

∕120

1

∕120

1

∕150

F1

As possible

6-12

Blunt

One

1

∕120

1

∕120

1

∕150

F1, J1

As possible

3-10

∕18

Blunt

One

1

∕120

1

∕120

1

∕150

F1, J1

As possible

1-2

Upper/lower lip

18

Blunt

One

1

∕180

1

∕180

1

∕180

M1

As possible

0.5-3

Chin

16

∕18

Blunt

One

1

∕120

1

∕120

1

∕150

J1

As possible

4-14

Prejaw depression

16

∕18

Blunt

One

1

∕120

1

∕120

1

∕150

J1

—

1-4

Earlobe

18

Blunt

One

1

∕180

1

∕180

1

∕180

E1

—

1-3

Deep Layer

Middle Layer

Size (gauge)

Tip

Side Hole

Forehead

16

Blunt

One

1

∕120

1

∕120

Sunken temporal fossa

16

∕18

Blunt

One

1

∕120

1

Sunken upper eyelid

18

Blunt

One

1

∕240

Nasojugal groove and lid-cheek junction

18

Blunt

One

Nasal dorsum

18

Blunt

One

Cheek

16

∕18

Blunt

Nasolabial groove

16

∕18

Marionette line

16

Area

Chapter 11 

Total Facial Rejuvenation With Microautologous Fat Transplantation

Fig. 11-12  MAFT was performed over the patient’s forehead, temporal fossa, sunken upper eyelids, nasojugal grooves, cheeks, nasolabial grooves, marionette lines, chin, and lips.

Fig. 11-13  Flesh-colored tape was applied postoperatively over her recipient areas.

will vary among individuals. To determine the endpoint of the MAFT procedure, the surgeon will feel fullness over the recipient areas; each time the surgeon performs the MAFT procedure, he or she should gain more confide ce in properly sensing this fullness over the recipient areas.

Per io pera tive Man a gement

Because patient safety is important in each cosmetic procedure, perioperative care is highly recommended by well-trained nursing personnel. Some notes regarding MAFT during the perioperative stages are outlined in Box 11-4and shown in Fig. 11-13. Autologous fat was harvested from this 38-year-old woman’s lower abdomen (see Figs. 11-8through 11-13), which is the most favorable donor site, through manual aspiration with a 10 cc syringe.

139

140

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

Box 11-4  Peri-MAFT Management Pre-MAFT 1. The patient must be NPO for 4 to 6 hours before MAFT, because TIVA is preferred. 2. Any hematologic diseases and any medication interfering with the operation must be evaluated and managed. Intra-MAFT 1. Vital signs (heart rate, blood pressure, arterial oxygen saturation, and so on) must be closely monitored. 2. Donor sites are dressed with an elastic bandage, and a pressure garment can be applied. 3. Recipient areas are dressed with fle h-colored tape, and the incision wounds are taped with hydrocolloid dressing after a 6-0 nylon suture is applied. Post-MAFT 1. No ice or warm pack compresses are positioned on the recipient areas. A red LED application can be considered to release the swelling. Two days after MAFT, warm pack compresses can be applied on the donor sites, followed by gentle massage. 2. The fle h-colored tape and incisional stitches are removed 2 days after MAFT, and a hydrocolloid dressing is applied over the insertion sites for 2 to 3 weeks with daily changes. 3. Lymphatic drainage by gentle massage over the facial recipient area is suggested for 3 to 4 weeks. 4. Some medication, such as free-radical scavengers (superoxide dismutases), can be prescribed. 5. An oral antibiotic is given for 2 or 3 days, and an NSAID might be prescribed if necessary.

Postoperative Care Regular postoperative care is necessary for nonsurgical minimally invasive procedures for facial rejuvenation. Special dressing or massage is not required after this procedure.

Results From January 2007 through September 2012, I performed MAFT on 968 patients (913 women, 55 men; average age 45.5) for facial rejuvenation. On average, a total of 3.5 cc of fat was grafted for total facial rejuvenation. The average procedural time of MAFT was 68.1 minutes, unless adjunct procedures such as upper or lower blepharoplasty or face lift ere combined. In most patients, only mild swelling and ecchymosis were noted postoperatively, and this resolved within 7 to 10 days. When seen at follow-up, patients were satisfi d with their results and appreciated the long-term (more than 6 months) outcome. The following four patients had various facial soft issue deficie cies in such areas as the forehead, temporal fossa, sunken upper eyelids, nasojugal grooves, cheeks, nasolabial grooves, marionette lines, chin, and lips. MAFT was performed with a MAFT-Gun in all cases, with other adjunct procedures as needed.

K23345_Pu_c11_Total Fac Rejuv Fat Trans_r6_dc_129-148.indd 140

4/2/2015 3:55:15 PM

Chapter 11 

A

Total Facial Rejuvenation With Microautologous Fat Transplantation

CASE 1 Nasojugal groove and lid-cheek junction

First MAFT L/R (cc)

Day 0

First MAFT and lower blepharoplasty

14 mo

Follow-up

1.5/1.5

Cheek (midcheek furrow)

4/4

Nasolabial groove and marionette line

4/4

Neck

12

B

C

D

E

F

G

H

I

Fig. 11-14 Th s 67-year-old woman requested rejuvenation of the middle to lower third of her face and neck. Both lower blepharoplasty and MAFT procedures. An outline of her surgeries and both preoperative (Fig. 1114, B through E) and postoperative (Fig. 11-14, F through I) photographs 14 months after the procedures are shown.

141

142

Part II 

A

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

First MAFT L/R (cc)

Second MAFT L/R (cc)

Nasojugal groove and lid-cheek junction

4/4

—

Cheek

—

5/5

Nasolabial groove

—

2/2

Chin

—

7

CASE 2

B

C

D

E

Before first MAFT procedure

Day 0

First MAFT

12 mo

Second MAFT

24 mo

Follow-up

Postoperatively

Fig. 11-15 MAFT was performed twice in 12 months on this 38-year-old woman. A summary of her surgeries is given.

K23345_Pu_c11_Total Fac Rejuv Fat Trans_r6_dc_129-148.indd 142

4/2/2015 3:55:18 PM

Chapter 11 

F

G

Before second MAFT procedure

H

Postoperatively

Postoperatively

K

Before second MAFT procedure

M

Before second MAFT procedure

I

Before second MAFT procedure

J

L

143

Total Facial Rejuvenation With Microautologous Fat Transplantation

Postoperatively

N

Postoperatively

Before second MAFT procedure

O

Postoperatively

Fig. 11-15, cont’d Her preoperative markings and postoperative photographs from her second MAFT surgery are shown.

K23345_Pu_c11_Total Fac Rejuv Fat Trans_r6_dc_129-148.indd 143

4/2/2015 3:55:20 PM

144

Part II 

A

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

CASE 3

First MAFT L/R (cc)

Sunken temporal fossa

3/2.8

Nasojugal groove and lid-cheek junction

3/2.5

Nasal dorsum

First MAFT

20 mo

Follow-up

2.2

Cheek

3.5/3

Nasolabial groove and marionette line

3.5/3

Chin

Day 0

7

B

C

D

E

F

G

H

I

Fig. 11-16 Th s 47-year-old woman complained of multiple soft issue losses on her face. MAFT was performed. A summary of her surgeries and both preoperative (Fig. 11-16, B through E) and postoperative (Fig. 11-16, F through I) photographs 20 months after MAFT are shown.

Chapter 11 

A

Total Facial Rejuvenation With Microautologous Fat Transplantation

CASE 4

First MAFT L/R (cc)

Sunken temporal fossa

2/1.7

Sunken upper eyelid

1.5/1

Nasojugal groove and lid-cheek junction

1/1

Nasal dorsum

1.5

Cheek Nasolabial groove

Day 0

First MAFT and endoscopic forehead lift

2.8/3 4/4

Chin

7.9

Neck

6/6

8 mo

Follow-up

B

C

D

E

F

G

H

I

Fig. 11-17 Total facial rejuvenation with MAFT and an endoscopic forehead lift were performed on this 70-year-old woman. The procedures resulted in a well-contoured facial appearance and retextured skin. A summary of her surgeries and both preoperative (Fig. 11-17, B through E) and postoperative (Fig. 11-17, F through I) photographs 8 months after the procedure are shown.

145

146

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

Discussion The Era of Fat Grafting:

Micr oaut ol o go us Fat Trans pl ant atio n

Fat grafting plays an important role as “more than a permanent filler,” according to Coleman,21 who emphasizes that fat grafting has a promising future in plastic and reconstructive surgery and regenerative medicine. The aging process on the face involves ptosis of the skin and underlying tissues and a volume deficie cy of related facial elements. With ptosis and the loss of facial soft tissue, it is important to have a strategy to restore ongoing tissue loss, such as lifting the ptotic areas.

Why Empha size Micr oaut ol o go us Fat Trans pl ant atio n? When performing MAFT, the surgeon should do the following: • Place each small fat parcel as accurately and precisely as possible. • Avoid the potential central necrosis of grafted fat and subsequent morbidities. • Fulfill the concept of “structural fat grafting” proposed by Coleman.21 • Increase the survival/retention rate of transplanted fat. • Shorten the down time and ensure rapid recovery from swelling (see Fig. 11-5).

What t o Expect When Per fo rming Micr oaut ol o go us Fat Trans pl ant atio n

The surgeon should keep the following points in mind when performing MAFT: • A predetermined volume of the fat parcel (1∕60 cc, 1∕90 cc, 1∕120 cc, 1∕150 cc, and 1∕180 cc, 1∕240 cc) is constantly maintained. • A droplet of fat with a volume smaller than 1∕3 0 cc (2 mm) in diameter should be placed. • Each delivered fat parcel should be equal and consistent in volume. • The delivered fat volume is adjustable and predetermined with a MAFT-Gun, depending on the recipient site. • The surgeon should strive to increase his or her own confide ce in performing the MAFT procedure and to increase the reliability of MAFT for patients.

Wher e Can Micr oaut ol o go us Fat Trans pl ant atio n Be Per fo rmed?

MAFT can be performed on the following areas: • Total face: forehead, sunken temporal areas, sunken upper eyes, nasojugal grooves, lid-cheek junction, midcheek furrow, dorsum of nose, cheek, nasolabial grooves, marionette lines, upper/lower lip, chin, jawline, prejaw depression • Neck • Hands • Breasts: Hypoplasia of breasts, postmastectomy deformity, Poland’s syndrome • Congenital anomaly with soft tissue deficie cy (hemifacial microsomia syndrome) • Soft tissue defects after trauma or tumor excision • Scars: Acne scars, burn scars, or hypertrophic scars

Chapter 11 

Total Facial Rejuvenation With Microautologous Fat Transplantation

147

What Ar e the Contraind ica tio ns t o Micr oaut ol o go us Fat Trans pl ant atio n?

Although no absolute contraindications or limitations to MAFT have been posited to date, it should not be performed on patients who are pregnant or who have severe hematologic disease. It is rare that a patient does not have enough donor adipose tissue for a MAFT procedure.

Pearls for Success • There have been tremendous evolutionary developments in autologous fat grafting since it was fi st advocated by Neüber in the nineteenth century. Many studies have proposed mechanisms and presented arguments for techniques to improve the fat survival/retention rate. • I proposed the concept of MAFT in 2006. In this chapter, I have presented additional clinical cases in which I performed MAFT with the assistance of the innovative instrument, the MAFT-Gun. • In each of my patients, facial rejuvenation was attained by restoring areas of soft tissue deficie cy and providing augmentation for their ongoing tissue loss. • Less morbidity, high patient satisfaction, and good long-term follow-up were achieved for each patient. • Fat transplanted with a MAFT-Gun is less likely to develop central necrosis than fat that has been overfilled with a parcel that is too large. • Ideally, the volume of each triggered fat parcel should be less than 1∕120 cc; periorbital areas should be less than 1∕240 cc. • The surgeon should strive for the least possible trauma after harvesting fat (low-pressure aspiration).20 • Unnecessary exposure of the fat to air should be avoided while purifying the lipoaspirate. • The surgeon should avoid both unnecessary overcorrection and vigorous massaging.

Refer ences 1. Neüber F. Fettransplantation. Bericht über die Verhandlungen der Deutschen Gesellschaft für Chirurgie. Zbl Chir 22:66, 1893. 2. Peer LA. Loss of weight and volume in human fat grafts: with postulation of a “cell survival theory.” Plast Reconstr Surg 5:217-230, 1950. 3. Bames HO. Augmentation mammaplasty by lipo-transplant. Plast Reconstr Surg 11:404-412, 1953. 4. Illouz YG. The fat cell “graft”: a new technique to fill depressions. Plast Reconstr Surg 78:122-123, 1986. 5. Fournier PF. Microlipoextraction et microlipoinjection. Rev Chir Esthet Lang Franc 10:36-40, 1985. 6. Chajchir A, Benzaquen I. Liposuction fat grafts in face rinkles and hemifacial atrophy. Aesthetic Plast Surg 10:115-11 7, 1986. 7. Asken S. Facial liposuction and microlipoinjection. J Dermatol Surg Oncol 14:297-305, 1988. 8. Nguyen A, Pasyk KA, Bouvier TN, et al. Comparative study of survival of autologous adipose tissue taken and transplanted by different techniques. Plast Reconstr Surg 85:378-386; discussion 387-389, 1990. 9. Carpaneda CA, Ribeiro MT. Study of the histologic alterations and viability of the adipose graft in humans. Aesthetic Plast Surg 17:43-47, 1993. 10. Carpaneda CA, Ribeiro MT. Percentage of graft viability versus injected volume in adipose autotransplants. Aesthetic Plast Surg 18:17-19, 1994. 11. Coleman SR. The technique of periorbital lipoinfiltration. Oper Tech Plast Reconstr Surg 1:20-26, 1994. 12. Lu F, Li J, Gao J, et al. Improvement of the survival of human autologous fat transplantation by using VEGFtransfected adipose-derived stem cells. Plast Reconstr Surg 124:1437-1446, 2009.

K23345_Pu_c11_Total Fac Rejuv Fat Trans_r6_dc_129-148.indd 147

4/2/2015 3:55:24 PM

148

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

13. Yoshimura K, Sato K, Aoi N, et al. Cell-assisted lipotransfer for cosmetic breast augmentation: supportive use of adipose-derived stem/stromal cells. Aesthetic Plast Surg 32:48-55; discussion 56-57, 2008. 14. Eto H, Kato H, Suga H, et al. The fate of adipocytes after nonvascularized fat grafting: evidence of early death and replacement of adipocytes. Plast Reconstr Surg 129:1081-1092, 2012. 15. Khawaja HA, Hernández-Pérez E. Fat transfer review: controversies, complications, their prevention and treatment. Int J Cosm Surg Aesthet Dermatol 4:131-138, 2002. 16. Dermato Plastica Beauty Co., Ltd., Kaohsiung, Taiwan. Available at http://www.MAFT-GUN.com/button_ content_1.html. 17. United States Patent No. US 7,632,251 B2. Available at http://www.MAFT-GUN.com. 18. Coleman SR. The technique of periorbital lipoinfiltration. Oper Tech Plast Reconstr Surg 1:120-126, 1994. 19. Coleman SR. Structural Fat Grafting. St Louis: Quality Medical Publishing, 2004. 20. Chou CK, Lin TM, Chiou JH, et al. Influential factors in autologous fat transplantation—focusing on the lumen size of injection needle and the injecting volume. Int Confed Plast Reconstr Aesthet Surg (IPRAS) J 9:25-27, 2012. 21. Coleman SR. Structural fat grafting: more than a permanent filler. Plast Reconstr Surg 118(3 Suppl):108S-120S, 2006.

12 Botulinum Toxin A Injections for Facial Rejuvenation and Reshaping

A

Woffles T.L. Wu

lthough botulinum toxin A only became available in some parts of Asia in the mid-1990s, during the past 20 years, the region has introduced many of the most innovative and advanced techniques employing this product. Many of the pioneers of these techniques are Asians from Singapore, Thailand, and South Korea. In part, this may have been the result of unrestricted freedom in Asia to use the drug in off label situations. Another reason is that many of the creative uses of botulinum toxin A in the Asian face and body were developed in response to our patients’ requests to change some of the undesirable features of the Asian face. The mindset of plastic surgeons and dermatologists worldwide has been changing regarding who should perform these injections. From 2000 to 2006, the common perception in the Western world was that the injection of toxins and fillers could be delegated to the nurse or clinic aesthetician, because the procedures were thought to be relatively simple. It was only in the latter half of that decade that these same aesthetic physicians began to appreciate the previously underestimated rejuvenative and restorative potential of injectable therapy. In Asia, however, physicians had always performed their own injections, gaining more experience and creativity with toxins and fillers. Their expertise in this rapidly emerging fi ld demanded refi ed techniques, a deep appreciation of facial proportion, and a thorough understanding of facial anatomy to consistently and predictably optimize results.

Special Considerations Asians and whites have distinct differences in their facial features, in skin thickness, and in fat content.1-5 During the past two decades, requests for injectables, nonablative skin-resurfacing techniques, and other nonsurgical procedures have increased tremendously. The number of new devices and the different kinds of fillers and botulinum toxins available to physicians can at times be overwhelming. Surgical procedures, by contrast, have grown at modest rates, even declining in areas such as open face lifts and forehead lifts.

149

150

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

Fig. 12-1  A typical full-faced Asian male at 45 years old and then 30 years later at 75 years old. Note the signifi ant vol-

ume loss in the upper lids, temples, and infraorbital, malar, and paranasal regions, which consequently led to sagging of the entire middle and lower face complex. Deeply etched lines have formed on the forehead, nasolabial, and marionette regions, and his neck shows pronounced platysmal banding. His face has lost vertical height and appears more square.

Patients have an enhanced awareness of the variety of treatment options available to them and have become more discerning in the treatments they wish to have. The most common request of both young and older patients has been for nonsurgical procedures wherever possible. Asian physicians have therefore had to respond to these desires and innovate new procedures accordingly. Botulinum toxin A has become the number one choice of injectable substance among doctors and their patients. The facial features that Asians consider undesirable are summarized as follows (Fig. 12-1): • A flat, square face, often with masseteric hypertrophy • Low-set brows with strong glabellar frown lines • Narrow, almond-shaped eyes with distinct epicanthal folds • A low nasal bridge with deficie t anterior projection of the face • Midface retrusion with deficie t infraorbital support • Bulging eyes and prominent bags under the eyes • Deficie t vertical height of the face, with a retruded “popply” chin (similar to the surface of an orange peel) • Bimaxillary protrusion • Thi k, oily skin with visible pores and a higher tendency to form hypertrophic and keloid scars What Asians want in a beautiful face is similar to what other races desire. The principles of beauty are governed by harmony, balance, and proportion. The lower end of the facial aesthetic spectrum is characterized by stronger ethnic features and a look that is distinctly different from other races. At the upper end of the facial aesthetic spectrum, however, beautiful people of all races look very similar, yet retain suffici t unique features to identify their origins. In some cases, ethnic differentiation can be blurred. Th s suggests a globalization of beauty and similar characteristics in all beautiful faces. Racial intermarriage, which often produces the most attractive faces, has undoubtedly contributed to the concept of a universal beauty.

Chapter 12 

Botulinum Toxin A Injections for Facial Rejuvenation and Reshaping

Box 12-1  Characteristics That Asians Wish to Achieve Th ough Cosmetic Rejuvenation and Reshaping • A slender, oval face • Big eyes • A rounded forehead • Increased vertical height of the face with a sharp, pointed chin • Increased anterior projection of the face with adequate midfacial support and malar highlights • A petite nose with a sharp tip and prominent nasal bridge, creating a continuous curved nasoorbital aesthetic line between the nose and the medial brow; this makes the eyes look more recessed and less bulgy • Thi k, shapely lips • A sharply defi ed jawline and cervicomental angle • A taut and fi m facial skin envelope

Most Asian patients do not wish to have the facial features of whites—a fact often overlooked by non-Asian physicians. Rather, their preference is to be at the upper end of their own ethnic facial aesthetic spectrum. The request for a more prominent nose does not imply a dorsum that would be appropriate in white patients and that emerges from a strong supraorbital ridge, but rather a prominent nose that can be found within their own Asian ethnicity.6 Most Asians have a naturally flat face. Creating a nose that protrudes from the middle of the face with no supporting projections of the brow and midface can look extremely odd, as in some of the disastrous results from the seventies and eighties, when it was thought that Asians all wanted to look like whites (Box 12-1). Although botulinum toxin A alone cannot provide the solution to all of these aesthetic problems, it is a critical component used in conjunction with other methods to achieve the desired result. In all of the techniques described in this chapter, the only one consisting of botulinum toxin A is Botox 100 units (Allergan), which will be referred to as Botox.

Botox Techniques Th s chapter describes the most common Botox techniques that I have developed and employ daily in Asian patients in my aesethetic practice. These include the following: • Botox brow lifting and brow shaping: Both of these techniques are used to create an aesthetically ageappropriate brow position and shape.7 • Botox facial slimming: Th s reduces hypertrophic masseter muscles and/or parotid gland hypertrophy, which narrows the lower facial width and creates triangulation of the face.8,9 • Microbotox technique: Th s technique smooths forehead and infraorbital lines without compromising eyebrow function, improves neck skin texture, elevates the jawline and lower face, and improves facial skin texture and pores.10 • Botox injections reduce mentalis strain and a popply chin. • Botox injected in the alar lobules reduces alar flaring and nostril dilation. • Botox in the columellar-labial angle reduces nasal tip droop and gummy smiles. • Infraorbital Botox to the pretarsal muscle bulge creates an open-eyed effect.

151

152

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

Bot ox Dil utio n and Anes thes ia

For all standard injections of Botox, I now use a 2.5 ml dilution comprising 2.0 ml normal saline solution and 0.5 ml lidocaine 1%. The anesthetic makes the injections much more comfortable and does not compromise the result or its longevity. A volume of 0.5 ml of reconstituted Botox contains 20 units, and every 0.05 ml is 2 units. Approximately 2 to 4 units will be injected at most of the injection points. I try never to inject more than 0.1 ml of solution at any given point to prevent unwanted diffusion effects to adjacent muscles. For the microbotox technique described later, I will withdraw 0.5 (20 units) to 0.7 (28 units) ml into a 1 ml syringe and then add saline solution or lidocaine for a fi al volume of 1.0 ml. Different concentrations are used in various regions of the face and neck, depending on the strength and thickness of the underlying muscles, and to create specific effects in the skin.

Bot ox Br ow Lifting and Br ow Shap ing

Many authors have reported their experience using Botox to eliminate glabellar frown lines, crow’s-feet, and horizontal forehead lines. Generally, three to five injections are made in the glabellar area, three to six injections in the lateral orbit, and multiple injections are made in the forehead in a variety of patterns. The dosage ranges from 6 to 20 units, which may appear to be a wide variance; however, authors have reasons for using more injection points and higher dosages. I have been employing my own Botox brow-lifting technique for the past 15 years, and this is described later in the chapter.

Considerations for Eyebrow Reshaping Creating an aesthetic, age-appropriate eyebrow contour requires not only an understanding of the underlying muscles and their interrelationship, but also the patient’s age and aesthetic goals. Young women look better with lower brows that tilt upward slightly toward the lateral end. Th s matches a low, crisp pretarsal crease and a narrower lid-cheek junction, all of which help to tightly frame the orbital aperture. A high, arched eyebrow is disproportionate and looks comical and inappropriate. By contrast, a mature woman who has developed hollowing of the upper lid and consequent deepening of the sulcus and/or a lengthening of the lid-cheek junction with a prominent infraorbital crease looks more appropriate with a smoothly arched and highly elevated eyebrow that is quite different in shape from that of a younger person. A low-set or flared brow creates a mean, sinister look in an older person. Men, on the other hand, look better with low, full eyebrows no matter their age. Elevation or overarching of the brow in a man is an aesthetic mistake and only feminizes the face unnecessarily, unless that is the intention.

Mechanism of Frowning Full knowledge of the muscles that elevate or depress the brow is required to create a brow-lift e ect and have the freedom to shape it. The existing shape of the eyebrows during elevation of the frontalis muscle needs to be determined. Some patients have central elevation of the brow, some have lateral elevation, and some elevate the brow evenly across its length. The distribution of botox injections therefore has to be varied accordingly (Fig. 12-2).

Chapter 12 

Botulinum Toxin A Injections for Facial Rejuvenation and Reshaping

A

B

C

D

E

F

Fig. 12-2  A, Central brow elevator at rest. B, Central brow elevator during contraction. C, Lateral brow elevator at rest. D, Lateral brow elevator during contraction. E, Even brow elevator at rest. F, Even brow elevator during contraction.

Anatomy The corrugators, procerus, depressor supercilii, and lateral orbicularis muscles have been described as the key muscles of eyebrow depression, whereas the frontalis is the sole elevator of the forehead (Fig. 12-3). The corrugator is the main muscle responsible for frowning; therefore it should be the fi st to be weakened for a brow lift ( ee Fig. 12-3, C). Ideally, it is preferable to weaken the corrugators and procerus without weakening the frontalis. Th s can be achieved repeatedly and predictably with knowledge of the underlying anatomy. The corrugator was previously thought to be an obliquely oriented muscle having its origin below the medial end of the eyebrow and terminating above the midpoint of the brow. Some older depictions of this muscle showed an appreciable angulation of the muscle. The muscle is actually more horizontally oriented than previously thought, and careful anatomic dissections have revealed that it lies flat at the level of the eyebrow itself, with very few fibers above the level of the brow (Fig. 12-4).

153

154

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

A

B

C Corrugators and depressor

Corrugator and depressor supercilii muscle supercilii and muscle Corrugator depressor supercilii muscle Procerus muscle Corrugator and depressor supercilii muscle Procerus muscle Procerus muscle Superior and lateral orbicularis muscle Procerus muscle Superior and lateral orbicularis muscle Superior and lateral Superior and lateral orbicularis muscle

orbicularis muscle

Fig. 12-3  A, Eyebrows at rest. B, Eyebrows on frowning. C, Mucles of frowning. Corrugator and depressor supercilii muscle Procerus muscle Superior and lateral orbicularis muscle

Fig. 12-4  Dissection showing the level and

orientation of the corrugator muscle. (Courtesy of Professor H.J. Kim, Seoul, South Korea.)

The other muscle that contributes to frowning is the orbicularis oculi. The superior orbicularis is an important segment of this muscle that is often ignored or thought to be unimportant. It lies directly under the eyebrow from its midpoint to the lateral tail. Those who are adept at endoscopic brow lifts ave been taught to locate the exit points of the supraorbital nerve (approximately at the midpoint of the eyebrow) and make two or three vertical myectomies in the superior orbicularis lateral to this point.11,12 Th s prevents contraction of that segment of muscle and allows elevation of the tail of the eyebrow. In a Botox brow lift, this effect is replicated by injecting one or two points of Botox (a chemical myectomy) lateral to the midpoint of the eyebrow to achieve the same degree of lateral elevation.

Chapter 12 

Botulinum Toxin A Injections for Facial Rejuvenation and Reshaping

Surgical Technique Injectio n Techniq ue My preferred technique is to make seven to nine injections along the upper border of the eyebrow from the midline to the lateral brow (Fig. 12-5). Th s elevates the entire eyebrow. I inject 2 or 3 mm above the eyebrow hairs—not 1 cm above the eyebrows, as was previously advocated. Injection closer to the eyebrows ensures full diffusion into the corrugators, depressors, and procerus without compromising frontalis function. Injection of Botox 1 cm above the eyebrows results in too much diffusion into the lower half of the frontalis, and full elevation will not be achieved. To maximize elevation of the lateral brow, four points on either side of the crow’s-feet are injected to negate the downward-squeezing effect of the lateral orbicularis. The last injection should be below the level of the lateral canthus. In the midline, only one injection point into the procerus is needed. Too much Botox here lateralizes the medial brow, which is unattractive. In an average patient without signifi ant forehead lines, the forehead does not need to be injected. If a patient complains of forehead lines or is young and wants a slightly flared eyebrow in which the medial end is a little lower and the lateral tail tilts upward, four or five points are injected vertically in the middle of the forehead. Th s will diffuse laterally about 1 cm into the frontalis and will be adequate to depress the medial brow and relax the medial frontalis, resulting in a clear zone in the center of the forehead without compromising mid to lateral eyebrow elevation. If a patient complains of lateral forehead lines or wants a smooth forehead, a microbotox technique is preferable. Th s will smooth the forehead without affecting deep muscle movement.

Dosa ge

The dosage surgeons use varies quite widely across Asia, ranging from 6 to 20 units in the glabellar region to 6 to 12 units for crow’s-feet on each side. Th s variation occurs because doctors have different injection patterns in the glabellar area that include three or seven injection points. I usually inject 20 units into the extended glabellar area, but this is distributed over seven injection points that extend beyond the midpoint of the brow, as described previously. Therefore each point receives 2 to 4 units. Th s is no different from injecting 6 to 8 units into three injection points over the glabella.

A

B Central frontalis muscle

Corrugator muscle Procerus muscle

Superior orbicularis muscle Lateral orbicularis muscle (crow’s-feet)

Fig. 12-5  A, Botox brow-lift c mponents. B, Botox brow-lift i jection pattern. Each point is 2 units 5 0.05 ml, using a 2.5 ml dilution. The white X indicates that no Botox should be injected in these areas if a maximum brow lift is desired.

155

156

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

Botox Facial Slimming and Botox Facial Sculpting Botox facial slimming and Botox facial sculpting are terms that I coined in 2000 to describe a purely chemical cosmetic technique in which the lower facial width is narrowed or triangulated to create a more aesthetic and youthful facial shape. Before this, the only technique to reduce a square jaw or boxy face was surgical resection of the mandibular angles.13-15Th s is an excellent technique in the hands of a trained surgeon, but complications can happen, and the downtime from swelling and bruising can be considerable. It is not a technique an average aesthetic physician can perform. In the mid-1990s, several authors reported on injection of Botox into the masseters to stop grinding and improve temporomandibular joint problems.16-18 Botox had not been described as a purely aesthetic sculpting tool. I started injecting masseter muscles in 1997 using as a scientific asis the bone-muscle matrix theory of Moss, Enlow, and Von Lindern and others.19-23 Th s theory states that the overlying muscles influence the thickness and density of the underlying bones to which they are attached. Th s is clearly demonstrated by the reduction in density and circumferential thickness of the tibia after prolonged immobilization of a fractured lower leg in a plaster cast and is a result of disuse atrophy. Conversely, older people are encouraged to exercise regularly so that the continued muscle influence on the bones prevents them from becoming brittle and fracturing easily. Muscles and muscle activity control the density and strength of the bones to which they are attached. In Botox facial slimming, my intention in injecting Botox into the masseters was not only to reduce the bulk of the masseteric muscles to create an immediate aesthetic result but also to generate such a degree of atrophy that the bone would begin to remodel to achieve longterm facial slimming. Over the past decade, Botox facial slimming in my practice has evolved to embrace two distinct techniques: (1) reduction of masseteric hypertrophy and (2) reduction of hypertrophic parotid glands, which can create an undesirable facial shape and contour.

Red uctio n of Ma ss eter ic Hyper tr ophy

Masseteric hypertrophy can occur in all races, but it is seldom seen in blacks and is more commonly seen in Asians, especially those from Korea, northeastern China, and parts of Japan. Because the Asian face is naturally short in vertical height, flat, and wide, the addition of masseteric hypertrophy makes the face even more squat and unattractive. Th s has given rise to the term square jaws or boxy face and may explain the popularity of this simple technique to drastically alter the facial shape in Asia.24-28 Patients can see results within 2 weeks, and continued periodic use of the toxin can allow bony remodeling of the mandible and long-term changes. The current aesthetic ideal in most Asians is a narrow, oval face with a sharply projecting chin. Asian women dislike having a wide lower face, because it makes them look too masculine and older. Masseteric reduction has a powerful effect on making the face look slimmer, longer, and younger. In whites, who tend to have longer, thinner faces with greater vertical height and anterior projection, masseteric hypertrophy can be very attractive, because it balances the facial shape, giving it structure and harmony. In men it makes the face more masculine and strong and is a common feature in many movie personalities, especially those who act in action hero roles. Some women are extremely attractive with a mild degree of masseteric hypertrophy, as seen in some models and actresses, because it produces a more determined, athletic appearance. Th s might explain why the technique of masseteric reduction in whites has not been as popular as in Asians.

Chapter 12 

A

Botulinum Toxin A Injections for Facial Rejuvenation and Reshaping

B

Fig. 12-6  A, Botox injection pattern for the masseter muscle. The dashed white line extends from the tragus to the cor-

ner of the mouth. If all of the injections are made inferior to this line, toxin diffusion through the coronoid notch into the pterygoid muscles is not a potential danger. B, Botox danger areas (Xs).

Injection Technique The extent of masseteric hypertrophy is established by asking the patient to clench his or her teeth. Th s delineates the anterior border of the masseter and its thickest, central portion, which is an overlap zone of the muscle’s three heads. The superior, posterior, and inferior limits of the muscle are the zygomatic arch, the posterior border of the mandible, and the inferior border of the mandible, respectively. The patient then relaxes the muscle, and Botox is injected at five or six evenly distributed points centered around its thickest part. For safety, a line can be drawn extending from the tragus obliquely downward to the corner of the mouth. If all of the injections are made inferior to this line, toxin diffusion through the coronoid notch into the pterygoid muscles is not a potential danger (Fig. 12-6). Similarly, injections given 1 cm behind the anterior border of the muscle decreases the risk of the toxin diffusing forward to the buccinator and the risorius and causing an asymmetrical smile or an inability to smile widely. None of my patients have had pterygoid muscle weakness after injections placed too inferiorly.

Dosage and Frequency The dosage and frequency in the masseteric area vary widely across Asia and depend on patient and physician preference. Doses as low as 20 units per side are reported as adequate to visibly narrow the face. In Korea this is the preferred dose, because Korean patients wish to retain some midcheek fullness. The frequency can range from once every 3 months to once every 6 months. I prefer to maximally reduce facial width wherever possible and to maintain this width without fluctuations in size. I tend to see patients with very large masseters. The average loading dose is 40 units (1 ml of standard dilution) on each side. Patients are given a second dose of 20 to 40 units 6 weeks later, and they are seen again 6 weeks after that. If the desired endpoint has not been achieved at the third visit, a third dose of 20 to 40 units is given according to the amount of shrinkage that has already occurred. These two to three initial doses constitute the start-up phase of treatment, and the endpoint is called the baseline, because further shrinkage should not occur. It is possible to give higher initial doses. (I have treated several patients with huge masseters requiring 60 to 70 units per side.) However, I prefer not to deliver more than 1 to 1.5 ml of volume per side to prevent diffusion problems and crooked smiles. During the fi st 3 months, the masseter volume can reduce in size remarkably, much faster than the overlying skin envelope can contract. Patients may notice slight jowling or lower facial skin laxity. Th s corrects itself after 3 months as the overlying skin envelope slowly contracts to adapt to the new shape of the muscle.

157

158

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

Box 12-2  Patient Exceptions to Botox Treatment • Two patients in their thirties had never received Botox injections before. They did not respond to repeated high doses of botulinum toxin. • I gave multiple Botox injections to a patient in her mid-forties over a 4- to 5-year period with good results and no problems. She had regular injections to her glabellar area, crow’s-feet, forehead, and enlarged masseters. She then developed an autoimmune thyrotoxicosis. After her thyroid was surgically removed, she no longer responded to Botox. • For more than 5 years, I gave regular Botox injections to an Indian man in his thirties. I injected his glabellar area, crow’s-feet, and enlarged masseters, all of which responded well. He did not return for 2 years. When he came back to resume treatment, his masseters responded very weakly, even to high doses (60 units per side) of Botox, whereas his glabellar frownlines responded in the usual fashion to my standard doses. • Th ee patients from the same family—a mother, her 21-year-old son, and her 22-year-old daughter—had huge, hard masseters. Repeated high doses of Botox (60 to 75 units per side) were required every 1 to 2 months before a modest response was seen. Recurrence appeared quickly after 2 months.

After the loading or start-up phase, a patient enters the maintenance phase, in which the frequency of injections is determined for each patient at 4- to 6-month intervals. I usually see each patient 3 months after the start-up phase to assess how much muscle activity has returned. If muscle activity occurs, I might give a small dose of 20 units to decrease it to the baseline level. If no appreciable movement is observed, then I assess the patient 1 to 2 months later. The variation in dosage and frequency can be quite wide, with some patients requiring injections every 3 months, whereas others maintain the desired result for up to 1 year. In more than 1000 patients who I have treated, only 7 have either been nonresponders or very slow responders (Box 12-2).

Red uctio n of Par otid and Submand ibul ar Gl and Hyper tr ophy

As the number of patients being treated for their square jaws increased, I began to notice that some of them had both masseteric and benign parotid gland hypertrophy, and if the former was treated without treating the latter, the aesthetic result was less than optimal. Classically, parotid gland enlargement is seen as a diffuse swelling on and extending posteriorly and inferiorly beyond the boundaries of the mandibular angle. It is best seen from a worm’s-eye view, with the patient tilting the head backward. The parotid enlargement extends beyond the boundaries of the mandibular angle, unlike the masseters, whose muscle bulk is confi ed within the boundaries of the mandibular ramus. In a patient with a square jaw, clenching the teeth will defi e the edges of the hypertrophic masseter. Any bulk that projects behind the mandibular angle or lifts up the earlobe is from parotid hypertrophy. A very large parotid bulge it is easy to distinguish from the masseter muscle and should be injected separately. A modest or mild enlargement, however, may be difficult to distinguish from the masseter and will become evident only after the masseter has been reduced in size. The gland can then be injected separately. Smaller parotids often will reduce in size in tandem with masseteric reduction as a result of passive diffusion from the masseter injections.

Chapter 12 

Botulinum Toxin A Injections for Facial Rejuvenation and Reshaping

In my practice, the average dose required to reduce parotid gland size is 30 to 40 units. It is injected directly into the bulk of the gland, which can be isolated between the thumb and index fi ger of the noninjecting hand. A patient with large masseter muscles and large parotid glands can receive up to 80 units (40 units per side) per session. Injections are given approximately every 3 to 4 months. Injection of the parotid glands is no longer controversial. Numerous reports exist in the literature documenting the use of Botox to reduce parotid cysts or sialorrhea after trauma or face-lift urgery and for cosmetic improvement of facial shape.19-33 Cholinergic receptors are present in hypertrophic mandibular glands and can similarly be treated by Botox injections. Th s is a useful treatment option in patients who have cosmetically undesirable submandibular glands. The usual dose is 20 units into each gland. The needle needs to penetrate through the capsule of the gland before the injection is given. The result of submandibular gland reduction is signifi ant but not as dramatic as that seen in parotid glands, possibly because the density of cholinergic receptors is less than in the parotid glands.

Microbotox or Intradermal Botox Technique for Facial Rejuvenation The growing popularity of microbotox warrants a more indepth description of the technique and a discussion of its original purpose. The microbotox technique is a method of injecting a diluted solution of Botox in microdroplets to the dermis or the junction between the dermis and the underlying facial mimetic muscles. The purpose is to smooth the overlying skin by decreasing its sweat and sebaceous activity and by weakening the superfi al layer of the muscle, which inserts into the undersurface of the dermis.34-36 I developed the technique in 2000 as a solution to the problem of persistent lateral forehead and undereye lines after standard Botox injections in the glabella and crow’s-feet. Initially called mesobotox, it is now more appropriately called microbotox or intradermal Botox. The term intradermal Botox alone, however, does not accurately convey that the injections have to be delivered in multiple, small-volume droplets; hence the term microbotox is preferred (Fig. 12-7).

Fig. 12-7  Microbotox droplets. The large droplet on the left is 0.1 ml (4 units using a 2.5 ml dilution), the droplet in the center is 0.05 ml (2 units), and the cluster of small droplets on the right all add up to 0.05 ml (2 units). Th s shows that instead of giving a single droplet of 0.05 ml, it can be divided into many smaller droplets that remain confi ed within the dermis or the superfic al layer of the facial muscles.

159

160

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

Before the microbotox technique was popularized, it was recommended that Botox be injected into the forehead at the intramuscular level. Although this was effective in eliminating all forehead lines, some patients were no longer able to fully elevate their eyebrows. Th s was an unwanted consequence in patients who desired a brow lift. Some patients reported a heavy, uncomfortable feeling in the forehead and an inability to open their eyes comfortably. They also had excessive overelevation of the lateral tail of the brow, causing a sinister “diablo” effect. Th s was a result of injecting too much Botox in the central two thirds of the forehead, which paralyzes the region so effectively that the medial brow drops excessively and compromises upward gaze, and the lateral brow compensates with overelevation. These patients often chose not to repeat the injections—yet they wanted to diminish disturbing lateral forehead lines and undereye lines. On the other hand, patients liked the widespread intramuscular injections, because they made the forehead smooth, satiny, and lustrous. It was easier to apply makeup. Th s effect most likely resulted from intramuscular Botox diffusion upward into the skin and reduction of sweat and sebaceous activity, similar in mechanism to that of treating hyperhidrosis. A solution was needed to retain the lustrous improvement in skin texture, to create a smooth wrinkle-free forehead, and to retain most of the frontalis function and natural movement. The only way to achieve this result was to inject Botox in the level of the dermis itself, which contains the glandular elements, and at the insertion of the superfic al fibers of the frontalis into the undersurface of the dermis. These insertions into the dermis create the lines of the face in response to movement of the facial mimetic muscles. Instead of diffusion of Botox from the muscle into the skin, the reverse was desired; that is, the skin would be targeted, and Botox would diffuse slightly into the superfic al layer of the muscle, preserving the deeper layers to function normally. Th s was achieved by making many tiny intradermal injection blebs over the entire forehead skin approximately 8 to 10 mm apart in a gridlike fashion, each bleb no more than 0.003 ml in volume. Small injection volumes prevented unwanted diffusion of the solution into deeper muscles, retaining more muscle function for a natural appearance. The results were very pleasing. Patients had a more natural appearance with a lifted brow and a smooth, bright forehead, yet they retained the ability to move their eyebrows freely. The mechanism of action is similar to the injection of Botox for axillary hyperhidrosis, which is well established.34-37 Many of the patients with axillary hyperhidrosis who were treated with this technique have noticed improved texture and smoother axillary skin in addition to reduced sweat activity.

Injectio n Techniq ue

Standard injections may still be used upon request by patients who have stronger muscles or patients who actually wish to have a frozen look. For standard injections of Botox in patients who request it, a 100 unit bottle of Botox is diluted with 2.5 ml of saline solution. Therefore 4 units is delivered in a 0.1 ml droplet and 2 units in 0.05 ml. This is used for all areas that may require higher concentrations of Botox, such as the medial glabella or the lateral crow’s-feet, where muscles are stronger. Diffusion of Botox is directly related to the droplet size. In the past, when droplets of 0.1 ml or more were injected, more unwanted effects of diffusion occurred. For the microbotox technique, 20 to 28 units are withdrawn from the standard solution and then further diluted in a 1 ml syringe using either saline solution or lidocaine 1% to a volume of 1 ml. A droplet of sodium bicarbonate can be added to further reduce the sting of injection. Alternatively, Botox can be reconstituted using preserved saline solution, which contains benzyl alchohol, is a mild anesthetic, and maintains a neutral pH.

Chapter 12 

Botulinum Toxin A Injections for Facial Rejuvenation and Reshaping

For ehead Applica tio n

In the forehead alone, a microbotox dilution of 16 to 20 units in a 1 ml syringe filled to 1.0 ml is used. If a patient wants both the Botox brow lift nd elimination of lateral forehead lines, standard Botox is used for the brow-lift i jection points and microbotox for the lateral forehead lines. Many patients who have enjoyed the effect of microbotox now request it in all areas on the face. For these patients, 28 units in 1 ml solution is used in all brow-lift injection points and over the lateral forehead. Patients prefer the light feel and the more natural appearance that results from the microbotox technique.

Lower Fa ce and Neck Applica tio n

The next most frequent site of microbotox administration in my practice is the lower face, jawline, and anterior neck. Th s area is injected to create a lifting effect of the jowls and jawline and to improve skin appearance. Th s corresponds with the anatomic extent of the platysma as it sweeps upward from the clavicle over the jawline to blend with the submuscular aponeurotic system of the face. A mark is made two fi gerbreadths above the jawline, from the earlobe sloping obliquely downward to one fi gerbreadth posterior to the depressor anguli oris. Th s indicates the area of distribution of microbotox above the jawline. Below the jawline, the entire neck anterior to the sternocleidomastoid muscle is delineated. No solution is injected lateral to the sternocleidomastoids unless horizontal neck lines are present, which are injected along their length, or unless lateral platysmal bands are present, which need to be relaxed. To cover this wide surface area, two to three 1.0 ml syringes are used, each containing 28 units in a 1.0 ml microbotox solution. Young patients who want to improve horizontal lines and skin texture can be adequately injected with 2.0 ml of solution, whereas older patients with neck bands and jowling will require up to 3.0 ml (Fig. 12-8). Clinically, the cervicomental angle and jawline appear sharper and the jowls appear lifted, because the platysma conforms more closely to the underlying neck shape. Neck bands are less pronounced, and the skin appears smoother and fi mer. The crêpey quality and the skin bunching and creasing that occur on contraction of the platysma in middle-aged to older patients are signifi antly reduced, giving the appearance of smoother, cleaner neck skin.

A

B

Fig. 12-8  A, Anterior and B, oblique views of microbotox injections on the neck.

161

162

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

Und er eye Lines Applica tio n

I applied the same technique to the numerous undereye lines that patients notice after standard Botox injections to the glabellar and crow’s-feet regions. Medially these are related to bunny lines, but centrally many fi e lines occur and laterally cross-hatching develops, which patients want smoothed. These result from insertion of the superfic al fibers of the orbicularis oculi into the overlying skin. Traditionally, these were eliminated with full-dose Botox injections in the pretarsal roll and bunny lines. However, this sometimes caused an unwanted, inanimate, frozen appearance, and patients were unhappy until the effects of the toxin wore off. The lower lid dropped slightly, making the orbital aperture appear wider, which was the intended effect in some patients wanting a wide-eyed look, but not in others. The microbotox technique (2 to 4 units per side) is effective in removing these lines and retaining natural movement of the lower lids.

Na sal Injectio ns of Bot ox

Asians tend to have a broad, flat nose with wide, flared nostrils. Those who do can benefit from 2 to 4 units of Botox injected into each alar lobule. Th s diminishes the pull exerted by the nasalis muscle and the dilator nares, perceptibly narrowing nasal width. Some of these patients also have prominent nasolabial folds. A single injection on each side of 2 to 4 units into a point immediately lateral to the alar lobule and above the nasolabial fold will reduce the severity of the nasolabial line and prevent lateral flaring of the alar lobule. A gummy smile is another feature commonly seen in Asians with bimaxillary protrusion. Th s can be easily corrected by injecting 4 units of Botox into the columellar-labial angle all the way down to the anterior nasal spine. Further injection of 4 units on either side of the nose just superior to the nasaolabial fold effectively blocks the elevators of the upper lip and helps to correct a gummy smile. In all cases of injections in and around the nose, patients need to be warned that their smiles may change.

Red uctio n of Ment alis Strain and a Poppl y Chin

Asians often have retrusive chins and bimaxillary protrusion, both of which place the mentalis muscle at a mechanical disadvantage, creating mentalis strain. The result is an aesthetically unpleasing, puckered, bitter appearance. As the muscle involuntarily contracts upward, the chin appears even shorter. Th s effect is reduced with 6 to 16 units of Botox injected in a diamond shape in five points on the prominence of the mentalis. The dosing range is wide, because the degree of mentalis strain varies. Patients should be assessed after a week to ensure that the entire muscle has been adequately relaxed. Botox should not be injected too close to the mental crease, because it can diffuse into the lower fibers of the orbicularis oris, causing a strange smile and an inability to evert the lower lip. Similarly, the toxin should not be injected too far laterally, because it can affect the depressor anguli oris and give rise to a lopsided smile. The additional injection of a filler deep to the mentalis at the chin point improves its function and appearance by increasing vertical height and anterior projection of the chin.

K23345_Pu_c12_Botox A Inject_r4_cl_149-170.indd 162

4/2/2015 4:03:36 PM

Chapter 12 

Botulinum Toxin A Injections for Facial Rejuvenation and Reshaping

Results

Br ow Lift A

B

C

Fig. 12-9 Most women do not require injections into the lateral forehead unless they have signifi ant transverse forehead lines. It is often better to have an elevated brow with a few natural lines than a smooth forehead with a low brow that cannot be elevated and that feels unnatural. In men, however, one or two injections in the lateral forehead are often needed to deliberately flatten and masculinize the brow. Compared with women, men look better with low-set brows.

Red uctio n of Ma ss eter ic Hyper tr ophy A

B

C

Fig. 12-10 Th s 20-year-old patient presented with the complaint that she had a square, boxy, and unfeminine face. Four units of Botox were given on each side every few months (Fig. 12-10, A). Two years after surgery, she had significant narrowing of both the bizygomatic and bimandibular angle width, underscoring the influence of profound masseteric muscle paralysis on bony remodeling (Fig. 12-10, B). Fifteen years after surgery, her triangular face shape has been maintained through an injection of 40 units on each side twice a year (Fig. 12-10, C).

163

164

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

Red uctio n of Par otid Gl and Hyper tr ophy A

B

Fig. 12-11 Th s 25-year-old woman presented with a square face because of enlarged masseters and an enlarged parotid gland (Fig. 12-11,A). At three monthly intervals, I injected 40 units into each masseter and 40 units into her parotid gland. Nine years later, she has narrowed lower facial width and better defin tion of the mandibular angle and jawline (Fig. 12-11,B). The chin has been injected with HA filler to enhance the desired triangularity of the face.

Red uctio n of Submand ibul ar Gl and Hyper tr ophy A

B

Fig. 12-12 This 40-year-old patient presented with the complaint of submandibular gland prominence (Fig. 12-12, A). She is shown 2 months after having 20 units injected into each submandibular gland (Fig. 12-12, B).

Chapter 12 

Botulinum Toxin A Injections for Facial Rejuvenation and Reshaping

Cor r ectio n of a Gummy Smile A

B

Fig. 12-13 Th s young man was troubled by excessive upper gingival exposure on smiling (Fig. 12-13,A). He is shown smiling after 4 units were placed at the anterior nasal spine and 4 units at each paranasal region at the upper end of the nasolabial fold to correct his gummy smile (Fig. 12-13, B).

Red uctio n of a Poppl y Chin A

B

C

Fig. 12-14 Th s woman presented with a popply (puckered) chin that resulted from mentalis strain or overactivity (Fig. 12-14, A and B). She has a smooth unpuckered appearance 2 weeks after the injection of 10 to 12 units into the mentalis muscle (Fig. 12-14, C).

165

166

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

Discussion In my opinion, Botox has been pivotal in spearheading the wave of nonsurgical aesthetic techniques for the face during the past 20 years. Together with injectable fillers and nonablative light and laser-based or radiofrequency energy devices, it has spun off n entirely new discipline that we now refer to as aesthetic medicine. Before the mid-1990s, the only injectable substance we were familiar with was collagen (Zyderm and Zyplast). These gave predictably good results, but they were expensive and short lived. Skin testing was needed, requiring patients to return a week later before they could achieve the cosmetic improvement that they desired. Patients wanted more—and better technology was required. Botox changed that paradigm. For the fi st time, we encountered an injectable substance that was easy to give, lasted up to 6 months (longer in some patients), and most important, delivered quick results that fulfilled the manufacturer’s promise. It completely changed the way physicians and patients perceived the attainment of beauty and rejuvenation, allowing instant gratifi ation and introducing the concept of minimal to no downtime. Patients around the world who desired beauty could now obtain it easily and without surgery. In Asia especially, the growth of aesthetic medicine and the use of botulinum toxins and fillers has been explosive, because our patients prefer nonsurgical techniques to surgery. We are privileged to have been in the forefront of innovation driven by our patients’ appetite for beauty and the desire for less and less downtime. In 2002 I introduced the four Rs principle of nonsurgical rejuvenation, which helped physicians to conceptually bundle these treatments in a comprehensive approach to global facial improvement38-41: • RELAX tissues with botulinum toxin A. • RESTORE volume with fillers. • RESURFACE the skin with nonablative techniques. • REDRAPE the skin soft tissue envelope with barbed sutures. Mastering these four basic maneuvers is easily possible for practicing aesthetic physicians and allows rejuvenation and beautifi ation of the Asian face in a logical, stepwise fashion.

Chapter 12 

Botulinum Toxin A Injections for Facial Rejuvenation and Reshaping

167

Pearls for Success • A fi e and steady injection technique is essential. Physicians can practice with a syringe attached to a 30-gauge needle and filled with saline solution by squirting droplets of varying sizes onto a smooth tabletop. Familiarity with droplet sizes is critical to injecting consistently, evenly, and predictably. • Injections are made less painful by mixing a small amount of lidocaine 1% in a 1 ml syringe of standard Botox. Alternatively, the dilution can be made with preserved saline solution. • An ideal standard dose for facial injection is 2.5 ml saline solution in a 100-unit bottle of botulinum toxin A (0.05 ml 5 2 units and 0.1 ml 5 4 units). It is not necessary to exceed 4 units per injection point for any area on the face. Th s standard dilution can be diluted further for axillary hyperhidrosis or the microbotox technique. • Caution is required with patients with many forehead wrinkles. The wrinkles are there for a reason—they indicate compensatory frontalis action. • Too much Botox in the forehead can result in an immobile, ptotic brow and an uncomfortable feeling. A series of injections along the midline of the forehead encourages the lateral brow to lift, thereby achieving a brow lift • When the masseter muscle is injected, the tip of the 30-gauge needle touches the mandibular bone. • A hyaluronic acid filler should be used in conjunction with Botox, especially in the glabellar area.

ACKNOWLEDGMENT I would like to thank my long-time collaborator and friend, Dr. John Rogers, Director of Medical Aff irs with Allergan, who over the past 15 years has been a source of constant stimulation, helping me to crystallize my thoughts and ideas about Botox and providing me with the scientific basis for many of these ideas.

Refer ences 1. Hwang HS, Park MK, Lee WJ, et al. Facial soft tissue thickness database for craniofacial reconstruction in Korean adults. J Forensic Sci 57:1442-1447, 2012. 2. De Greef S, Claes P, Vandermeulen D, et al. Large-scale in-vivo Caucasian facial soft issue thickness database for craniofacial reconstruction. Forensic Sci Int 159 Suppl 1:S126-S146, 2006. 3. Chan WN, Listi GA, Manhein MH. In vivo facial tissue depth study of Chinese-American adults in New York City. J Forensic Sci 56:350-358, 2011. 4. Rohrich R, Pessa JE. The fat compartments of the face: anatomy and clinical implications for cosmetic surgery. Plast Reconstr Surg 119:2219-2227, 2007. 5. Lee JM, Lee H, Park M, et al. The volumetric change of orbital fat with age in Asians. Ann Plast Surg 66:192-195, 2011. 6. Le TT, Farkas LG, Ngim RC, et al. Proportionality in Asian and North American Caucasian faces using neoclassical facial canons as criteria. Aesthetic Plast Surg 26:64-69, 2002. 7. Wu WT. Non surgical facial rejuvenation with the 4R principle: innovative uses of Botox and facelifting with the Woffle lift. In Panfilov D, ed. Aesthetic Surgery of the Facial Mosaic. Berlin: Springer-Verlag, 2006. 8. Wu WT. Botox facial slimming/facial sculpting: the role of botulinum toxin-A in the treatment of hypertrophic masseteric muscle and parotid gland enlargement to narrow the lower facial width. Facial Plast Surg Clin North Am 18:133-140, 2010.

K23345_Pu_c12_Botox A Inject_r4_cl_149-170.indd 167

4/2/2015 4:03:38 PM

168

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

9. Wu WT. Facial and lower limb contouring. In Bendetto AV, ed. Botulinum Toxins in Clinical Aesthetic Practice, ed 2. London: Informa Healthcare, 2011. 10. Wu WT. Skin resurfacing with microbotox and the treatment of keloids. In Bendetto AV, ed. Botulinum Toxins in Clinical Aesthetic Practice, ed 2. London: Informa Healthcare, 2011. 11. Isse NG. Endoscopic facial rejuvenation: endoforehead, the functional lift. ase reports. Aesthetic Plast Surg 18:21-29, 1994. 12. Massoud KS. Endoscopic forehead lift: screws and temporal fasciae sutures, versus concentric double cable fix tion in suspension of the forehead. J Plast Reconstr Surg 32:163-168, 2008. 13. Gurney CE. Chronic bilateral benign hypertrophy of the masseter muscle. Am J Surg 78:137-139, 1947. 14. Adams WM. Bilateral hypertrophy of the masseter muscle; an operation for correction; case report. Br J Plast Surg 2:78-81, 1949. 15. Baek SM, Kim SS, Bindinger A. The prominent mandibular angle: preoperative management, operative technique and results. Plast Reconstr Surg 83:272-280, 1989. 16. Moore AP, Wood GD. The medical management of masseteric hypertrophy with botulinum toxin type A. Br J Oral Maxillofac Surg 32:26-28, 1994. 17. Smyth AG. Botulinum toxin type A treatment of bilateral masseteric hypertrophy. Br J Oral Maxillofac Surg 32:29-33, 1994. 18. Mandel L, Tharakan M. Treatment of unilateral masseteric hypertrophy with botulinum toxin: case report. J Oral Maxillofac Surg 57:1017-1019, 1999. 19. Moss ML. The primacy of functional matrices in orofacial growth. Dent Pract Dent Rec 19:65-73, 1968. 20. Moss ML, Rankow RM. The role of the functional matrix in mandibular growth. Angle Orthod 38:95-103, 1968. 21. Moss ML. The functional matrix hypothesis revisited. 2. The role of an osseous connected cellular network. Am J Orthod Dentofacial Orthop 112:221-226, 1997. 22. Enlow DH. Facial Growth, ed 3. Philadelphia: Saunders, 1990. 23. Von Lindern JJ, Niederhagen B, Appel T, et al. Type A botulinum toxin for the treatment of hypertrophy of the masseter and temporal muscles: an alternative treatment. Plast Reconstr Surg 107:327-332, 2001. 24. Park MY, Ahn KY, Jung DS. Botulinum toxin type A treatment for contouring of lower face. Dermatolog Surg 29:477-483, 2003. 25. Kim ST, Choi JH, Park MY, et al. The change of the maximal bite-force after botulinum toxin a injection for lower face contouring. J Korean Soc Aesthetic Plast Surg 11:45-50, 2005. 26. Yu CC, Chen PK, Chen YR. Botulinum toxin a for lower facial contouring: a prospective study. Aesthetic Plast Surg 31:445-451, 2007. 27. Kim HJ, Yum KW, Lee SS, et al. Effects of botulinum toxin type A on bilateral masseteric hypertrophy evaluated with computer tomographic measurement. Dermatol Surg 29:484-489, 2003. 28. Kim KS, Byun YS, Kim YJ, et al. Muscle weakness after repeated injection of botulinum toxin type A evaluated according to bite force measurement of human masseter muscle. Dermatol Surg 35:1902-1907, 2009. 29. Fuster Torres MA, Berini-Aytés L, Gay Escoda C. Salivary gland application of botulinum toxin for the treatment of sialorrhea. Med Oral Patol Oral Cir Bucal 12:E511-E517, 2007. 30. Vargas H, Galati LT, Parnes SM. A pilot study evaluating the treatment of postparotidectomy sialoceles with botulinum toxin type A. Arch Otolaryngol Head Neck Surg 126:421-424, 2000. 31. Chow TL, Kwok SP. Use of botulinum toxin type A in a case of persistent parotid sialocele. Hong Kong Med J 9:293-294, 2003. 32. Giess R, Naumann M, Werner E, et al. Injections of botulinum toxin A into the salivary glands improve sialorrhoea in amyotrophic lateral sclerosis. J Neurol Neurosurg Psychiatry 69:121-123, 2000. 33. Manrique D. Application of botulinum toxin to reduce the saliva in patients with amyotrophic lateral sclerosis. Bras J Otorinolaringol 71:566-569, 2005. 34. Bushara KO, Park DM, Jones JC, et al. Botulinum toxin: a possible new treatment for axillary hyperhydrosis. Clin Exp Dermatol 21:276-278, 1996. 35. Glogau RG. Botulinum A neurotoxin for axillary hyperhydrosis: no sweat Botox. Dermatol Surg 24:817-819, 1998. 36. Naumann M, Lowe NJ. Botulinum toxin type A in the treatment of bilateral primary axillary hyperhydrosis: a randomised, parallel group, double blind, placebo controlled trial. BMJ 323:596-599, 2001.

K23345_Pu_c12_Botox A Inject_r4_cl_149-170.indd 168

4/2/2015 4:03:38 PM

Chapter 12 

Botulinum Toxin A Injections for Facial Rejuvenation and Reshaping

169

37. Shah AR. Use of intradermal botulinum toxin to reduce sebum production and facial pore size. J Drugs Dermatol 7:847-850, 2008. 38. Wu WT. Facial rejuvenation without facelifts—personal strategies. Presented at the Regional Conference in Dermatological Laser and Facial Cosmetic Surgery, Hong Kong, Sept 2002. 39. Rose AE, Goldberg DJ. Safety and efficacy of intradermal injection of botulinum toxin for the treatment of oily skin. Dermatol Surg 39:443-448, 2013. 40. Permatasari F, Hu YY, Zhang JA, et al. Anti-aging potential of Botulinum Toxin Type A in UVB-induced premature senescence of human dermal fibroblasts in vitro through decreasing senescence-related proteins. J Photochemistry Photobiology B, Biology 133:115-123, 2014. 41. Oh SH, Lee Y, Seo YJ, Lee JH, et al. The potential effect of Botulinum Toxin type A on human dermal fibroblasts: an in vitro study. Dermatol Surg 38:1689-1694, 2012.

K23345_Pu_c12_Botox A Inject_r4_cl_149-170.indd 169

4/2/2015 4:03:38 PM

K23345_Pu_c12_Botox A Inject_r4_cl_149-170.indd 170

4/2/2015 4:03:38 PM

13 Botulinum Toxin A Injections for Facial Contouring Nam Ho Kim, Tae Joo Ahn, Ro Hyuk Park, Jong Beum Park, Edward I. Lee

T

he   number of patients undergoing noninvasive cosmetic procedures is increasing. In the United States alone, 15.1million cosmetic procedures were performed in 2013, 13.4 million of which were minimally invasive.1 The role of botulinum toxin A in aesthetic rhytid reduction and the role of injectable fillers in facial contouring are well documented.2,3 Although injectable fillers are useful for volume enhancement and contour defin tion, volume reduction presents a treatment dilemma. Th s is the case in patients with a square-angled jaw, a common problem in Asians. Historically, surgical resection of the mandible and/or masseter muscle has been the treatment of choice.4 However, since the fi st report of botulinum toxin A injection for masseter muscle reduction in cases of masseter hypertrophy, this technique has become a mainstay treatment modality, in isolation or in conjunction with surgical resection.5 The goal of this chapter is to discuss the use of botulinum toxin A for facial contouring, specifi ally for the treatment of masseteric hypertrophy.

Etiologic Factors The size of the mandible and the volume of surrounding muscles and subcutaneous tissues determine the width of the lower third of the face. East Asians, in general, have a rather round or square-angled face because of both a wider mandible and well-developed masticatory muscles.6 In addition, excess subcutaneous tissue, including the parotid gland, can give the appearance of a square-angled face. An excessively wide mandibular angle can be an inherited trait and one of many anthropometric differences between Asians and members of other races. It can be a familial trait or an acquired trait from differential use over time from dietary and chewing habits. Masseteric hypertrophy has been shown to be both an inherited and acquired trait.7 Muscle hypertrophy has long been hypothesized as the cause of an overdeveloped masseter muscle. The most common causes are thought to be clenching and bruxism, but only 20% of affected individuals are aware of this association.4 Attrition of teeth is commonly seen in patients with bruxism, and patients with clenching habits often have stiffness of the jaw because of muscle fatigue. Chewing hard and tough food regularly allows the masseter muscles to hypertrophy and can lead

171

172

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

to a square-angled face over time.8 However, in general, chewing food, even if rigid and hard, does not affect muscle hypertrophy to a signifi ant degree, because the food is swallowed once crushed. It is the continuous, long-term chewing that induces muscle hypertrophy, as in patients who chew gum. Bruxism and clenching must be carefully managed and chewing gum strictly prohibited before and after treatment to improve the outcome.

Anatomy Understanding facial anatomy and the intricate relationships between the various structures is integral to any successful facial rejuvenation or contouring technique. The muscles of mastication comprise the masseter, temporalis, medial pterygoid, and lateral pterygoid. They derive from the fi st branchial arch, and they are innervated by the mandibular branch of the fi h cranial nerve (trigeminal nerve) and located laterally on the face. As with other skeletal muscles, they originate and insert onto bone. As the name suggests, the four muscles of mastication are involved in mandibular excursion. In general, the temporalis, masseter, and medial pterygoid muscles contract to elevate the mandible, whereas the lateral pterygoid muscle contracts to depress the mandible. From a clinical standpoint, the masseter is the largest and strongest of the muscles of mastication. It is divided into two segments, superfic al and deep. The superfic al segment is larger and located more laterally than the deeper portion. The superfic al portion originates from the zygomatic process and arch and inserts into the ramus and angle of the mandible. The deeper portion originates from the inner aspect of the zygomatic arch and descends vertically into the ramus of the mandible and coronoid process. The parotid gland is intimately associated with the masseter. The gland covers the posterior portion of the masseter, and the parotid duct runs on its external surface, penetrating into the buccinator muscle at the anterior edge of the masseter. The masseter is innervated by the masseteric branch of the trigeminal nerve, and the blood supply comes from branches of the internal maxillary artery. The vein to the masseter runs parallel to the masseteric branch of the trigeminal nerve. The mean bigonial distance (the width of the lower face) of Western women is 105 mm, whereas that of Korean women ranges from 117.8 to 125.25 mm, approximately 12 to 20 mm wider.4 Aesthetically, a square face is viewed as masculine. It is more desirable for the bigonial distance to be narrower than the bizygomatic distance (the width of the midface). The classic, standard bigonial/bizygomatic ratio is 9:10, but a narrower bigonial distance has become preferred in Asian cultures4 (Fig. 13-1). A

B

Fig. 13-1  Two types of facial shapes. A, Square. B, Narrow.

Chapter 13 

Botulinum Toxin A Injections for Facial Contouring

Pathophysiology of Botulinum Toxin A Injection for Masseter Hypertrophy The mechanism of action of masseter reduction with botulinum toxin A injection is based on the concepts of work hypertrophy and disuse atrophy. Continuous load on muscle over time causes work hypertrophy, as in a body builder with thick, stiff rms composed mostly of enlarged muscles over normal bones. In the same manner, the masseter can enlarge from work hypertrophy, leading to a square-angled face by thickening of the lower chin and broadening of the lower face. The concept of disuse atrophy, on the other hand, is best demonstrated in an extremity that has been immobilized for a prolonged period. Limiting the amount of masseter contraction induces disuse atrophy, causing the desired reduction in muscle volume. Botulinum toxin A exerts its effects at the neuromuscular junction by inhibiting the release of acetylcholine, causing flaccid paralysis and muscle atrophy through chemical denervation. Once paralyzed, the muscles do not contract, and over time muscle volume decreases (for example, in disuse atrophy). The action of botulinum toxin A occurs in three phases: binding, internalization, and neuromuscular blockade.4 Once botulinum toxin A combines with the cholinergic receptor through the heavy chain of the 50-kDa carboxy-terminal, receptor-mediated endocytosis occurs. Botulinum toxin A then transiently inhibits the release of acetylcholine through the proteolysis of synaptosomal-associated protein (SNAP-25). Th s in turn causes chemical denervation, resulting in flaccid paralysis.

Indications The importance of determining whether subcutaneous fat, muscle, or bone is the source of increased width of the lower face cannot be overemphasized. Botulinum toxin A injection is indicated in the following cases: • Absolute indication: A patient who has masseter hypertrophy with normal bone, fat, and parotid glands • Relative indications: (1) A patient who has masseter hypertrophy in addition to abnormal bone, fat, and/or parotid glands and (2) a patient who is dissatisfi d with the results of bone resection or liposuction

Preoperative Assessment The cause of a square-angled face can be determined by a combination of physical examination and imaging studies.

Phy sical Examinatio n

In a physical examination, facial lines and symmetry should be assessed fi st. From a frontal view, the lateral facial line begins from the hairline and passes by the temple, the zygomatic arches (a determinant of bizygomatic distance), and the gonion (a determinant of bigonial distance), ending at the chin. The widest portion of the face is the bizygomatic distance. The vertical facial line is divided into equal thirds: the upper face (the hairline to the top of the eyebrows), the midface (the top of the eyebrows to soft issue of the subnasale), and the lower face (soft tissue of the subnasale to the menton). The ideal ratio of the vertical thirds of the face is 1:1:1.However, as the preference for a smaller face with a narrow width of the lower face is emerging, the desired ratio is closer to 1:1:0.9. In addition, the ideal ratio of the vertical length to the bizygomatic distance is 1.3:1.

173

174

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

Next, the face is palpated to deduce the relative thickness of the muscle and the skeletal framework. A pinch test can be performed to assess the thickness of the subcutaneous fat layer. For this assessment, the widest portion of the lower face is identified first. Usually, the bigonial distance is widest, but depending on the thickness of the subcutaneous layer, the anterior cheek can be wider than the bigonial distance. Botulinum toxin A injection is contraindicated in patients with this facial morphology, because masseter volume reduction can lead to a depressed, gaunt appearance of the mandible. The size of the parotid gland, located posterior to the masseter muscle, can affect the width of the lower face. In some patients, the parotid bulges more laterally than the masseter. The only way to reduce the volume of the parotid gland is through a superfic al parotidectomy, a procedure that is difficult to justify in this elective setting because of its scar burden and potential morbidity.

Imaging Stud ies

Plain radiography, including a panoramic view and frontal cephalogram, is recommended to assess the skeletal framework. On a panoramic view, the location and shape of the condyle, the height of the ramus, and the location of the gonial angle are assessed. The developmental status of the gonial angle should be assessed on a frontal cephalogram. Ultrasonography allows simple evaluation and measurement of the muscle, the subcutaneous fat layer, and the parotid gland (Fig. 13-2,A). The target area should not be compressed with the probe, because this causes measurements to be smaller than the actual values. A practical way to obtain consistent results is to normalize the target area. In our practice, all measurements are made on a line connecting the earlobe and the corner of the mouth (Fig. 13-2,B). In our previous published study, the mean thickness of the masseter in the resting state before injection was 13.36 mm (range 9.1 to 19.1 mm) on the left nd 13.69 mm (range 9.4 to 20.1 mm) on the right.4 Although cost prohibitive in some clinical settings, three-dimensional CT is a useful modality for preoperative assessment and treatment planning. It allows more precise measurements and defi es the threedimensional relationship between the mandible, the masseter, and the subcutaneous tissue (Fig. 13-2, C).

A

B

C

Measurement line

Fig. 13-2  Imaging modalities. A, Ultrasonography is a simple study that can be performed in the office r at bedside. B, To obtain consistent results between patients, all muscle thickness measurements should be made on a line connecting the earlobe and the corner of the mouth. C, The use of three-dimensional CT is becoming increasingly common. It allows accurate measurement of all soft tissue components, including muscle.

Chapter 13 

Botulinum Toxin A Injections for Facial Contouring

Table 13-1  Standard Scale for Volume of Injection Muscle Thickness (mm)

BoNT Unit*

10

30

100

11

32.5

110

12

35

120

13

37.5

125

14

40

130

15

42.5

135

16

45

140

Dysport Unit*

*Total injected units for one side. BoNT, Botulinum neurotoxin. Includes non-Dysport botulinum toxin A products such as Botox Cosmetic, Botulax, Medytoxin, Nabota, and Xeomin.

Surgical Technique Dosa ge and Dil utio n

An injection dosage should be enough to completely inhibit movement of the masseter muscle. A less than optimal dose leads to less efficacy and incomplete correction. Overdosage leads to unnecessary waste and possibly increased complications. In addition, the type of botulinum toxin A must be considered in determining the amount of toxin to inject. We have devised a dosing schedule of botulinum toxin A based on muscle thickness and the type of toxin used (Table 13-1). In general, botulinum toxin A can be divided into two categories. Botox Cosmetic, Botulax, Medytoxin, Nabota, and Xeomin can be grouped together as botulinum neurotoxin (BoNT), because they share similar pharmacologic properties. Each vial contains 100 BoNT units. Dysport has slightly different pharmacologic properties, and in general, 300 Dysport units is equivalent to 100 BoNT units. One vial of Dysport is reconstituted with 2.5 ml of normal saline solution to make a concentration of 100 Dysport units per 0.5 ml. BoNT is reconstituted with 2 ml of normal saline solution for a concentration of 25 BoNT units per 0.5 ml.

Pr o ced ur e

The patient is placed in an upright or slightly tilted position. The target area is then cleansed using alcohol swabs. In general, the injection should be given in the thickest region of the masseter muscle. However, to improve the consistency of the injections and minimize complications, we have devised a safety zone, which is a quadrangular area devoid of important and vital structures. First, a line is drawn on the skin linking the earlobe and the corner of the mouth. Next, the masseter muscle is palpated, and two lines are drawn demarcating the anterior and posterior margins of the muscle, which should intersect the fi st line. The inferior border of this quadrangular zone is drawn in line with the mandibular angle (Fig. 13-3,A). Within the quadrangular safe zone, three points are marked for injection (Fig. 13-3,B). The diffusion potential of the toxin needs to be considered. Generally, a point that is 1.5 cm anterior to the mandibular angle and near the center of this zone is the thickest portion of the muscle. Th s is set as the central point. Two

175

176

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

A

B

Earlobe to mouth corner Posterior border of masseter

Anterior border of masseter Mandible border

Safety zone

Mandible angle

Fig. 13-3  Reference landmarks for injection. A, A quadrangular zone is drawn demarcating the area in which the masseter is well developed and at a safe distance from vital anatomic structures. B, Th ee injection points are selected. The diffusion potential of the toxin should be considered.

more injection points are chosen that are approximately 1 cm from the central point in either direction. Fifty percent of the total dose is injected on the central point, and 25% of the total dose is injected into each of the other two points. Additional injections, if needed, can be given every 3 to 6 months.

Results In our initial study, 383 of the 1021 patients who were treated with botulinum toxin A were followed for at least 3 months after initial injection.6,9 At 3 months, the average reduction in the thickness of the masseter muscle was 31%. The atrophic effect of injection was observed after 2 to 4 weeks in most patients. Seventy percent of the 383 patients were greatly satisfi d with the result, and 23% were generally satisfi d. Shortterm complications were related to the weakening of the masseter muscle and included diminished chewing power, irregular muscle movements during mastication, awkward facial expressions, and loss of facial dimples, all of which were self-limited and resolved over time. No long-term complications were observed. In the follow-up study, a retrospective analysis was conducted on 121 patients who were treated for more than 1 year with serial injections.9 Six of these patients received two injections, 28 received three injections, 41 received four injections, 23 received five injections, 16 received six injections, 6 received seven injections, and 1 patient received eight injections. On average, the masseter was reduced from 13.32 mm at the fi st visit (baseline) to 9.94 mm at the last visit. The number of injections correlated positively with the reduction in muscle volume.

Chapter 13 

177

Botulinum Toxin A Injections for Facial Contouring

Pretreatment

4 months: second injection given

14 months: third injection given

36 months: fourth injection given

60 months: result

Fig. 13-4 Th s 34-year-old woman presented for evaluation for treatment of her wide-angled face. On examination, the patient had hypertrophy of her masseter muscle and mandibular bone. She did not want surgery and opted to pursue treatment with botulinum toxin A alone. The patient was treated with three additional injections at 4 months, 14 months, and 36 months after initial injection and was followed for 60 months. She is very satisfi d with her result.

K23345_Pu_c13_Bot Tox Contour_r4_cl_171-182.indd 177

4/2/2015 4:24:02 PM

178

Part II 

Pretreatment

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

1 month after injection

6 months after injection

Fig. 13-5 Th s 28-year-old woman presented for evaluation for treatment of her wide-angled face. On examination, the patient had a hypertrophic masseter with relatively normal mandibular bone and subcutaneous tissue. She was treated with botulinum toxin A injection and was followed serially for 6 months. The patient is very pleased with the result and desires no further injections.

Pretreatment

3 months: second injection given

6 months after initial injection

24 months: third injection given

Fig. 13-6 This 32-year-old woman presented with a hypertrophic masseter and desired correction.* The patient was treated with serial botulinum toxin A injections. The initial injection consisted of 130 units of Dysport on each side. To maintain volume reduction, additional injections were given 3 months (120 units) and 24 months (110 units) after the initial injection. Her masseter measured 14.1 mm on the left and 13.7 mm *With permission from Kim NH, Chung JH, Park RH, Park JB. The use of botulinum toxin A in aesthetic mandible contouring. Plast Reconstr Surg 115:919-930, 2005.

K23345_Pu_c13_Bot Tox Contour_r4_cl_171-182.indd 178

4/2/2015 4:24:03 PM

Chapter 13 

179

Botulinum Toxin A Injections for Facial Contouring

on the right before treatment. Maximal results were seen 6 months after the initial treatment (3 months after the second treatment). The masseter measured 8.4 mm on the left nd 8.1 mm on the right at this time. At 68 months, the masseter measured 12.1 mm on the left nd 11.8 mm on the right, representing a 14.2% and 13.9% overall reduction in volume, respectively. The patient is very pleased with her results.6

Outcomes Since Legg10 fi st described benign masseteric hypertrophy in 1880, a number of treatment modalities have been developed. Traditionally, these methods involved resection of either a portion of the masseter or the mandible or a combination of both.11-17 However, these involved the possibility of complications such as considerable bleeding, facial nerve injury, trismus from postoperative scar contracture, and a poor aesthetic outcome from unexpected secondary remodeling of the mandible. Symmetrical contour lines can be difficult to create with equal resection of both sides. In 1994 Smyth5 introduced the use of botulinum toxin A for the treatment of masseteric hypertrophy. Since then, botulinum toxin A injection has become an important modality in the treatment of a square-angled jaw.18,19 In 2005 we published our experience in 383 patients followed for more than 3 years, including a discussion of the technique, results, and clinical pearls.3 More recently, we published our study on longterm effects of botulinum toxin A injection on masseter muscle hypertrophy, discussing the appropriate timing and frequency of injections.9 We think that botulinum toxin A injection is a simple and effective treatment for masseteric hypertrophy. It has a favorable complication profile and is minimally disruptive to patient’s life. It can be used alone or in conjunction with other treatment modalities such as surgical reduction of the masseter and/or mandible. Moreover, the effects can be maintained over the long term with repeated treatments.

Appropriate Timing and Frequency of Injections After botulinum toxin A treatment, the masseter muscle undergoes the following four distinct phases of change (Fig. 13-7): 1. A decrease in muscle tension 2. A decrease in muscle volume 3. Recovery of muscle tension 4. Recovery of muscle volume

Effect Maximal 100%

Muscle atony (decrease of muscle tension) Second injection

Visible point 50%

Muscle atony (decrease of muscle volume)

2 wk

1

2

3

Muscle atony and fibrosis (recurrence of muscle volume)

Action recovery (recurrence of muscle tension)

4

5

6

7

12

Fig. 13-7  Physiologic changes to muscles after chemical denervation.

13

14

Time (mo)

180

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

Clinically, a subtle change in muscle tone occurs 3 to 5 days after the fi st injection. A patient can feel weakness when clenching the molars. After 1 week, softening of the muscle is apparent, and visual changes to muscle volume can be seen after 2 to 4 weeks. The effect of the toxin reaches a maximal level at 10 to 12 weeks, followed by muscle action recovery starting at approximately 3 months after injection. Volume recovery occurs gradually over time, an important fi ding that explains the longer duration of effect of toxin in volume reduction, compared with its efficacy in rhytid reduction. From our previous study, we know that volume reduction is maintained despite muscle recovery 6 months after injection, often extending to a year or longer after injection9 (Fig. 13-8). A single injection of toxin cannot maintain the effect permanently. After the maximal effect (atonic stage) is achieved, muscle tone and volume recover gradually, but a percentage of sustained effect is seen more than 1 year after treatment (Fig. 13-9). As the number of injections increases, the sustained effect on muscle over time increases. Therefore not only the quantity but also the timing of the additional injections is critical. To maintain the continual interception of nerve transmission, an additional injection is needed in the early period of tone recovery. The dosage of the second injection is flex ble depending on the result of the fi st treatment and is usually 70% to 80% of the initial dose. However, if the second injection is delayed A

B

Fig. 13-8  Ultrasonographic fi dings. A, The masseter muscle is on average 14.3 mm thick before injection. B, Six months after the injection, the thickness of the muscle decreases to an average of 10.0 mm. Effect

Atonic stage

Maximal Sustained effect Second injection

First injection

1

4

6

28.1%

Third injection

8

10

19.4%

12

14

16

18

20

22

23

12.8% Time (mo)

Fig. 13-9  The relationship between maximum and sustained effects. Th s graph shows the change in muscle volume

after botulinum toxin A injections. A sustained eff ct is described as preservation of reduced muscle for longer than 1 year after treatment. As the number of botulinum toxin A treatments increases, the sustained effect on the muscle increases. The effici cy of treatment (permanence of the reduced muscle) becomes greater. Therefore, to continually reduce the movement of the masseter, additional treatments are needed.

Chapter 13 

Botulinum Toxin A Injections for Facial Contouring

and muscle volume has recovered, then a higher dose is indicated. Because the period of denervation is about 3 to 6 months, two to four additional injections are needed to maintain the effect for longer than 1 year after treatment.

Management of Complications Complications from injection itself, such as bruising or edema, can be prevented with careful technique. By and large, complications of botulinum toxin A injection for masseter hypertrophy relate to the side effects of temporary muscle paralysis.6 Patients should be counseled about the following potential complications before undergoing treatment: • Ineffective masticatory power. Th s is an unavoidable consequence of muscle paralysis and disuse atrophy seen in 50% of patients about 1 to 2 months after injection. It is relieved by compensatory actions of other muscles of mastication over time. • Irregular muscle movements during mastication. About 10% of patients note that the masseter muscle appears irregular during chewing about 1 to 2 weeks after injection. Th s can last for 2 to 4 weeks and the causes are multifactorial, including differential response of muscle at various points, differential muscle volume, differential skin thickness, and possibly injection error. Most cases resolve by 3 to 4 weeks, but additional injections may be needed. • Awkward facial features. About 2% to 5% of patients report drooping in the corners of the mouth 2 to 4 weeks after injection. This lasts about 4 to 8 weeks before resolving spontaneously. It is likely caused by inadvertent injection of the risorius, zygomaticus minor, or zygomaticus major muscle. • Protrusion of zygomatic bones. Because of the diffusion of toxin after injection, the masseter muscle near its origin on the zygoma can undergo atrophic changes, which can cause the zygoma to appear more prominent. Th s resolves over time but can be a serious concern for some patients. Therefore careful consideration should be given to patients who are more likely to have this problem, including those with large and wide cheekbones, a long face, mandibular prognathism, or a thin face. Though spontaneous resolution is the norm, fat grafting or zygoma reduction can be helpful. • Incomplete correction. About 7% of our patients report dissatisfaction with the procedure because of less than expected or desired changes. More often these patients have features that are less amenable to change, such as bony hypertrophy, well-developed parotid glands, low elasticity of the skin, and protrusive cheekbones. In patients who have mainly bony hypertrophy or very thick masseter muscles, chemical denervation alone will not make a signifi ant difference. In such cases a combination of mandibular angle resection with muscle resection can provide a better outcome (Fig. 13-10).

A B

Fig. 13-10  Surgical correction. A, Mandibular angle resection. B, Masseter muscle resection. In patients with mainly bony hypertrophy or very thick muscles, a combination of mandibular angle and masseter muscle resection can provide results that are not possible with injection alone.

181

182

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

Pearls for Success • Determining the cause of a square-angled jaw is important in treatment planning. Botulinum toxin A injection is ideal for treatment of patients who have masseter hypertrophy with normal bone, fat, and parotid glands. • Careful consideration should be given to patients with large and wide cheekbones and those with a long face, mandibular prognathism, or a thin face, because they are more likely to have undesired results. • The thickest region of the masseter muscle should be injected, within the quadrangular safety zone described. • Two to four additional injections given 3 to 6 months apart are needed to maintain the effects for longer than 1 year after treatment. Ideally, repeat injections are given before muscle volume has recovered, and the dosage is usually 70% to 80% of the initial dose. • Complications are minor and temporary, but they should be monitored and treated, if needed.

Refer ences 1. American Society of Plastic Surgeons. 2013plastic surgery statistics report. Available at http://www.plasticsurgery. org/news/plastic-surgery-statistics/2013.html. 2. Rohrich RJ, Janis JE, Fagien S, et al. The cosmetic use of botulinum toxin. Plast Reconstr Surg 112(Suppl):S177S187, 2003. 3. Rohrich RJ, Hanke CW, Busso M, et al. Facial soft- issue fillers conference: assessing the state of the science. Plast Reconstr Surg 127(4 Suppl):S22, 2011. 4. Kim NH, Chung JH, Park RH. Masseteric muscle hypertrophy and leg treatments. In Ascher B, ed. Injection Treatments in Cosmetic Surgery. London: Informa Healthcare, 2009. 5. Smyth AG. Botulinum toxin treatment of bilateral masseteric hypertrophy. Br J Oral Maxillofac Surg 32:29-33, 1994. 6. Kim NH, Chung JH, Park RH, Park JB. The use of botulinum toxin type A in aesthetic mandible contouring. Plast Reconstr Surg 115:919-930, 2005. 7. Carruthers A, Carruthers J. History of the cosmetic use of botulinum A exotoxin. Dermatol Surg 24:1168-1170, 1988. 8. Lee YJ, Han KH, Kang JS. Korean craniofacial standard measurement. J Korean Soc Plast Surg 21:438-451, 1994. 9. Kim NH, Park RH, Park JB. Botulinum toxin type A for the treatment of hypertrophy of the masseter muscle. Plast Reconstr Surg 125:1693-1705, 2010. 10. Legg JW. Enlargement of the temporal and masseter muscles on both sides. Trans Pathol Soc London 31:361-366, 1880. 11. Gurney CE. Chronic bilateral benign hypertrophy of the masseter muscle. Am J Surg 73:137-139, 1947. 12. Farkas LG. Anthropometry of the Head and Face in Medicine, ed 2. New York: Elsevier, 1994. 13. Whitaker LA. Aesthetic contouring of the facial support system. Clin Plast Surg 16:815-816, 1989. 14. Baek SM, Kim SS, Bindiger A. The prominent mandibular angle: preoperative management, operative technique, and results in 42 patients. Plast Reconstr Surg 83:272-280, 1989. 15. Baek SM. Aesthetic contouring of the facial skeleton. Probl Plast Reconstr Surg 1:667-682, 1991. 16. Hong JU, Choi J, Baek SM. Study on resected area and masticatory muscle’s histopathology and radiologic changes after Gato’s mandibular osteotomy. J Korean Soc Plast Surg 21:857, 1994. 17. Yang DB, Park CG. Mandibular contouring surgery for purely aesthetic reasons. Aesthetic Plast Surg 15:53-60, 1991. 18. Moore AP, Wood GD. The medical management of masseteric hypertrophy with botulinum toxin type A. Br J Oral Maxillofac Surg 32:26-28, 1994. 19. von Lindern JJ, Niederhagen B, Appel T, et al. Type A botulinum toxin for the treatment of hypertrophy of the masseter and temporal muscles: an alternative treatment. Plast Reconstr Surg 107:327-332, 2001.

14 Radiofrequency for Facial Rejuvenation

S

Jin Wang Kim, Haiyan Cui

ince 1994 many ablative and nonablative techniques have been developed for rejuvenation of photodamaged skin in Asians. The use of radiofrequency (RF) energy is a recent trend in skin therapy1 that is emerging as a gentler, nonablative skin-tightening technique that delivers uniform heat to the dermis at a controlled depth.2 Facial rejuvenation with RF energy give the appearance of upward-lifted skin, but it is not a face lift r a replacement for surgery. It is a single procedure that can be combined with other approaches such as laser, light therapy, platelet-rich plasma treatments, and high-frequency ultrasound. It is a viable option for patients who are not ready for a face lift nd those who wish to prolong the effects of cosmetic surgery. The use of electric currents in medicine dates nearly to the discovery of electricity. Nonablative RF energy is the newest addition to the treatment options available for the aging face.3 It is used worldwide to treat cellulite, acne scars, hypertrophic scars and keloids, rosacea, and inflammatory acne.

Basic Physics of Radiofrequency RF is the lowest of the electromagnetic radiation frequencies within the spectrum, which spans from radio waves to microwaves, infrared, optical (visible light), ultraviolet, x-rays, and gamma rays. Electromagnetic waves can be generated by feeding an alternating current or voltage through an antenna or electrode. Waves that radiate through space at the speed of light are known as radio waves. RFs, or radio waves, have wavelengths ranging from less than 1 cm to 100 km.4 When RF energy is applied to the human body, which can conduct current and therefore act as part of an electrical circuit, any resistance encountered by the energy fl w will cause heat to be produced at the site of maximal resistance. Th s heat can be used to cut or coagulate tissue. RF energy employed for skin tightening penetrates deep into the skin and affects the deeper dermis and subcutaneous layers, causing tightening and improvement of the underlying tissue structure with little change in skin texture or fi e lines and wrinkling.5

183

184

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

Types of Rad io fr eq uency Deliver ies Monopolar Delivery

Monopolar, also known as unipolar, describes a device having one pole or electrode. Th s type of delivery involves passage of a current from a generating device, through a single electrode on the handpiece, and through the body. The current encounters maximal resistance in the tissues around the tip of the handpiece, generating heat in the subdermal layers. A grounding, or return pad, attached to the patient’s lower back or abdomen establishes a low-resistance path through which the current travels to return to the generating machine. Monopolar RF–only devices are often used for facial rejuvenation.6

Bipolar Delivery Bipolar devices have two poles or electrodes.6-8 The electrical circuit begins at one electrode and ends at the other. With this type of delivery, the current fl ws only through the tissue between the two electrodes on the handpiece. Because no current fl ws through the rest of the body, no grounding or return pad is required. Heat is generated by the resistance to the current fl w in the tissue and not by the electrode.

Relevant Skin Anatomy and the Wound-Healing Process After Radiofrequency Facial Rejuvenation RF energy is produced by an electric current rather than by a light source. It is conducted electrically to tissue, and heat is produced when the tissue’s inherent resistance (impedance) converts the electrical current to thermal energy. Th s reaction is represented by the following formula: energy (J) 5 I2 3 R 3 T, where J 5 current, R 5 tissue impedance, and T 5 time of application.9 According to the skin rejuvenation theory for RF, intense pulsed light, laser, and ultrasound, the deeper tissues are heated to cause collagen denaturation and neocollagenesis. The threshold for collagen denaturation is approximately 60° to 65° C. Lin et al10 used a second-harmonic generation microscope to directly observe the effects of heat (from 25° to 60° C) on collagen fibers from rodent tail tendons. They noted that collagen fibers began to curve at 52° to 55° C, and collagen denaturation occurred at 60° C. After collagen denatured, neocollagenesis occurred. Collagen rejuvenated for approximately 1 month after treatment. Increased small collagen fiber formation, evidence of neocollagenesis, was noted 30 days after heat treatment. In another study that tracked tissue changes after heating to effect denaturation, the authors observed neocollagenesis and deposition of new hyaluronic acid 10 weeks after treatment.11 Temperatures below 60° C had minimal effects on collagen structure and thus were unlikely to have signifi ant effects on collagenesis. After a treatment, inflammatory skin conditions subside in 1 to 7 days. Damaged tissues heal in 5 to 15 days, and damaged collagen fibers recover in 3 days to 1 month. New collagen is synthesized from 3 weeks to 1 year. Fig. 14-1 shows the typical phases of wound healing. Ultraviolet radiation from sunlight can cause elastic fiber deformation, thickening, bifurcation, degeneration, and the accumulation of lumps. These effects decrease elasticity and compliance and lead to skin laxity, cracks, and hyperextension. A typical phase of sun-damaged skin is shown in Fig. 14-2. Type I collagen accounts for approximately 80% of skin collagen. It is gathered in the dermis into thick, leathery, parallel fibers and is interwoven into a network with a high degree of mechanical stability. It helps to maintain skin tone, can withstand tension, and maintains skin plumpness. Sun damage can reduce the formation of type I collagen. Type III collagen comprises small, thin collagen fibers and is the main component of reticular fibers. Approximately 50% type III collagen is found in embryonic skin. It is also pre­s– ent in the adult epidermis and the skin covering the appendages. It can be proliferated in wound healing and certain pathologic conditions. The amount of type III collagen is relatively increased during aging and can lead to a reduction of mature collagen bundles; thus the skin can sag and wrinkle. Box 14-1 lists indications and contraindications for RF.

Chapter 14 

Proliferation

185

Radiofrequency for Facial Rejuvenation

Wound contraction 5 to 15 days

Inflammation

Collagen synthesis 3 days to 4 weeks

Tissue formation Remodeling 3 weeks to 1 year 0

1

2

3

4

5

Macrophages

6

7

Days

14

21

Mast cells

Fibroblasts

Fig. 14-1  Phases of wound healing and formation of macrophages, fibroblasts, and mast cells.

Fig. 14-2  A hematoxylin and eosin stain with a magnifi ation of 1003 shows the pathophysiology of elastolysis in an Asian patient with sun-damaged skin. Numerous type III collagen exist in the dermis.

Box 14-1  Indications and Contraindications for Radiofrequency Facial Rejuvenation Indications • Wrinkles • Skin laxity • Scars, including acne scars • Textural irregularities • Low skin tone • Superfic al skin lesions • Double chin • Fat or flabby cheeks

K23345_Pu_c14_Radiofreq_r3_183-202.indd 185

Contraindications • An implanted cardiac pacemaker • Epilepsy • Pregnancy or lactation • Heart disease (for example, angina pectoris and heart failure) • Cancer and/or skin tumors • Autoimmune diseases • Psychiatric conditions • Inflammatory skin diseases such as eczema or psoriasis • A metallic prosthesis in the treatment area, as in patients who have had a hip replacement • As a follow-up procedure within 1 to 2 weeks of laser, intense pulsed light, or ultrasound treatment

4/2/2015 4:26:37 PM

186

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

Pretreatment Assessment Skin type is determined using the Fitzpatrick classifi ation (Table 14-1).12 Wrinkles are classifi d with the Glogau classifi ation of photoaging (Table 14-2).13 The Vancouver skin scar scale is helpful for analyzing scars (Table 14-3).14 Patients with moderate facial aging manifested by skin laxity, rhytids, ptosis (brow, midface, and jowls), stretch marks, stitch marks, scars, Fitzpatrick skin type III or IV, and Glogau class I or II wrinkles can be treated for a 6-month period. Asian patients typically have Fitzpatrick skin type IV or V. The duration of the session is based on the condition of the skin. If a patient’s skin is too sensitive, we recommend the use of low energy in repeated sessions. Sensitive skin can cause inflammation of the phenomenon of overstimulation, and thus stimulate capillary proliferation, pigmentation phenomena, and so on.

Table 14-1  Fitzpatrick Skin Types Type 1

Red and blond hair Blue eyes Burns easily, never tans Freckles, very fair skin MC1R gene risk

High risk of skin cancer May scar if slow to heal Higher potential for vascular (venous) damage

Type 2

Fair sandy and red hair Green and blue eyes Burns easily, tans with difficulty Some freckles MC1R gene risk

High risk of skin cancer May pigment with trauma and may scar if slow to heal Higher potential for vascular damage

Type 3

Brown, fair, and sandy hair Green, hazel, and blue eyes Slow to burn, will tan May have MC1R gene risk

High risk for all pigmented skin conditions Moderate risk for skin cancer Higher potential for scarring Moderate risk for vascular damage

Type 4

Dark brown hair Green, hazel, or brown eyes Slow to burn and tans easily

High risk for pigmentation from trauma, heat, and chemicals Moderate risk for all other pigmented skin conditions High risk for scarring and visible vascular damage

Type 5

Dark brown and black hair Brown and dark brown eyes May never burn

Very high risk for pigmentation from trauma, heat, and chemicals Lower risk for solar-pigmented skin conditions High risk for scarring (keloid) Moderate risk for visible vascular damage

Type 6

Black hair Dark brown eyes May never burn

Very high risk for pigmentation from trauma, heat, and chemicals Lower risk for solar-pigmented skin conditions High risk for scarring (keloid) Moderate risk for visible vascular damage

From Fitzpatrick TB. Soleil et peau. Journal de Médecine Esthétique 2:33-34, 1975. MC1R, Melanocortin 1 receptor.

Chapter 14 

Radiofrequency for Facial Rejuvenation

187

Table 14-2  Glogau Classifi ation of Photoaging Class

Typical Age (years)

Damage

Characteristics

Description

I

Mild

28-35

No wrinkles

Early photoaging: mild pigment changes, no keratosis, minimal wrinkles

II

Moderate

35-50

Wrinkles in motion

Early to moderate photoaging: early brown spots visible, keratosis palpable but not visible, parallel smile lines begin to appear

III

Advanced

50-65

Wrinkles at rest

Advanced photoaging: obvious discolorations, visible capillaries, telangiectasias, visible keratosis

IV

Severe

60-75

Only wrinkles

Severe photoaging: yellow-gray skin color, prior skin malignancies, wrinkles throughout

From Glogau RG. Aesthetic and anatomic analysis of the aging skin. Semin Cutan Med Surg 15:134-138, 1996.

Table 14-3  The Vancouver Scar Scale Scar Characteristics

Score

Vascularity

Normal Pink Red Purple

0 1 2 3

Pigmentation

Normal Hypopigmentation Hyperpigmentation

0 1 2

Pliability

Normal Supple Yielding Firm Ropes Contracture

0 1 2 3 4 5

Height

Flat ,2 mm 2 to 5 mm .5 mm

0 1 2 3

t ota l From Sullivan T, Smith J, Kermode J, et al. Rating the burn scar. J Burn Care Rehabil 11:256-260, 1990.

K23345_Pu_c14_Radiofreq_r3_183-202.indd 187

4/2/2015 4:26:37 PM

188

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

Equipment and Techniques for Treatment Mono pol ar Rad io fr eq uency

Thermage is a nonsurgical skin tightening procedure that effectively eliminates subtle signs of aging in the face through the application of monopolar RF energy. It works beneath the outer layer of skin called the dermis. Thermal collagen contraction can be induced in the skin for aesthetic rejuvenation, reducing skin laxity and aging symptoms. The technique is used to smooth wrinkles, tighten the skin, and redefi e facial contours. During a procedure, high levels of heat are applied to the area being treated using RF energy. High levels of RF energy have a wider thermal dispersion region and can heat deeper-layer dermis. The generated heat produces subtle damage to collagen, and in combination with the subsequent inflammatory cascade induced by heating, causes a tightening effect. The device heats tissues to 65° to 75° C, which is the temperature at which collagen denatures. During the healing process, collagen is rebuilt and the skin tightens. The handpiece facilitates the transport of monopolar RF energy from the generator to the treatment head of the refrigerant coolant. The generator produces 6 MHz of energy and a monopolar RF signal to provide an interactive-process tip. The front panel displays the tissue impedance measurement, the processing sequence, and the energy level delivered in real time. The system can receive the feedback signal about the skin temperature from a temperature sensor; the data are processed, and coolant is delivered as needed. The membrane electrode is designed to uniformly treat the surface of the skin in a process known as capacitive coupling, whereby heat is generated subdermally while the surface is cooled. The depth of treatment is up to 20 mm. The skin temperature is maintained at 35° to 45° C.15 The device allows communication between the generator and the sensors on the treatment tip. The different tips can be fitted onto the handpiece. They uniformly distribute monopolar RF energy across treatment areas. These single-use tips are manufactured in a range of sizes (0.25 cm2, 1.0 cm2, 1.5 cm2, and 3.0 cm2). Each tip is designed to provide a specific, uni orm depth of penetration of monopolar RF energy. Each energy pulse lasts 2 to 7 seconds. Treatment of an entire face may require 400 to 600 pulses. The number of pulses varies, depending on the body part being treated and a patient’s needs. To avoid damage to the epidermis, the handpiece has a contact cooling tip to cool the epidermis.16 Skin will be red and swollen after treatment, but patients have no downtime. Adverse effects subside in a few days. Depending on the severity of the laxity, one or two treatments may be necessary to achieve desired results. A second treatment is recommended at 3 months. Results can be seen for up to 2 years. The Thermage handpiece is shown in Fig. 14-3. Other monopolar RF systems for skin rejuvenation are listed in Table 14-4.

Fig. 14-3  Thermage handpiece. (Courtesy of Solta Medical Ltd., Hayward, CA.)

Chapter 14 

Radiofrequency for Facial Rejuvenation

Table 14-4  Additional Monopolar Radiofrequency Systems System

Manufacturer

Capabilities

Pellevé

Ellman International, Inc. (Hicksville, NY)

4.0 MHz, Pellevé GlideSafe handpieces are available in four sizes (7.5 mm, 10 mm, 15 mm, and 20 mm) for customized treatment. The fi ed-life, reusable design minimizes patient costs. The Pellevé S5 generator powers GlideSafe handpieces and hundreds of traditional electrosurgery tips for a variety of surgical procedures.

truSculpt

Cutera, Inc. (Brisbane, CA)

The 1 MHz handpiece notifies the operator once the temperature is optimal: 43°-45° C.

Fig. 14-4  The BodyTite system. (Courtesy of Invasix, Ltd., Irvine, CA.)

Bipol ar Rad io fr eq uency

BodyTite provides bipolar RF to treat a wide array of aging symptoms, including fi e lines, deep wrinkles, poor texture, blood vessels, redness, and pigment irregularities like brown spots. FDA approval is pending. Treatment of such a broad range of symptoms traditionally required a multitreatment approach but can now be achieved with one modality. BodyTite is commonly employed to treat the upper and lower eyelids, cheeks, mouth, smile lines, and neck. RF energy is applied to the treatment area, where it promotes the production of new collagen, thus rejuvenating the skin for an improved appearance. Discomfort is minimal, and few adverse effects are reported. Because BodyTite treats the area fractionally rather than by ablating the entire region, healing is faster and patients return to their daily routine sooner. The BodyTite system has a handpiece composed of internal and external electrodes (Fig. 14-4). The internal electrode is in a cannula, which emits RF energy and heat while fat is simultaneously aspirated. The controllable settings of the system include RF power, the cut-off temperature, and high and low impedance limits.

189

190

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

A

B

Fig. 14-5  A, BodyTite cannula. (Courtesy of Invasix, Ltd., Irvine, CA.) B, A Tefl n-coated internal electrode is passed directly under the skin in the hypodermal-subcutaneous fat space.

Fig. 14-6  Facial zones for treatment. (Courtesy of Invasix, Ltd., Irvine, CA.)

The BodyTite applicator is a bipolar, solid-probe, RF device (Fig. 14-5, A). A Teflon-coated internal electrode is passed directly under the skin in the hypodermal-subcutaneous fat space (Fig. 14-5, B). The internal and external electrodes are connected at the handgrip.17 A frequency of 1 MHz provides a power range of 10 to 25 W (an RF power of up to 75 W). An RF current passed between an internal and external electrode coagulates adipose tissue and provides controlled heating of the dermis and subcutaneous tissue collagen. The internal electrode acts as an energy source and is housed within a cannula having a diameter of 1.5 mm at its distal end. Th s end is inserted through the incision. One centimeter of the disc-shaped external electrode is applied to the skin surface over the location of the internal electrode. The internal electrode is directly above the tip of the RF transmitter and sends RF energy to the external electrode. The current alternates between the two electrodes. The process parameters used for treatment are a depth of approximately 3 mm (the superfic al skin plane), RF power of 10 to 15 W, and a skin surface temperature of 38° to 40° C, which is controlled by the user.18

Chapter 14 

Radiofrequency for Facial Rejuvenation

In addition to reducing pain and bleeding, tumescent anesthesia distends the subcutaneous adipose tissue. If the previous composition of the adipose tissue had a greater surface area, RF energy will allow safe manipulation of the increased dermal thickness in the subdermal SMAS. Th s makes the treatment area smoother and provides better contact between the skin surface and the external electrode. Fig. 14-6 shows typical surface treatment zones. Heat treatment is completed in each zone before the process is started in the next one. The internal electrode is passed through the soft tissue, and the external electrode is fastened to make contact with the epidermis. On the face, the internal electrode typically is placed in the subdermal fat to a depth of 3 to 4 mm, or at the same depth a skin flap would be inset. It should not be inserted too deeply to prevent facial nerve damage. Before RF treatment, the treatment depth can be adjusted through the internal electrode. Before the amount of RF subdermal tissue on the top of the inner electrode is applied, palpation can be easily determined. Because energy is transferred only between the electrodes, the deeper facial fat and facial nerve structures remain safe from a demyelinating neurapraxia, as long as the treating physician works in the correct planes.19 The BodyTite System has the following advantages: • Skin contraction of the entire facial subcutaneous tissue and septal matrix results in unprecedented tightening. • The use of a cannula with a small diameter ensures a smaller incision and decreased downtime and scarring. • Controlled directional energy distribution maximizes RF energy in the treated area while protecting against unwanted heating in other areas. Other bipolar RF systems for skin rejuvenation are listed in Table 14-5.

Table 14-5  Additional Bipolar Radiofrequency Systems System

Manufacturer

Capabilities

Aluma

Lumenis, Inc. (San Jose, CA)

40.68 MHz, up to 300 W Bipolar handpieces use functional aspiration-controlled electrothermal stimulation (FACES) technology with functional aspiration

BodyFX (formerly TiteFx)

Invasix (Irvine, CA)

1 MHz, 60 W Bipolar RF 1 vacuum Bipolar with suction and real-time epidermal temperature monitor

Venus Freeze

Venus Concept (Toronto, Ontario, Canada)

1 MHz magnetic pulse, 15 Hz RF, up to 150 W Magnetic flux of 15 G Large handpiece with eight poles 5 mm apart Dual-mode, five bipolar, one magnetic fi ld multipolar RF and magnetic pulse

EndyMed PRO 3Deep

EndyMed (Caesarea, Israel)

1 MHz, 65 W, four handpieces, 3Deep RF technology Handpieces customized for skin tightening, body contouring, facial tightening, and fractional skin resurfacing

geneO1

Pollogen (Tel Aviv, Israel)

TriPollar RF technology treats double chins, fat or flabby cheeks, sagging jowls, and crepey necks Used for facial sculpting

191

192

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

Mul tip ol ar Rad io fr eq uency : Fra ctio nal Rad io fr eq uency

Unlike unipolar or bipolar RF, multipolar RF systems use three or more electrodes. The eMatrix system delivers bipolar RF energy through a matrix of electrodes in the disposable applicator tip (Figs. 14-7 and 14-8; see Table 14-6). The RF energy generates fractional deep dermal heating in the region of the electrode matrix to induce skin injury, eliciting a wound-healing response. Less affected tissue surrounding the matrix points may be stimulated by heat, which helps to accelerate the healing process and leads to a smoother, rejuvenated skin appearance. The eMatrix system uses sublative treatment. Fractional bipolar RF technology delivers heat energy to targeted areas in the dermis to induce collagen regeneration and remodeling. Energy is delivered in a nonhomogeneous, fractional pattern, and it is controlled to minimally affect the epidermis. Treatments are performed for soft tissue ablation and skin resurfacing. The approach can be customized for all skin types and locations (except the eyelids and lips). Benefits include reduced wrinkles, skin laxity, scars, acne scars, textural irregularities, tone, and superfic al skin lesions. The system uses a handheld applicator with a small, disposable tip. Each tip contains an array of positively and negatively charged electrodes, through which bipolar RF energy passes. The number of pins on the tip is determined by the density and the area of skin to be treated. Typically, 64 pins are used. The energy level can be customized for the treatment of wrinkles, acne, and traumatic facial scars.20

Fig. 14-7  The eMatrix system. (Courtesy of Syneron, Inc., Yokneam, Israel.)

Fig. 14-8  The eMatrix tip with RF pins.

(Courtesy of Syneron, Inc., Yokneam, Israel.)

Chapter 14 

Radiofrequency for Facial Rejuvenation

The skin should be dry and is prepared with alcohol to remove residue. Usually, three treatments are performed during a 4- to 6-week period. The number of treatments and the length of the intervals vary for each patient. eMatrix RF technology does not use an air-chilling system to precool the treatment area. However, one can be applied after the procedure to control redness. Settings can be adjusted during treatments to vary energy delivery according to the depth of the area. Typically, patients have maintenance procedures every 6 to 12 months.

Mul tip ol ar Rad io fr eq uency : Scan Fra ctio nal Rad io fr eq uency

The Venus Viva system uses NanoFractional RF technology (Fig. 14-9). Numerous patterns are available for customized treatment to reduce wrinkles and fi e lines and to smooth skin texture and appearance. More than 1500 pulses are delivered through 160 pins per tip, with 62 mJ per pin (a footprint of 150 by 20 m per pin). The depth of penetration can be up to 400 m. The Venus Viva tip design creates small dermal wounds for quick healing and may reduce patient discomfort (Fig. 14-10).

Fig. 14-9  The Venus Viva system. (Courtesy of Venus Concept, Toronto, Ontario, Canada.)

Fig. 14-10  The Venus Viva scan fractional RF tip design. (Courtesy of Venus Concept, Toronto, Ontario, Canada.)

193

194

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

Fig. 14-11  The Tornado skin rejuvenation treatment system and treatment module. (Courtesy of Chongqing Derma Optic and Electronic Technique Co., Ltd., Chong­qing, China.)

Table 14-6  Additional Fractional Radiofrequency Systems System

Manufacturer

Capabilities

IntraGen

Jeisys Corporation (Seoul, South Korea)

Nonablative fractional RF Up to 200 W in 0 to 2 seconds Grid RF Full and small tips available

V-touch

Viora (Jersey City, NJ)

Fractional RF: 1 MHz, up to 10 J, 10 to 100 ms Proprietary switching, vacuum, cooling (SVC) technology Bipolar handpiece for skin tightening using (channeling optimized RF energy) CORE technology with multiple RF channels

eMatrix

Syneron (Yokneam, Israel)

Fractional bipolar RF Up to 62 mJ per pin Standard 64-pin tip with a 12 by 12 mm spot Focal 44-pin tip with a 11by 3 mm spot

Accent RF

Alma Lasers, Ltd. (Buff lo Grove, IL)

40.68 MHz, up to 200 W Unipolar energy to heat fat Bipolar energy to deliver energy to dermis

K23345_Pu_c14_Radiofreq_r3_183-202.indd 194

4/2/2015 4:26:43 PM

Chapter 14 

195

Radiofrequency for Facial Rejuvenation

Some products can be employed to perform multiple types of RF. For example, the Tornado system has multiple RF functions and phototherapy (Fig. 14-11). Other fractional RF systems for skin rejuvenation are listed in Table 14-6.

Mul tip ol ar Rad io fr eq uency : Micr oneed le Fra ctio nal Rad io fr eq uency

The Fractora system uses the Invasix platform. RF energy is delivered to the skin through pins in the tip (Fig. 14-12). These generate localized heat, producing small microlesions in the treatment area. The heat promotes collagen restructuring in the subdermal tissue for skin rejuvenation. The microlesions are scattered to speed healing. Fractora is employed to treat fi e or deep wrinkles, scars, and discolored red and brown skin tone. The most commonly treated areas are the lower eyelid, upper eyelid, smile lines, cheeks, mouth, and neck. Fractora treatment tips are available in various sizes (Table 14-7).

Fig. 14-12  The treatment tip of the Fractora system. (Courtesy Invasix, Ltd., Irvine, CA.)

Table 14-7  Fractora Treatment Tip Sizes Fractora Tip

Pins

Pin Length (m)

Depth (mm)

Configuration

Strong epidermal impact

126 high-density

600

0.6

14 3 9

Mid-dermal

60

600

0.6 to 1

10 3 6

Whole deep dermal

24

3000

3

634

Dermal and subdermal

24 coated

3000

31

6 3 4 coated

Courtesy of Invasix, Ltd., Irvine, CA.

196

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

Table 14-8  Microneedle Radiofrequency Systems System

Manufacturer

Capabilities

INTRAcel

Jeisys Corporation (Seoul, South Korea)

Up to 78.4 J/cm2 RF microneedles 49-microneedle tip superfic al RF rejuvenation

Infin

Lutronic, Ltd. (Freemont, CA)

Bipolar fractional RF: 50 W, 10 to 1000 ms Multiple handpieces and tips MFR handpiece options:   49-microneedle tip (7 3 7 needles, 10 3 10 mm scan size)   Comfort, 16-microneedle tip (4 3 4 needles, 5 3 5 mm scan size) SFR handpiece options:   144L tip (12 3 12 electrodes, dual channels, 20 3 20 mm scan size)   64S tip (8 3 8 electrodes, single channel, 10 3 10 mm scan size)

ePrime

Syneron, Inc. (Yokneam, Israel)

Bipolar RF: 460 6 5 kHz Maximal output voltage of 84 VRMS Seven independent bipolar channels Single-use sterile cartridge with five independently controlled bipolar microneedle pairs

Secret RF

Ilooda Co., Ltd. (Suwon, South Korea)

RF microneedles: 50 W, 50 to 940 ms 16-pin or 25-pin sterilized RF bipolar tip Includes monopolar tip for smaller treatment areas

MFR, Microneedle fractional radiofrequency; SFR, superfic al fractional radiofrequency.

Some microneedle RF systems can adjust the depth of treatment from 0.5 to 2.0 mm by using invasive microneedles subcutaneously. Table 14-8 presents systems employing microneedle fractional RF for skin rejuvenation.

Results Studies have shown that approximately 90% of patients have a measurable and noticeable effect at 6 months. Many patients see results immediately. Fewer than 2% of patients with moderately to severely sagging skin do not see visible tightening. Complications and adverse effects were minimal. Complications include pain or discomfort around the treated area, numbness of the skin covering the treated area, increasing pain caused by muscle spasms in the treated area, permanent nerve pain, allergies or reactions to medications used, and infection. Patients were uniformly satisfied. Most had significant improvement in cheek and neck skin laxity. Patient satisfaction paralleled the clinical improvements observed. Adverse effects were mild and limited to transient erythema and rare dysesthesia; no scarring or pigmentation was seen in Asian patients.7

Chapter 14 

Radiofrequency for Facial Rejuvenation

197

Pretreatment

1 week after treatment

3 months after treatment

Fig. 14-13 This woman is shown before RF treatment to tighten the cheeks, and then 1 week and 3 months after treatment.

K23345_Pu_c14_Radiofreq_r3_183-202.indd 197

4/2/2015 4:26:44 PM

198

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

Pretreatment

Immediately after treatment

1 year after treatment

Fig. 14-14 Th s 49-year-old woman underwent upper brow incision and upper and lower blepharoplasty with a lateral canthoplasty 4 years previously. The scars from the blepharoplasties had widened on her upper and lower eyebrow margins, and her facial contour line had sagged bilaterally. She is shown immediately after RF treatment. Swelling and redness subsided within a day, and she returned to work. One year postoperatively, scars on her upper and lower brow margins and periorbital region are improved. Her forehead wrinkles are smoother.

K23345_Pu_c14_Radiofreq_r4_183-202.indd 198

4/9/2015 7:44:19 AM

Chapter 14 

Radiofrequency for Facial Rejuvenation

Pretreatment

Immediately after treatment

1 year after treatment

2 years after treatment

199

Fig. 14-15 Th s 55-year-old woman desired treatment of her sun-damaged skin and the wrinkles on both sides of her nose. She did not want to have a surgical procedure. She is shown immediately, 1 year, and 2 years after treatment. The skin texture over her nasojugal area is improved.

K23345_Pu_c14_Radiofreq_r4_183-202.indd 199

4/9/2015 7:44:20 AM

200

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

Pretreatment

Immediately after treatment

1 year after treatment

Fig. 14-16 Th s 58-year-old woman had asymmetrical nasojugal, nasolabial fold, and bilateral facial drooping. She is shown immediately and 1 year after the procedure. There is some swelling immediately after treatment. The treatment effect lasts approximately 1 year.

Discussion RF technology has been performed to treat all skin types for many indications, including cellulite, acne scars, inflammatory acne, keloids, and rosacea. It is most commonly employed for skin tightening to improve skin laxity and reduce wrinkles. Nonablative RF technology has become a standard treatment because of its versatility, efficacy, and safety. It has proved safe and effici t in stimulating collagen contraction and neocollagenesis in daily practice. RF devices are classifi d as unipolar, bipolar, or multipolar depending on the number of electrodes used. As RF technology continues to rapidly evolve, physicians and patients can choose from a sophisticated selection of treatment techniques to improve skin appearance. Additional modalities include fractional RF, scan fractional RF, microneedle fractional RF, focus RF, and combination RF with light, massage, and pulsed electromagnetic fields. Because of these advances, along with future developments, RF technology will remain a popular option in dermatologists’ armamentarium for skin tightening and rejuvenation.21 RF facial rejuvenation is also a useful tool for prolonging the rejuvenation effect when combined with other procedures such as injection of hyaluronic acid filler.17 RF energy treatment is a new and promising technology for early signs of aging. It is ideal for patients who do not want a surgical procedure and those who do not think that they are old enough to have one to resolve their onset of skin laxity. Most people should see at least a mild improvement in their skin tightness, with minimal risks and downtime, compared with surgery.15 It can be a useful conservative approach for prolonging rejuvenation results after a surgical procedure and after correction of sun-damaged skin in most Asians.16,18-20 Although the results may not be as impressive as those obtained by ablative treatments, RF is a promising treatment option for photoaging with fewer adverse effects and minimal downtime.

Chapter 14 

Radiofrequency for Facial Rejuvenation

Pearls for Success • Patients should be carefully selected and thoroughly informed about the procedure, including possible adverse effects and complications, to prevent unrealistic patient expectations. • Before a procedure is performed, the patient is pretreated with retinA and hydroquinone for 2 weeks. • After 5% EMLA cream is applied, an occlusive dressing is placed to maintain hydration. • Before treatment, the energy level is tested by applying the tip to an unexposed area such as a posterior earlobe. • Areas to be treated are marked with an easily erasable marking pen. • Precise times are recorded for left-side and right-side passes; the length of time of each pass depends on the skin type and severity of wrinkles. • Appropriate management after treatment is essential for good results. Patients are instructed to avoid sunlight and to moisturize their skin after treatments. • Modern technologies, such as high-frequency ultrasound (sonodynamic energy), LED (photodynamic energy), and Endermology (pneumodynamic energy or “vacuum”) with RF (electrodynamic energy), show promising synergistic effects.

Refer ences 1. Alster TS, Tanzi E. Improvement of neck and cheek laxity with a nonablative radiofrequency device: a lifting experience. Dermatol Surg 30:503-507; discussion 507, 2004. 2. van der Lugt C, Romero C, Ancona D, et al. A multicenter study of cellulite treatment with a variable emission radiofrequency system. Dermatol Ther 22:74-84, 2009. 3. Biesman BS, Pope K. Monopolar radiofrequency treatment of the eyelids: a safety evaluation. Dermatol Surg 7:794-801, 2007. 4. Nahm WK, Su TT, Rotunda AM, et al. Objective changes in brow position, superior palpebral crease, peak angle of the eyebrow, and jowl surface area after volumetric radiofrequency treatments to half of the face. Dermatol Surg 6:922-928; discussion 928, 2004. 5. Abraham MT, Chiang SK, Keller GS, et al. Clinical evaluation of non-ablative radiofrequency facial rejuvenation. J Cosmet Laser Ther 3:136-144, 2004. 6. The Consulting Room. Radiofrequency for facial rejuvenation information. Available at http://www.consulting room.com/treatments/radiofrequency-facial-tightening. 7. Fisher GH, Jacobson LG, Bernstein LJ, et al. Nonablative radiofrequency treatment of facial laxity. Dermatol Surg 31:1237-1241; discussion 1241, 2009. 8. Bogle MA, Ubelhoer N, Weiss RA, et al. Evaluation of the multiple pass, low fluence algorithm for radiofrequency tightening of the lower face. Lasers Surg Med 3:210-217, 2007. 9. Fitzpatrick R, Geronemus R, Goldberg D, et al. Multicenter study of noninvasive radiofrequency for periorbital tissue tightening. Lasers Surg Med 33:232-242, 2003. 10. Lin SJ, Hsiao CY, Lo W, et al. Monitoring the thermally induced structural transitions of collagen by use of second-harmonic generation microscopy. Optics Letters 30:622-624, 2005. 11. Hanlash BM, Ubeid AA, Chang H, et al. Bipolar fractional radiofrequency treatment induces neoelastogenesis and neocollagenesis. Lasers Surg Med 41:1-9,2009. 12. Fitzpatrick TB. Soleil et peau. Journal de Médecine Esthétique 2:33-34, 1975. 13. Glogau RG. Aesthetic and anatomic analysis of the aging skin. Semin Cutan Med Surg 15:134-138, 1996. 14. Sullivan T, Smith J, Kermode J, et al. Rating the burn scar. J Burn Care Rehabil 11:256-260, 1990. 15. Beasley KL, Weiss RA. Radiofrequency in cosmetic dermatology. Dermatol Clin 32:79-90, 2014. 16. Abraham MT, Mashkevich G. Monopolar radiofrequency skin tightening. Facial Plast Surg Clin North Am 15:169-177, 2007.

201

202

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

17. Kim H, Park KY, Choi SY, et al. The efficacy, longevity, and safety of combined radiofrequency treatment and hyaluronic acid filler for skin rejuvenation. Ann Dermatol 26:447-456, 2014. 18. Divaris M, Blugerman G, Paul MD. Face expressive lifting (FEL): an original surgical concept combined with bipolar radiofrequency. Eur J Plast Surg 37:69-76, 2014. 19. Ahn DH, Mulholland RS, Duncan D, et al. Non-excisional face and neck tightening using a novel subdermal radiofrequency thermo-coagulative device. J Cosmet Dermatol Sci App 1:141-146, 2011. 20. Gold MH. Sublative rejuvenation: a literature review of fractional radiofrequency with the eMatrix device. Expert Rev Dermatol 8:659-666, 2013. 21. Krueger N, Sadick NS. New-generation radiofrequency technology. Cutis 91:39-46, 2013.

K23345_Pu_c14_Radiofreq_r3_183-202.indd 202

4/2/2015 4:26:47 PM

15 Facial Rejuvenation With Thread Lift

T

Woffles T.L. Wu

he   use of barbed-suture technology is not new; Alcamo1,2 fi st conceptualized it for wound closure in 1964. Th s was followed by Fukuda,3 Buncke,4 and Ruff,5 who designed monodirectional and bidirectional barbed threads for similar reconstructive purposes, such as wound closure and tendon repair. It was Sulamanidze in 20006,7 who fi st popularized the use of short barbed sutures for cosmetic applications in the face with his APTOS (antiptosis) technique. Several variations of the APTOS thread emerged from various parts of the globe in an attempt to increase the holding power of the barbs and longevity of the results. However, a true face-lifting effect was not attainable with these short threads. A barbed suture sling was conceived in 2002. It combined the properties of a suture suspension sling with the self-retaining properties of the barbed threads, and clinical application of this Woffles thread commenced in late 2002 in a technique called the Woffles lift (version 1.0). The concept of application is completely different from that of the APTOS threads although both threads are barbed.1,5 The Woffles hread is inserted through a long spinal needle into the face along the vectors of lifting and can be deployed in three patterns (described later). Version 2.0 of the Woffle lift uses a method in which the sling is inverted, with the U-bend of the thread engaged superiorly in the dense deep temporal fascia while the free ends of the thread are engaged inferiorly in the loose and saggy tissues of the face and neck. For the past 8 years I have been exclusively using version 2.0 of the Woffles lift, i hich the sling is inverted with the U-bend of the thread engaged superiorly in the dense deep temporal fascia while the free ends of the thread are engaged inferiorly in the loose and saggy tissues of the face and neck.

What Is the Woffles Lift and Woffles Thread? The Woffles l 8 is essentially a nonsurgical face lift using barbed self-retaining slings (Woffles threads) inserted with a needle to suspend loose, saggy facial tissue to the dense tissue of the scalp. There is no cutting or delamination of skin and soft tissues. The Woffle lift is not an APTOS procedure.

203

204

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

Fig. 15-1  Woffle thread.

Box 15-1  Advantages of the Woffle Lift • Th s procedure can be done without delamination of facial soft tissue and without the disturbance of the anatomic relationship of skin, muscles, nerves, and vessels. • It is a fast procedure and can be performed in under 20 minutes. • It does not require a general anesthetic; it can be performed with a local anesthetic without sedation. • Minimal downtime is required. • Complications are few and are easily resolved.

The Woffle thread (Fig. 15-1)is made of a blue Prolene 2-0 or 3-0 suture 40 to 60 cm in length. Barbs are cut onto its surface, creating a bidirectional barbed suture sling with a 4 cm clear, smooth zone (nonbarbed area) at the midpoint of the thread that allows it to be folded on itself 9 (Box 15-1).

Mech anis m of the Woffles Thr ead Lift

If a normal nonbarbed Prolene suture is used as a sling, the greatest tension of the suture is at the anchor points or load-bearing areas, with no load-bearing from the tissue between these two points. Th s leads to “cheese-wiring” of the thread through the soft issue and eventual loss of the lifting effect. The Woffle thread, with its self-retaining barbs, provides load-bearing throughout the length of the suture because of the multiple barbs. Thus there is a more even distribution of tension on tissue, and less cheese-wiring occurs. The loop design of the thread confers a stronger lifting effect and greater pull-out strength.10 At the same time, the fibrosis that develops around the Prolene suture strengthens and reinforces the subdermal matrix and creates new artific al ligaments between the deep dermis and the deep temporal fascia. Th s is demonstrated after completion of the procedure, when any attempt to push the facial soft issues downward will be met by strong resistance from the multiple columns of barbs encircling each suture. After the fibrous capsule is formed, even if the thread were removed, it would not affect the overall result as the remnant fibrous tissue acts as an additional “ligament” to support the overlying skin envelope.

Chapter 15 

205

Facial Rejuvenation With Th ead Lift

Evol utio n of the Woffles Lift

Although version 1.0 was able to give signifi ant lifting, its duration was short lived (about 1 year), because the U-loop of the sling had a tendency to cut through the loose areolar tissue of the mid and lower face. Therefore it seemed logical to reverse this and place the barbs of the thread in the facial tissues, while the U-loop was anchored in the dense tissues of the temporal region. Th s would reduce the effect of cheesewiring. Version 2.0 of the Woffle lift was introduced in 2004; in this iteration, the U-loop of the Woffle thread is fi mly embedded in the deep temporal fascia, while the filaments of the thread extend down into the face and neck, creating long columns of barbs with which to distribute the forces of lifting evenly along the length of the thread (Fig. 15-2).Th s has increased the longevity of the lift to between 2 to 4 years, depending on the patient’s own rate of aging. In 2005, to further reduce the effect of cheese-wiring and therefore the loss of lifting effect, the Woffle lift version 3.0X was introduced. Th s is a combination of versions 1.0 and 2.0 in which the two U-loops are interlinked at the level of the anterior hairline to prevent each other from cutting through the soft tissues (Fig. 15-3). The version 1.0 threads pass from the anterior hairline up into the temporal scalp, while the version 2.0 threads loop around the former and pass down into the face, suspending the key suspension points. It is a very effective technique, but it can be complicated and time consuming to perform.

Fig. 15-2  Design of the Woffle lift version 2.0.

1 2

6

3 4

5

Fig. 15-3  A, A combination of versions 1.0 and 2.0, version 3.0X of the Woffle lift uses two interlinked U-loops. B, Interlinked loops.

A

B

1 2

6

3 4

5

206

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

Indications for the Woffles Lift The best candidates for the Woffle lift are patients who: • Do not wish to have a surgical face lift because of the downtime and complications associated with it • Have had one or more face lifts, et have residual laxity for which they do not want to undergo another procedure • Are already receiving botulinum toxin and/or filler injections and are familiar and comfortable with the concept of their use, their temporary nature, and the need for repeated injections • Want a quick result with a short recovery time • Do not mind coming back every 1 to 2 years to supplement the already existing threads and to “repull” the face • Are elderly and may not be candidates for a long, invasive surgical procedure • Are keloid prone

Location of the Woffles Threads Woffle threads are used in a variety of patterns for facial suspension (Fig. 15-4): • Temporal suspension • Brow suspension • Lateral canthus suspension • Suspension of malar mound • Midface suspension • Jowls • Neck tightening

A

B

C

Fig. 15-4  Lifts erformed with the Woffles lift ersion 1.0. A, Temporal lifting. B, Lower and midface lifting. C, Midface lifting.

Chapter 15 

Facial Rejuvenation With Th ead Lift

D

E

Fig. 15-4, cont’d  D, Neck lifting, version 1.0. E, Lower and midface lifting with version 2.0. Th s is my current preferred technique. Four threads (eight filaments) are usually used to effectively and smoothly lift one side of the face.

Preoperative Assessment Not all patients are candidates for this lift. Patients with severe laxity of the face and neck should be treated with a traditional open rhytidectomy in which the skin can be removed. Patients expecting the longevity that can be achieved with a traditional face lift might also be disappointed with the Woffle lift’s short- to mid-term longevity. The patient’s expectations must be fully explored before a procedure is undertaken. With the patient sitting, the degree of facial laxity is assessed by pushing the facial tissues upward to the temples using the fi gers. Th s helps to determine how much restoration of midface volume can be achieved and how much bunching or pleating of the skin there will be at the anterior hairline. It is important to determine whether this elevation will be accompanied by significant lateral canthal elevation, and whether the patient likes this effect. If the patient does like the effect and wants a smooth lateral facial contour with less volumetric restoration of the midface, he or she would be a good candidate for version 1.0. However, if the patient does not want the eye shape to change in any way or desires or needs more midface volume enhancement, he or she is a better candidate for version 2.0.

Identifying Fa ci al Vect ors

There are six key suspension points or vectors that are identifi d for the midface and jowls (Fig. 15-5): 1. Upper nasolabial 2. Lower nasolabial 3. Marionette 4. Anterior jowls 5. Posterior jowls 6. Mandibular angle

207

208

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

1 2

6

3 4

5

Fig. 15-5  The vectors of rejuvenation are directed toward the temple to create a more vertical lift effect. These are marked

on the face. Then the vectors of suspension are drawn from these points to the temple. These vectors are the guides for inserting the needle introducers.

For the forehead, the vectors are determined by the desired shape and height of the eyebrow. For a neck lift, a horizontal marking is made at the cervicomental angle at the midline. A line is drawn from this point, under the jawline, to the mastoid region. Th s is the vector for inserting the needle introducer at the elevation of the neck. Either version 1.0 or 2.0 can be used.

Surgical Technique Consumables and Instr ument atio n

• 1 packet of plain gauze • Basic dressing set • No. 11blade • Bard-Parker blade holder No. 3 • Nontoothed Adson dissecting forceps • Derf needle holder, 5 inch • Straight iridectomy scissors • Sutures, Ethilon 6-0 or chromic catgut 6-0 • Bactroban ointment • 18-gauge introducer or spinal needle (included with the Woffle lift set) • 8 Woffle threads • Ela-Max 5% or equivalent • Comb • Rubber bands to tie hair • Hair clips that can be soaked in cleansing solution • Cleansing solution of cetrimide 1% and aqueous chlorhexedine

K23345_Pu_c15_Fac Rejuv Thread Lift_r3_dc_203-214.indd 208

4/2/2015 4:30:25 PM

Chapter 15 

209

Facial Rejuvenation With Th ead Lift

Lo cal Anes the tic

Lidocaine 2% with epinephrine 1:80,000, 12 ml is injected to produce local anesthesia and control bleeding. Syringes, 1 ml with detachable 30-gauge superglide needles, are used. The lidocaine solution is used for infraorbital, supraorbital, and inferior mandibular blocks, and lines of anesthetic are injected along the vectors marked on the face or neck. Th s employs the mesoanesthetic technique fi st described for alleviating pain during a full-face Thermage procedure. Multiple tiny blebs of anesthetic are infiltrated into the dermis and subdermal layer of the area to be anesthetized. Th s allows adequate anesthesia to be achieved with a small volume of fluid.

Pr eo pera tive Consul t atio n and Pr epara tio n

1. The patient sits in an upright position, 90 degrees. The standard preoperative photos are taken: frontal, lateral, and oblique. 2. The physician and patient discuss and determine the degree of sag or ptosis and the areas of desired correction. 3. Ela-Max 5% cream is applied to the face and neck for approximately 20 minutes, after which the patient washes off the cream. 4. Facial vectors are identifi d and marked with a skin marker. 5. A facial block is given with the lidocaine 2% with epinephrine 1:80,000 using multiple mesoanesthetic injections. 6. The hair is then completely soaked with cetrimide 1% solution and combed back neatly. 7. The face and neck are then prepared with a sterile technique and draped appropriately.

Sur gical Techniq ue: Woffles Lift Vers io n 2.0

1. The introducer (18-gauge spinal needle) is inserted from point A (Fig. 15-6, A) upward (from the jowls, through the SMAS and the malar mound) and exits at point B (dense temporal fascia ), a No. 11 blade is used to make a small stab incision at point B. The stylet of the introducer is removed and one Woffl thread is inserted from point B until the midpoint of the thread (nonbarbed area/smooth clear zone) is seen and felt at point B. The introducer is removed.

A

B

Fig. 15-6  A, The needle is inserted at point A and emerges through point B. Half of the Woffle lift is threaded through the needle at point B.

Continued

A

C

210

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

B

C

B

A

B

A

C

C

Fig. 15-6, cont’d  B, The needle is then reinserted at point C and emerges through point B again. The other end of the

Woffle thread is inserted through point B to complete the inverted loop. The thread should be oriented so that the smooth central portion is folded to form the apex of the loop which is engaged in the deep temporal fascia. C, The completed loop of the Woffle lift version 2.0.

2. The introducer is then reintroduced from a new point (point C, Fig. 15-6, B) of the jowl, which is another of the key suspension points. The end of the introducer will again exit at point B. The stylet is once again removed and the other half of the Woffle thread is inserted into point B until it exits at point C. The needle is removed and the facial tissues are draped upward. The thread ends are shortened. The same process is repeated for all the different vectors. For a well-supported lower and midface lift, four Woffle threads (eight filaments) are used per side. Once all threads are inserted, the doctor then holds on to the ends of the threads while gently sweeping/massaging the facial tissue upward in a vertical direction (Fig. 15-6, C). 3. The ends of the threads are cut flush to the skin and the stab incision site (at the scalp) is closed with 6/0 Ethilon or 6-0 catgut, and Bactroban (mupirocin 2%) ointment is applied to the wound. 4. Any dents or undulations on the skin surface can be smoothed by gently tapping on the bunched-up skin above this level.

Postoperative Care Recovery time for the Woffle lift is 2 to 4 days. Slight bruising can occur, but this is usually easily concealed with makeup or restyling of the patient’s hair. At discharge, painkillers and oral antibiotics are prescribed for 3 days. Patients are advised to avoid extreme facial expressions or animation for the fi st week. They should be informed that they may feel a bit of tension at the scalp and along the line of the threads for about a week.

Chapter 15 

Facial Rejuvenation With Th ead Lift

Results Patients are instructed that the lift asts from 1 to 4 years, depending on their own rate of aging, and that they will need additional threads periodically. When new threads are inserted, the existing threads are not removed. I fi d that with the repeated addition of threads, the result is better and lasts longer.

A

C

B

D

E

Fig. 15-7 Th s 54-year-old woman is shown before having a Woffle neck lift (Fig. 15-7,A). She is shown immediately after having two threads inserted on each side from the mastoid to anterior midline of neck (Fig. 15-7, B), and 2 weeks (Fig. 15-7, C), 14 months (Fig. 15-7, D), and 2 years (Fig. 15-7, E) after surgery.

211

212

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

A

B

C

D

Fig. 15-8 Th s 60-year-old woman presented with complaints of a sagging jawline, jowls, and nasolabial and marionette lines, and overall facial “squaring.” I used four threads (8 filaments) to perform a Woffles lift version 2.0 on each side of her face. The procedure resulted in lifting of the key facial points, improved facial triangulation, and smoother jowls, jawline, and nasolabial and marionette lines.

Management of Complications In the past 10 years, the complications have remained minor and correctable. When version 1.0 was used in the fi st 2 years, a knot was tied at the temporal scalp to strengthen and stabilize the U-loop of the suture. Th s caused a few cases of stitch granulomas and extrusion of the suture. There were no frank infections of the threads necessitating complete removal. The overall complication rate was 17%. After developing and implementing version 2.0 in which no knots are tied anywhere, the complication rate fell dramatically to less than 2%. There have been no infections of the threads when deployed in version 2.0 in the past 8 years.

K23345_Pu_c15_Fac Rejuv Thread Lift_r3_dc_203-214.indd 212

4/2/2015 4:30:29 PM

Chapter 15 

Facial Rejuvenation With Th ead Lift

213

Other minor complications include entrapment of hairs, granuloma, thread extrusion, dimpling, and pleating of the skin. Most of these complications are associated with version 1.0. There is always the potential for infection or granuloma formation, since the suture material used (Prolene) does not dissolve. However, the incidence is very low when proper sterile surgical technique is used while performing the procedure. Infection usually presents as a small area of painful inflammation on the surface of the overlying skin. The offending threads can be located and removed immediately. The entry points on the scalp are easily identifiable, and a small incision under local anesthesia is made. The looped ends of the threads can be seen, and the thread is removed in its entirety with a gentle tug. In the case of thread extrusion, the thread end can be pulled out of the skin by 1 to 2 cm and then trimmed flush with the skin surface. The remaining end retracts into the soft tissue. If there is impending extrusion, an 18-gauge needle is used to puncture the skin over the end of the thread that abuts the skin. The thread end is then delivered and removed as described. Entrapped hairs in the scalp can be tweezed out with a fi e forceps, or the entire hair with its follicle can be pulled out. In most cases, dimpling is seen immediately after the procedure and spontaneously disappears within a week. Persistent dimpling can be easily massaged away with fi m digital pressure, or gentle tapping of the overlying skin, within the fi st 10 days.

Discussion The future of barbed threads is promising. Barbed sutures can create a face-lifting effect if effectively deployed. Better technology and increased understanding of the causes of loss of longevity of the lift r relapse will lead to longer-lasting results. The Woffle lift is a suitable nonsurgical technique for patients who want a lifting effect but are not prepared for surgery and the downtime associated with an operation. They may also want a lift that is more subtle and does not signifi antly alter their appearance. For best effect, the Woffle lift should be combined with botulinum toxin A and/or filler injections to achieve a lifted, relaxed, and more three-dimensional appearance.

Pearls for Success • The procedure should always be performed with the patient sitting upright. • Adequate local anesthetic should be delivered so that the patient is comfortable. • Sterility of the entire face and scalp and hair is crucial to minimize infection. The entire body from neck down must be surgically draped. • The needle enters and is passed from the jowl to the temple. • The plane of the needle should be in the “liposuction” plane of the face; that is, subcutaneous or slightly deeper. • More threads can be added to “spread the load.” • The depth of the threads should be varied to sculpt the soft tissues. • The patient must be advised that this procedure provides a temporary face-lift effect that will need to be repeated periodically, whenever the effect is lost.

K23345_Pu_c15_Fac Rejuv Thread Lift_r3_dc_203-214.indd 213

4/2/2015 4:30:29 PM

214

Part II 

Nonsurgical or Minimally Invasive Procedures for Facial Rejuvenation

Refer ences 1. Alcamo JH. Surgeon’s suturing device. US Patent 2,988,028, 1961. 2. Alcamo JH. Surgical suture. US Patent 3,123,077, 1964. 3. Fukuda M. Surgical barbed suture. US Patent 4,467,805, 1984. 4. Buncke HJ. Surgical methods using one-way suture. US Patent 5,931,855, 1999. 5. Ruff GL. Barbed bodily tissue connector. US Patent 6,241,747B1, 2001. 6. Sulamanidze MA, Fournier PF, Paikidz TG, et al. Removal of facial soft issue ptosis with special threads. Dermatol Surg 28:367-371, 2002. 7. Sulamanidze MA, Sulamanidze GM. Facial lifting with “APTOS” threads: featherlift. Otolaryngol Clin North Am 8:1109-1117, 2005. 8. Wu WTL. Surgical thread. US Patent 8,236,027B2, 2012. 9. Kress DW. The history of barbed suture suspension: applications, and visions for the future. In Shiffman MA, Mirrafati SJ, Lam SM, eds. Simplifi d Facial Rejuvenation. New York: Springer-Verlag, 2008. 10. Sasaki GH, Komorowska-Timek ED, Bennett DC, et al. An objective comparison of holding, slippage, and pullout tensions for eight suspension sutures in the malar fat pads of fresh-frozen human cadavers. Aesthet Surg J 28:387-396, 2008.

K23345_Pu_c15_Fac Rejuv Thread Lift_r3_dc_203-214.indd 214

4/2/2015 4:30:29 PM

Part III

Rejuvenation Surgery of the Face

K23345_Pu_c16p_Asian Fac Rejuv Surg_r4_cl.indd 215

4/2/2015 4:42:44 PM

K23345_Pu_c16p_Asian Fac Rejuv Surg_r4_cl.indd 216

4/2/2015 4:42:44 PM

16 Special Considerations in Rejuvenation Surgery of the Asian Face

F

Daping Yang, Lee L.Q. Pu

acial   rejuvenation surgery in general is a demanding procedure for Asians. There are a number of differences between Asians and whites in terms of facial anatomy, facial aging, and expectations regarding surgical alteration of the face. The facial rejuvenation procedures and expectations of Asian patients can be quite different from those of white patients. In this chapter we will describe the anatomy of Asian faces and facial aging in Asians, present a comparison of aging between Asians and whites, and discuss preoperative evaluation for facial rejuvenation surgery, the common approaches for Asian facial rejuvenation, the combination of various approaches to facial rejuvenation surgery, the expected outcomes, and the common problems in Asian facial rejuvenation surgery.

Anatomy of the Asian Face The Asian face is anatomically distinct from the white face. The Asian face is characterized by a thick dermis, dense fat both superfic al and deep to the superfic al musculoaponeurotic system (SMAS), a relatively prominent zygoma and mandibular angle, and a relatively flat nose. Because of these characteristics, there are some differences between Asians and whites in the main components of the face that affect the aging process (Table 16-1). These specific anatomic features often dictate the rate and manner of facial aging. First, in most Asian patients, the skin is thicker and more fibrous than the typical skin of white patients. The combination of increased superfic al fat and a thickened dermis in Asian patients lessens the incidence of superfic al rhytids. The dense fat and fibrous connections between the superfic al fascia and deep fascia of most Asians diminish the amount of soft issue ptosis in their midfacial tissue. For these reasons, the midface in Asians usually has very few rhytids and only minimal to moderate sagging as the patient ages. However, because of the dense fibrous attachments between the fascial layers, a surgical rejuvenation procedure usually does not provide as much tissue lift as it does in white patients. In addition, the increased skin density in Asians is associated with greater pigmentation.

217

218

Part III 

Rejuvenation Surgery of the Face

Table 16-1  Differences Between the Facial Anatomy of Asians and Whites Featured Anatomy

Asians

Whites

Dermis

Thi k

Thi

Fat/fibrous attachment

Dense

Less dense

Zygomatic-mandibular angle

Prominent, wide

Relatively fl t

Nose

Flat or underprojected

High

Second, the facial skeleton in Asians consists of a strong and wide zygomaticomalar region. A prominent malar eminence is of great assistance to the surgeon, because it provides the patient with excellent surgical results. “High cheekbones,” as they are often described, are classically associated with youth and beauty. High cheekbones serve as the scaffolding that enables the surgeon to suspend the ptotic tissues of an aging face. However, high cheekbones with signifi ant submalar soft tissue volume loss may emphasize the facial skeleton, projecting an aged appearance. Ptotic and atrophic midface tissue not only accentuates the nasolabial fold and other retaining ligaments, but also creates depressions and hollowness in the submalar and lower eyelid region. Additionally, Asians typically have more vigorous fibroplasia during wound healing. The greater fibroblast reaction in Asians may be associated with prolonged erythema and postauricular hypertrophic scarring during scar maturation. Finally, the facial muscles in Asians are slightly thicker than those in whites. However, central dehiscence of the platysma muscles of the neck is less common in Asians, resulting in less platysma muscle banding.

Facial Aging in Asians Mild Aging

A patient with mild aging is usually in her late thirties or early forties with aging that is primarily evident in the face (Fig. 16-1). She has early slight lateral brow descent, tear troughs, nasolabial folds, jowls, and cervical laxity, but her skin elasticity is still good. Recently, more Chinese women at a younger age, before the onset of signifi ant signs of facial aging, are seeking facial rejuvenation in our clinics. Most of these women are in their forties and are at the peak of their career. The overt signs of facial aging are noted in most patients around the age of 40 and are generally periorbital in location. The cause of these changes is the combined effect of gravity and the activity of the orbicularis oculi muscle. Patients with facial aging most frequently complain that they look tired despite being well rested.

Modera te Aging

Patients with moderate aging are usually in their late forties to early fi ies, with moderate lateral brow descent, malar fat pad descent with tear troughs and malar grooves, nasolabial folds, jowls, and moderate cervical skin laxity (Fig. 16-2). Submandibular and submental fat are usually present, and they may have microgenia.

Chapter 16 

A

Special Considerations in Rejuvenation Surgery of the Asian Face

219

B

Fig. 16-1  Th s 39-year-old woman presented with midfacial ptosis with a tear-trough deformity and hollowness in the

periocular region. A midface lift ith lower blepharoplasty was performed. Her facial shape and periocular region have changed as a result of facial malar fat pad repositioning.

A

B

C

D

Fig. 16-2  This 48-year-old woman presented with a hollowed effect along the periocular and preparotid regions. To

volumetrically enhance the submalar region, we used an oblique SMAS vector to reposition a greater volume of fat into the submalar region, allowing the periocular and preparotid regions to appear fuller. Her facial shape has changed as a result of facial malar fat pad repositioning from the lower anterior midface into the upper lateral midface and filling the areas of deflation.

K23345_Pu_c16p_Asian Fac Rejuv Surg_r4_cl.indd 219

4/2/2015 4:42:45 PM

220

Part III 

A

Rejuvenation Surgery of the Face

B

Fig. 16-3  Th s 55-year-old woman presented after signifi ant weight loss. She had facial deflation, a strong malar eminence (most signifi antly on the left side), nd a wide bizygomatic diameter. After undergoing a face lift, he has an improved appearance of the lower two thirds of her face because of repositioning of the malar fat pad and jowl SMAS layer. The aesthetic relationship between the malar and submalar regions has also improved.

Sever e Aging

Patients who exhibit severe signs of facial aging are usually in their late fi ies and sixties (Fig. 16-3). They have signifi ant lateral brow descent, malar fat pad descent with deepened tear troughs and malar grooves, nasolabial folds, jowls, moderate cervical laxity, and submental and submandibular fat. The cervical skin elasticity of these patients is poor, and skin folds and deep creases below the cricoid are often present.

Comparison of Aging in Asians and Whites Anatomic differences between Asians and whites are manifested in skin thickness and texture, patterns of fat accumulation, and skeletal structure. In general, increased dermal thickness may account for a substantially lower incidence of fi e facial rhytids in both darker-skinned Asians and Asians with a fair complexion compared with whites of an equivalent age. Th s may account for the myth that the Asian face ages slower than the white face. Actually, a considerable number of fair-skinned Asians do develop fi e wrinkles as aging progresses; however, Asian skin tends to respond to sun exposure and the aging process with an accelerated development of pigmented dermatoses, compared with the skin of whites. Also, skin malignancies of all types are signifi antly less common in Asians. On the other hand, the Asian face and neck tend to accumulate more fat during the aging process, particularly in the jowls, nasolabial mound, buccal area, and submental region, compared with whites of a comparable age. The clinical signifi ance of fat accumulation in these areas is accentuated by the skeletal structure of the Asian face, such as the prominent malar eminences associated with a relative deficie cy of the premaxillary region, which results in shallowness of the midface and deepening of the nasolabial folds. Wide, prominent mandibular angles are often present in Asians, contributing to a square, flat face. In other patients, facial aging is often accompanied by atrophy of fat in the buccal region and the temporal fossa. Table 16-2 summarizes the differences of facial aging between Asians and whites.

Chapter 16 

Special Considerations in Rejuvenation Surgery of the Asian Face

221

Table 16-2  Comparison of Facial Aging Between Asians and Whites Features

Asians

Whites

Fine facial rhytids

Less common

Common

Skin pigmentations

Common

Less common

Fat accumulation over face and neck

Common

Less common

Jowling, platysmal banding, and excess neck skin

Less common

Common

Location for early signs of aging

Periocular region and midface

Lower face

Preoperative Assessment Successful rejuvenation of the aging face and neck demands a careful assessment of various factors that may contribute to the deformity manifested by each patient. There are two keys to successful surgical rejuvenation: management of midfacial ptosis and management of facial volume loss. Successful facial rejuvenation begins with the surgeon’s understanding of the mechanisms of midfacial ptosis and its corrective methods, using malar fat pad elevation, accompanied by the injection of filler materials into the nasolabial folds. When analyzing a patient for facial rejuvenation, the surgeon intuitively evaluates facial shape and contour. Restoration of malar highlights and malar volume is essential to improve facial shape. Restoring the shape is better than trying to tighten a “loose” face. To consistently improve facial shape in face lifting requires that the surgeon accurately understand the anatomic changes that have occurred as the patient ages, appreciate the importance of underlying skeletal support in formulating the treatment plan, and incorporate his or her aesthetic vision into a surgical approach that is appropriate for the patient. Because facial skeletal configur tion is asymmetrical in most individuals, the SMAS repositioning vectors should be specific for both sides of the face. The vector in which the SMAS is repositioned has a signifi ant effect on the location and volume of elevated facial fat. The postoperative facial shape is influenced by the SMAS vectors and these should be determined for both sides of the face before surgery, because it is difficult to make vector judgments with the patient recumbent during the procedure. Vertical SMAS repositioning provides a larger amount of fat for enhancing the malar eminence, and it allows a reduction in fullness within the submalar region, because fat is forced vertically. If the SMAS is vectored more obliquely, less fat volume is brought into the malar region and more fat volume is repositioned into the submalar region. Therefore oblique SMAS repositioning is helpful in elderly patients who appear gaunt over the buccal recess, because it allows the surgeon to volumetrically enhance the submalar region.

Common Surgical Approaches In our practice, surgical facial rejuvenation remains the standard for long-lasting improvement of the anatomic changes of facial aging. Despite the many long-term benefits of traditional face-lift surgery for white patients, there is a paucity of studies on patient satisfaction with surgical facial rejuvenation among Asians. A lack of peer-reviewed data often leads the plastic surgeon to rely solely on his or her experience to counsel the Asian patient, but this approach is subject to signifi ant bias. The benefit of face-lift urgery relies on the longevity of the facial rejuvenation; however, this is hard to explain to an Asian patient, because it

K23345_Pu_c16p_Asian Fac Rejuv Surg_r4_cl.indd 221

4/2/2015 4:42:46 PM

222

Part III 

Rejuvenation Surgery of the Face

is difficult to quantify the longevity of face lifts and to prove the superiority of one face-lift technique over another. We have found that patients younger than 50 years of age who undergo face-lift surgery tend to have greater long-term satisfaction with so-called maintenance face lifts. Special attention should be taken when planning a facial rejuvenation procedure for an Asian patient. Although the goals for rejuvenation of the aging face and neck are the same for Asians as for whites, anatomic variations dictate a greater emphasis on the management of tissue ptosis, particularly regarding lateral brow descent, malar fat pad descent, with deepened tear troughs and malar grooves, and fat accumulation in the nasolabial folds and jowls. The anatomy of the Asian face does not necessitate substantial modifi ation of the surgical techniques for successful facial rejuvenation. Because the primary cause of facial aging is ptosis of the skin and subcutaneous fat, the most effective technique for the Asian face is to restore the tissue to a more youthful position. In addition, fillers or fat grafting can also be employed to enhance the results during or after facial rejuvenation surgery, because the atrophy of soft tissue in the face is corrected further.

Patient s With Ear l y Aging

Patients showing early signs of aging do well with liposuction of the neck and jowls, wide subcutaneous skin undermining, and lateral SMASectomy or plication. No retroauricular incision is necessary to improve the neck along with the face (see Fig. 16-1).

Patient s With Modera te Aging

Liposuction of the neck and jowls along with lateral SMASectomy or plication produces a good result in patients with moderate aging. If indicated, a chin implant enhances the result. A retroauricular incision is usually not required, but a short retroauricular incision can be made to correct a dog-ear at the earlobe (see Fig. 16-2).

Patient s With Sever e Aging

A lateral SMASectomy or plication along with liposuction of the neck and jowls produces a good result in patients with severe aging. If redundant skin is present at the earlobe after tissue redraping, it can be removed with a short retroauricular incision (see Fig. 16-3). Some patients in their sixties with signifi ant jowls and active lax platysma bands are not good candidates for a short-scar rhytidectomy. Th s can be presented to the patient as a compromise that keeps open the option of extending the retroauricular incision if necessary. Laterally and posteriorly, a short-scar rhytidectomy is usually necessary to undermine over the mastoid and sternocleidomastoid to obtain proper tissue redraping. Excess cervical skin must be tailored into the retroauricular sulcus. As a general rule, it is not worth compromising the fi al result for a shorter scar.

Combinatio n Appr oa ches

Depending on the different facial regions, there are many combined approaches that can be considered as treatment options (Table 16-3).

Forehead and Brow Complex The aging process in the forehead and brow complex requires specific management. When weighing treatment considerations, the surgeon should think of rhytids and ptotic tissue as two independent processes. The dynamic forehead and glabellar rhytids should be treated by using neuromuscular paralytic agents such as botulinum A toxin. Deep glabellar and forehead rhytids can be improved by using fillers such as

Chapter 16 

Special Considerations in Rejuvenation Surgery of the Asian Face

223

Table 16-3  Treatment Considerations With Combined Approaches by Region Region

Treatment Considerations

Combined Approaches

Forehead and brow complex

Endoscopic brow lift

Botulinum A toxin, hyaluronic acid

Periorbital region

Midface lift

Botulinum A toxin, fat grafting

Midface

Midface lift

Fat grafting

Lower face and neck

Face and neck lift

Fat grafting or injectable fillers

hyaluronic acid. Brow ptosis is almost always treated surgically. Coronal and endoscopic brow lifts re the most commonly used techniques. Th pretrichial forehead lift—making an incision a few millimeters within the hairline—should be considered in patients who have a high hairline.

Eyelid and Periorbital Region Dynamic rhytids in the crow’s-feet can be also treated with botulinum A toxin. Upper blepharoplasty has become standardized, and lower blepharoplasty can be performed using the skin–muscle flap techniques. Patients with a tear-trough deformity may need to undergo fat transfer. A signifi ant double-convexity deformity should be treated with midface lifts and volume restoration using soft tissue fillers. A midface lift hould be considered in patients with lower lid laxity. Treatment considerations in periorbital rejuvenation should always include a midface lift

Midface Individuals with early signs of aging can be treated with fillers to restore facial volume, efface the nasolabial fold, and improve depressions near the lower eyelid. Patients with moderate midface ptosis without signifi ant volume loss can be surgically treated with a midface lift. Patients with advanced volume loss will additionally require volume enhancements through fat grafting.

Lower Face and Neck The lower face and neck require a combination of surgical and nonsurgical methods to achieve the best possible aesthetic outcome. The perioral region, for example, is a very difficult area to treat surgically. Soft tissue fillers and skin resurfacing are indispensable tools in the management of this area. The marionette furrows are also not signifi antly improved with face-lift echniques and almost always require fat grafting or injectable fillers. Patients with microgenia are candidates for chin augmentation. Chin augmentation with alloplastic chin implants is a straightforward and excellent procedure in patients with mild-to-moderate microgenia and a shallow labiomental sulcus. Sliding genioplasty is a technically more demanding operation that should be reserved for patients with vertical microgenia or a deep labiomental sulcus. The jowls are very well treated with most types of face lifts including the deep plane rhytidectomy, lateral SMASectomy, and short-flap SMAS rhytidectomy. The prejowl sulcus is difficult to address, even with aggressive face-lifting techniques. Extended chin implants can successfully address this region and should be considered if the prejowl sulcus is an aesthetic complaint that the patient wants to have remedied. Suction-assisted lipectomy, corset platysmaplasty, chin augmentation, and cervicofacial rhytidectomy are indispensable techniques for neck rejuvenation. In patients who do not desire surgical intervention, isolated platysmal banding can be successfully treated with high doses of botulinum A toxin.

K23345_Pu_c16p_Asian Fac Rejuv Surg_r4_cl.indd 223

4/2/2015 4:42:46 PM

224

Part III 

Rejuvenation Surgery of the Face

Discussion Asian women are increasingly requesting procedures with minimal recovery, minimal cost, minimal risk, and maximal benefit with a natural-appearing and long-lasting result. Most patients are familiar with the “pulled,” “windswept,” and “operated” look that is the hallmark of traditional rhytidectomy. These obvious defects result from a misunderstanding of the process of release and resuspension. We feel that each face lift must be individually determined. The adjustments necessitated by each patient’s unique anatomy are the key factors to a natural-appearing result. We advocate a fresh and mature look after the face-lifting procedure and a reasonably fast recovery. We also advocate the need for volume repletion in modern facial rejuvenation with fat transfer and alloplastic implants to correct soft tissue atrophy.

Pearls for Success • Increased fibroplasia, often associated with wound healing, requires meticulous surgical execution and minimal wound tension to create optimal cutaneous scars. • Anatomic variants must be recognized to customize surgical procedures. • Restoring facial shape is better than trying to tighten a loose face. • To consistently improve facial shape, the surgeon must accurately understand the anatomic changes that have occurred in aging for any particular patient, appreciate the importance of underlying skeletal support in formulating a treatment plan, and incorporate his or her aesthetic vision into a surgical approach that is appropriate for the specific patient. • The complete tissue release of surgical planes is necessary before fix tion and closure can be performed. • Lower lid retraction, ectropion, and canthal malposition can be corrected through the midface procedure in conjunction with the orbicularis sutures. • Surgical rejuvenation procedures can create a long-lasting, natural appearance.

Additio nal Read ings Baker DC. Lateral SMASectomy. Plast Reconstr Surg 100:509-513, 1997. Barton FE Jr. Rhytidectomy and the nasolabial fold. Plast Reconstr Surg 90:601-607, 1992. Connell BF, Semlacher RA. Contemporary deep layer facial rejuvenation. Plast Reconstr Surg 100:1513-1523, 1997. Hamra ST. Composite rhytidectomy. Plast Reconstr Surg 90:1-13,1992. Owsley JQ Jr. SMAS-platysma face lift. Plast Reconstr Surg 71:573-576, 1983. Pitanguy I. Facial cosmetic surgery: a 30-year perspective. Plast Reconstr Surg 105:1516-1526; discussion 1527, 2000. Rohrich RJ, Pessa JE. The fat compartments of the face: anatomy and clinical implications for cosmetic surgery. Plast Reconstr Surg 119:2219-2227; discussion 2228-2231, 2007. Shirakabe Y. The Oriental aging face: an evaluation of a decade of experience with the triangular SMAS flap technique in facelifting. Aesthetic Plast Surg 12:25-32, 1988. Stuzin J. Restoring facial shape in face lifting: the role of skeletal support in facial analysis and midface soft- issue repositioning. Plast Reconstr Surg 119:362-376; discussion 377-378, 2007. Stuzin J, Baker TJ, Baker TM. Refi ements in face lifting: enhanced facial contour using vicryl mesh incorporated into SMAS fix tion. Plast Reconstr Surg 105:290-301, 2000. Stuzin JM, Baker TJ, Gordon HL. The relationship of the superfic al and deep facial fascias: relevance to rhytidectomy and aging. Plast Reconstr Surg 89:441-449; discussion 450-451, 1992.

K23345_Pu_c16p_Asian Fac Rejuv Surg_r4_cl.indd 224

4/2/2015 4:42:46 PM

17 Open Brow Lift

A

Fuan Chiang Chan, Raymond C.W. Goh, Yu-Ray Chen

brow lift can be performed as an isolated procedure for the upper face or as a vital and complementary component of total facial rejuvenation. Lifts to the mid and lower face that do not address the upper face will frequently result in peculiar facial disharmony. The technique of performing an open brow lift in an Asian patient is comparable to that described for a white patient requiring forehead rejuvenation. The key to successful restoration of forehead aesthetics in an Asian patient lies in attaining a fi m understanding of the idiosyncratic nature and effects of upper facial aging that are distinctive to the Asian population. The myriad endoscopic and limited-incision techniques for forehead rejuvenation appear enticing, because these options result in less visible scarring, potentially less morbidity, and an earlier recovery.1 However, we think, and others agree, that the open brow lift emains the simplest and most effective way to ensure long-lasting results for optimal forehead rejuvenation.2,3 It offers unparalleled exposure of the supraorbital region for adequate soft tissue release, comprehensive glabellar muscle modifi ation, and the opportunity for frontal bone contouring. In this chapter we will discuss ideal forehead aesthetics, relevant anatomy and pathophysiology, indications for surgery, and our preferred technique of open brow lifting.

Asian Forehead Aesthetics Societal trends in defini g the physical traits of an attractive face are constantly evolving and are subject to various external influential factors. However, certain features of brow and forehead appearance remain unchanging ideals in Asian culture: an open and smooth forehead contour accompanied by an appropriately elevated brow conveys a brighter, more youthful, and energetic countenance. On the other hand, a narrow and forward-projecting forehead, which is frequently encountered with variable degrees of coexisting brow ptosis, can project an impression of anger, fatigue, and senescence. Both brow contour and position contribute to optimal brow appearance. Various criteria that involve anatomic ratios have been proposed to defi e the idealized brow and to serve as an assessment tool for the eyebrow. For practical purposes, however, eyebrow position is almost always pleasing if the lateral segment is higher than the medial segment in females and level with the medial segment in males. Additionally, the eyebrow should lie at or above the supraorbital rim of females, and at the supraorbital rim of males. The male brow should remain straight, whereas the female brow should have an arched profile, which tends to feminize the frame that surrounds the periorbital structures.

225

226 A

Part III 

Rejuvenation Surgery of the Face

B

Fig. 17-1  A, A youthful, aesthetically pleasing broweyelid complex is made complete by a well-defi ed and clearly displayed supratarsal fold, a lack of excess lateral eyelid skin, and the absence of static crow’s-feet lines. B, Over time, a depressed brow that results in lateral hooding of the upper eyelid skin can conceal the lateral portion of the supratarsal fold and accentuate existing crow’s-feet lines.

The brow and upper eyelid are two structures that are intimately related and codependent in producing an attractive brow-eyelid complex. A youthful brow in its elevated position opens up the lateral orbit and creates a more spacious frame for the periorbital structures (Fig. 17-1). The shape and contour of the forehead, and the dramatic visual illusionary effects that it can portray, compose an aspect of forehead aesthetics that we have observed to be peculiar to the Asian perception of beauty, youth, and vitality. In Asian culture, the favored description of an attractive face is said to be ovalor egg-shaped, with a progressive narrowing of facial width from the upper to the lower face. One way to achieve such a facial outline is through mandible reduction surgery.4 Another way of attaining a similar visual effect is through modifi ation of the frontal contour.5

Anatomic Considerations Surgeons must be familiar with the relevant anatomy of the aging upper face to identify the areas of patient concern and to select the appropriate intervention. A number of muscles provide expression to the forehead, and their chronic overactivity is responsible for predictable patterns of rhytid formation. 6 Originating as paired vertical extensions of the galea, the frontalis muscle inserts into the dermis of the forehead skin and is the sole elevator of the brow; frequent contraction of this muscle is responsible for transverse forehead lines. In opposition to the cephalic pull of the frontalis muscle are the coordinated actions of the corrugator supercilii muscle, the procerus muscle, and the medial fibers of the orbital portion of the orbicularis oculi muscle, which act in unison to cause depression of the medial brow. The corrugator supercilii muscle comprises transverse and oblique heads, both of which arise from the superomedial orbital rim and insert into the dermis above the medial portion of the eyebrow and just medial to the brow, respectively. Contraction of these muscles pulls the eyebrows medially and downward, producing a combination of vertical and oblique glabellar frown lines. The procerus muscle—which originates from the dorsum of the nasal bone, splits into a Y configur tion, and inserts into the lower medial edge of each frontalis muscle and into the midglabellar dermis between the frontalis muscles—acts as a strong depressor of the medial eyebrow, and chronic contraction causes horizontal lines at the root of the nose (Fig. 17-2). The superior temporal fusion line of the skull is an important landmark for understanding the pathophysiology of lateral brow descent. The lateral margin of the frontalis muscle typically lies along this line; this muscle can essentially suspend or elevate only the medial two thirds of the eyebrow, because the superior temporal fusion line crosses the eyebrow near the junction of the middle and lateral thirds of the brow (Fig. 17-3).

Chapter 17 

227

Open Brow Lift

Frontalis muscle Corrugator supercilii muscle Depressor supercilii muscle

Orbicularis oculi muscle

Transverse corrugator muscle Procerus muscle (resected)

Temporal branch of facial nerve

Zygomatic branch of facial nerve

Fig. 17-2  Muscles of the forehead and temporal fossa.

Adhesions

Temporal ligamentous adhesion (orbital ligament)

Superior temporal septum (zone of adhesion)

Supraorbital ligamentous adhesion

Sentinel vein Lateral orbital thickening of periorbital septum

Inferior temporal septum Zygomaticotemporal nerve

Temporal branches of the facial nerve Orbicularis retaining ligament

Fig. 17-3  Anatomic structures associated with a brow lift

K23345_Pu_c17 18_Open Brow Lift_r4_cl_225-238.indd 227

4/2/2015 5:00:06 PM

228

Part III 

Rejuvenation Surgery of the Face

The lack of frontalis action in the lateral third of the brow, coupled with the unopposed brow-lowering action of the lateral orbicularis oculi, help explain why the lateral brow becomes ptotic much earlier in the aging process than the medial segment. Lateral hooding gradually becomes more pronounced, because lateral eyebrow skin fl ws into the upper orbit, augmenting any redundant upper eyelid skin and making coexistent dermatochalasis much more prominent. Excess lateral upper eyelid skin can obscure the lateral portion of the supratarsal fold, if present, and can accentuate the prominence of any existing lateral crow’s-feet lines. Lateral to the superior temporal fusion line, the galea continues over the temporal fossa as the superfic al temporal fascia, and the periosteum is confluent with the deep temporal fascia. Just medial to the superior temporal fusion line is a 5 mm wide strip called the zone of fi ation, where these fascial layers become fused and tightly adherent to the underlying bone (see Fig. 18-3). Inferiorly, where the zone of fixation reaches the orbital rim, there is a dense fascial condensation called the orbital ligament that is fi mly anchored to the underlying bone just above the zygomaticofrontal suture. Additionally, the galeal fascia fuses to the periosteum that densely adheres to the lower 2 cm of the frontal bone. These ligamentous attachments over the supraorbital rim, together with the zone of fixation, limit lateral brow movement in response to posterior traction; therefore these structures must be adequately released from their bony attachments during a brow lift to allow suffici t brow movement. Sensation to the forehead is provided by the supratrochlear and supraorbital nerves.7 Th supratrochlear nerve exits the superomedial orbit just lateral to the origin of the corrugator supercilii muscle and immediately enters the substance of the muscle. It then penetrates the frontalis muscle to innervate the ipsilateral forehead skin from the glabella to the trichion. The supratrochlear nerve is at risk of injury with techniques that emphasize aggressive resection of the corrugator muscle. The supraorbital nerve exits from the supraorbital notch or anywhere along the supraorbital rim. The superfic al branch of this nerve runs over the frontalis muscle to supply sensation to the forehead skin and the anterior part of the frontal scalp. The deep branch of the supraorbital nerve runs between the galea and periosteum initially before piercing the galea to supply the frontoparietal scalp. Dissection in the subgaleal plane often transects the deep branch of the supraorbital nerve, which is primarily responsible for most of the troublesome numbness and dysesthesia of the scalp after open brow lifts The frontal branch of the facial nerve courses over the zygomatic arch and within the layers of the superfic al temporal fascia, to eventually enter the deep surface of the frontalis muscle, which it supplies. Injury to this important motor nerve remains minimal in an open brow lift if he plane of dissection remains deep to the galea and superfic al temporal fascia.

Indications Patients who are at least 50 years of age and have more than three of the six aging signs listed in Box 17-1 can be considered candidates for open brow lift.

Box 17-1  Indications for Open Brow Lift 1. Forehead wrinkles 2. Glabellar frown lines 3. Brow ptosis

4. Supraorbital depression 5. Low frontal hairlines 6. Fifty years of age or older

Chapter 17 

Open Brow Lift

229

Preoperative Assessment When conducting an accurate and systematic assessment of the patient’s upper face, the surgeon should give special attention to the areas of the unwanted changes of aging indicated by the patient to ensure that the best course of treatment is chosen. The signs of forehead aging that can be corrected with an open brow are forehead wrinkles, glabellar frown lines, brow ptosis, and supraorbital depression. The examination begins with a survey of the upper face skin. Static and dynamic forehead and glabellar rhytids are observed with the patient’s face at rest and when he or she is actively elevating the brow and frowning. The orientation of glabellar lines should be noted to determine which underlying glabellar muscle requires modifi ation. As previously mentioned, forehead and glabellar rhytids are not particularly pronounced in Asian patients. Most frequently, only the corrugators require resection to even out and prevent recurrence of vertical and oblique glabellar lines. Asian patients seldom go to the surgeon’s office ith a specific equest for a brow lift. nstead, they often present with concerns about the appearance of excessive upper eyelid skin with hooding and concealment of the double eyelid folds. Th oughout this process, however, these patients are not aware of brow descent as a major contributing factor to the appearance of upper eyelid redundancy. Th s is known as compensated brow ptosis. In such patients, merely performing an upper blepharoplasty with resection of precious upper eyelid skin and without consideration for the brow, may potentiate further brow descent, much to the patient’s dismay. The eyebrow and upper eyelid complex are the next areas on which the surgeon should focus. It is important to note the position of the eyebrow, especially the lateral segment, in relation to the supraorbital rim. Any asymmetries that exist between the left nd right eyebrows are documented. As with brow descent, the eyelid skin beneath the brow and above the supratarsal fold can become redundant, causing lateral hooding and obscuring the visibility of the lateral segment of the supratarsal fold and the pretarsal skin. What proportion of the upper eyelid redundancy is caused by brow ptosis is determined by manually elevating the brow to observe the remaining skin excess in the upper eyelid. If the excess upper lid skin is still present when the brow is elevated, then an upper blepharoplasty will be required in addition to a brow lift, in which case we choose to perform the upper blepharoplasty under local anesthesia at a later stage. The uniformity of the bony contour over the forehead needs to be ascertained. We do this by sight rather than by palpation. Under conditions of even lighting, the surgeon should inspect the patient’s forehead from anterior to posterior, noting specific areas of visual highlights that usually occur bilaterally, because these areas may indicate underlying areas of frontal prominence or bossing. These areas are recorded during the examination so that they can be contoured appropriately during the brow-lift procedure. The height of the forehead, the position of the frontal and temporal hairlines, and the areas of alopecia are evaluated. A patient with a distance of greater than 6 cm from the eyebrow to the trichion is considered to have a relatively high forehead. If a routine coronal incision placed behind the hairline is used in a patient with a high forehead or a posteriorly displaced temporal hairline, the result after redundant hair-bearing scalp has been resected will be a further increase in forehead distance. Th s potential sequela must be clearly communicated to the patient to avoid his or her postoperative dissatisfaction. The forehead skin of an Asian patient is often thicker and less susceptible to actinic change than that of a white patient. The onset of forehead and glabellar rhytid formation tends to develop later in life; when rhytids are present, they are likely to be less pronounced, and thus it is rarely a major concern for the patient. Clinically, this requires a less aggressive approach to frontalis and glabellar muscle modifi ation. Surgical intervention for forehead skin changes in an Asian patient demands relatively less attention compared with corrections in a white patient; dramatic improvements in the Asian patient’s appearance can

K23345_Pu_c17 18_Open Brow Lift_r4_cl_225-238.indd 229

4/2/2015 5:00:06 PM

230

Part III 

Rejuvenation Surgery of the Face

be achieved by instituting minor adjustments to the bony contour of the forehead and by elevating the eyebrow to open up the lateral orbit. Male pattern baldness can be considered a relative contraindication to using the standard coronal incision for brow lifting, unless the patient is willing to accept a visible scar. Patients with male pattern baldness can consider endoscopic or minimal-incision alternatives. In patients with complete dome alopecia for whom we have chosen to use a coronal incision, the resultant scar has often become inconspicuous over time. Because the scar is positioned over the superior aspect of the patient’s head, it is usually not visible when the patient is in social situations, unless the patient is very short.

Surgical Technique Anes thes ia and Hair Contr ol

Although a brow lift can be undertaken with a local anesthetic and adequate sedation, we prefer to perform it with the use of a general anesthetic if possible, because this provides optimal patient comfort, especially if frontal bone contouring is to be performed. The patient is positioned supine, with the oral intubation tube securely fastened in the midline. We previously employed modifi d hairline incisions in patients with high foreheads to avoid posterior transposition of the trichion, but we found that the resultant hairline scar has a rather unsatisfactory appearance. There usually exists a gradation of fi e to coarse hair at the anterior hairline, and any incision at this zone will disrupt the integrity of this unique hair pattern and create a noticeable scar that seems to persist over time. As a result, we are guided toward using a coronal incision even in patients with high foreheads, accepting the likely consequence of having to raise the height of the forehead even more. The exception is the patient who is adamant about maintaining the hairline distance or covering the scar with his or her hairstyle, in which case a modified anterior hairline incision can be considered, with the mutual acceptance of a likely noticeable scar, which is mentioned in the informed consent. The planned incision is approximately 8 cm posterior to the anterior hairline in the midline. From the midline, the incision is extended laterally and inferiorly to the root of the helix. When the hairline is high, a modified anterior hairline incision can be considered. Th s incision follows the frontal hairline in the central portion of the forehead, then turns posteriorly for about 8 cm in the temporal hair-bearing area, before curving caudally toward the top of the ear. If a face lift is being performed concomitantly, it is generally performed after the forehead lift is completed; in this case, the incision for the forehead lift joins the temporal extension of the face-lift incision. No shaving of hair is necessary; instead, “hair control” is the best method to simplify an open brow lift. The hair is parted anterior and posterior to the incision line. The hairs anterior to the incision line are bundled into four symmetrical bundles. The hair is fi st parted centrally and then along a sagittal line extending from the lateral end of the brow. The hair between the two partings is tied securely with an elastic band. The temporoparietal hair lateral to the lateral parting is similarly tied into a bundle. The same maneuver is carried out on the other side. The hair posterior to the incision line can be tied into a single bundle. Ensuring accurate hair control will facilitate ease of surgery and prevent hair from entering the wound. The positions of the hair parting centrally and laterally have been strategically chosen, because these will be the sites where initial redundant scalp excision and fixation of the elevated scalp flap will take place (Fig. 17-4). A fi ld block to facilitate postoperative patient comfort is accomplished by injecting 10 ml of a long-lasting local anesthetic agent such as bupivacaine (0.5% with 1:100,000 epinephrine) over the location of the supraorbital and supratrochlear nerves. A solution of diluted bupivacaine (0.1% with 1:200,000 epinephrine) is then injected intradermally over the incision line to promote vasoconstriction at the incision site. The

Chapter 17 

Open Brow Lift

same solution is infiltrated in the subgaleal plane over the frontal and temporal regions as a form of hydrodissection to facilitate later frontal flap elevation.

Incis io n and Fl ap Ele vatio n

After noting the direction of the hair along the incision line, the surgeon makes the incision parallel to the hair follicles and down to the subgaleal layer but above the periosteum. To minimize the risk of alopecia from thermal damage to hair follicles, electrocautery should be avoided. Laterally, the subgaleal dissection is continued over the temporal region up to 2 cm above the orbital rim, then turned into and under the superficial layer of deep temporal fascia. This dissection can be continued down to the zygomatic arch if necessary. Up to this stage, the frontal branch of the facial nerve is not at risk, as long as the dissection is maintained deep to the superfic al layer of the deep temporal fascia (Fig. 17-5).

A

B

Fig. 17-4  A and B, “Hair control” is the key step in simplifying an open brow lift A

B

C

D

Fig. 17-5  A, The direction of the hair along the incision line is noted, and the incision is made parallel to the hair fol-

licles down to the periosteum. B and C, Baby Raney clips are applied to the scalp edge to control blood loss. D, The frontal flap is rapidly elevated in the previously hydrodissected subgaleal plane, and this is facilitated by downward traction on the scalp with skin hooks.

231

232

Part III 

Rejuvenation Surgery of the Face

Inferiorly, the dissection is extended down over the orbital rim to at least 0.5 cm below the supraorbital rim, just superfic al to the orbital septum. When dissecting these dense fibrotic ligaments and bands from lateral to medial along the supraorbital rim, the surgeon needs to be careful to identify and preserve the supraorbital neurovascular bundles.7 The supratrochlear nerves lie within the substance of the corrugator muscle; therefore it usually is not necessary to identify these nerves.

Relea se of Ligament ous At t a chment s

Important ligamentous attachments, which can tether and restrict movement of the brow, are located at the zone of fix tion, the orbital ligament, and along the supraorbital rim. Ligamentous adhesions at the zone of fix tion just medial to the superior temporal line need to be divided in the course of flap elevation, because dissection passes from the subgaleal plane in the frontal region into the temporal region under the superfic al temporal fascia. The dense fibrous attachments that strongly adhere the dermis of the brow to the underlying periosteum of the orbital rim are released with fine scissors using a spread-andcut technique. Th s is especially important laterally, at the site of the orbital ligament just superior to the zygomaticofrontal suture, to liberate adequate mobility of the lateral brow and temporal skin (Fig. 17-6).

Gl abell ar Muscle Res ectio n

With the forehead flap elevated, the muscles that are responsible for glabellar rhytids can be resected or modifi d under direct vision. The corrugator supercilii is identifi d and isolated, and a 5 mm medial segment of the muscle is excised, sparing the supratrochlear nerves that run within its bulk (Fig. 17-7). Resection of the procerus muscle is performed only if prominent transverse glabellar lines are present. To prevent soft issue depression in the glabellar region, overresection of the glabellar muscles should be avoided. If prominent transverse frontal rhytids need to be addressed, frontalis weakening by scoring the galeal fascia underneath these lines with electrocautery can help improve but not totally eliminate these lines. The galeal-relaxing incisions should be performed away from the course of the supraorbital nerves. Resection or ablation of the frontalis muscle is not advocated.

Fig. 17-6  The dense fibrous attachments that strongly adhere the dermis of the brow to the underlying periosteum of the orbital rim are released with fi e scissors used in a spread-and-cut technique. The white arrow points to the sentinel vein. Inset, Left frontotemporal area.

Chapter 17 

Open Brow Lift

Fig. 17-7  The muscles that are responsible for glabellar rhytids can be resected or modifi d under direct vision. The

straight arrow points to the corrugator supercilii that has not been divided, and the curved arrow points to the divided corrugator supercilii. Inset, Bilateral frontal and supraorbital regions.

Fr ont al Bone Cont our ing

The frontal periosteum is incised just medial to the superior temporal line on both sides, and superiorly. An inferiorly based periosteal flap is then raised with a periosteal elevator to expose the frontal bone. The locations of frontal bossing, which were previously noted during clinical examination, are confi med. An oval-shaped burr is used to carefully shave down the prominent areas; throughout this process, the contour and symmetry of the frontal bone should be reassessed. Continuous irrigation while burring prevents excessive heat buildup and thermal bone damage. Once a smooth and symmetrical frontal outline has been attained, the surgeon refl cts the periosteal flap back, and then starts to elevate and close the scalp flap.

Scalp Excis io n and Cl os ur e

The adequately mobilized forehead flap is transposed in a vertical direction over the posterior scalp incision line until the eyebrows are elevated to the desired level. Maximal lift nd redundant scalp excision, which correspond with maximal emphasis on lateral brow elevation, should occur at the temporoparietal region. The amount of tension and scalp excision should progressively reduce toward the midline. Excess pull centrally will result in undesired overcorrection of the medial brow and an unattractive, startled look. If signifi ant brow asymmetry exists, the surgeon can plan to excise more scalp tissue on the side of the more ptotic brow. Th ee signifi ant fix tion points are established: midline, and both sides bilaterally along the lines extending vertically from the lateral end of the brow. These three fix tion sites correspond to where hair was parted and tied during the initial preparation of the patient. At these three points is where redundant scalp excision and fix tion of the elevated frontal flap will initially be performed. The central fix tion point is addressed before the lateral two fix tion points. The amount of the redundant overlapping scalp edge is marked using a d’Assumpção face-lift forceps. A square piece of excess scalp tissue is excised centrally on the forehead flap, and a temporary fix tion suture is placed in the galeal layer to approximate the wound edges. A similar maneuver is performed on each lateral fix tion point, with greater elevation of the frontal flap at these points to ensure suffici t lateral brow elevation. The four segments of overlapping excess scalp between the initial three fix tion points are then excised (Fig. 17-8). Before the scalp is closed, fibrin glue is sparingly sprayed into the wound, and pressure is applied for a few minutes over the redraped forehead to promote adhesion and minimize potential dead space.8 The galeal layer is closed with interrupted 3-0 Vicryl sutures, and the skin is closed with staples. Tension-free closure

233

234

Part III 

Rejuvenation Surgery of the Face

A

B

C

D

E

F

Fig. 17-8  A, The amount of redundant overlapping scalp edge is marked using a d’Assumpção assessing forceps. B, A square piece of excess scalp tissue is excised centrally on the forehead flap. The excision is performed so that the galeal layer is carefully dissected before excision to preserve additional galeal layer at the wound edges. Th s step will facilitate closure without tension to minimize risk of scarring and scalp alopecia. C, A temporary fix tion suture is placed in the galeal layer to approximate the wound edges, while a similar maneuver is performed on each of the lateral fix tion points. D, The remaining segments of overlapping excess scalp between the initial three fixation points are then excised. E, Fibrin glue is sparingly sprayed into the wound before closure. F, The galeal layer is closed with interrupted 3-0 Vicryl sutures, and the skin is closed with staples.

of the scalp is a vital step in attaining a fi e scar and avoiding alopecia along the incision line. Drains are rarely required, antibiotic ointment is applied over the closure site, and no other special dressing is needed.

Postoperative Care The patient recovers with his or her head in an elevated position. Application of cold packs can help reduce swelling. The patient can shampoo his or her hair on the second postoperative day. An oral antibiotic is administered for 5 days, and scalp staples are removed after 7 to 10 days.

K23345_Pu_c17 18_Open Brow Lift_r4_cl_225-238.indd 234

4/2/2015 5:00:10 PM

Chapter 17 

235

Open Brow Lift

Results

A

B

C

D

Fig. 17-9 Th s 54-year-old woman presented with complaints of forehead wrinkles, brow ptosis, and frown lines at the glabella, as well as a supraorbital depression groove (Fig. 17-9, A and B). An open brow lift with shaving of the frontal bone was performed, resulting in signifi ant improvement of her signs of forehead aging 1 year after surgery (Fig. 17-9, C and D).

A

B

C

D

Fig. 17-10 Th s 46-year-old woman disliked her aging midface and ptotic brow (Fig. 17-10, A and B). An open brow lift and a face lift were performed, with satisfactory improvement of her aging signs (Fig. 17-10, C and D).

236

Part III 

Rejuvenation Surgery of the Face

Discussion Successful forehead rejuvenation relies on fi st establishing the patient’s priorities and then identifying the anatomic basis responsible for the patient’s complaints. Consideration must be given to the eyebrow and upper eyelid as mutually dependent components of a single aesthetic complex. Elevation of the eyebrow not only restores a youthful brow position but also opens up the lateral orbit to highlight periorbital structures such as the supratarsal fold, which holds signifi ant aesthetic value within Asian culture (see Figs. 17-9 and 17-10). The visual effects and corresponding emotional connotations that frontal bossing can convey must not be overlooked. Incorporating frontal bone contouring into the brow-lift procedure is a simple and effective means of maximizing aesthetic results. Despite the long scar and potential sensory changes that may occur, a well-executed open brow lift emains the single most effective way to address all the undesired changes in the upper face that are induced by aging and to provide long-lasting restoration of a youthful, energetic, and harmonious countenance. Hematoma formation and infection are rare sequelae. After the operation, patients will frequently have a sensation of tightness and pressure, but they rarely have pain. Patients may have initial palsy of the frontalis muscle as a result of traction injury of the frontal branch of the facial nerve; however, this is almost always transient, and recovery is usually rapid. If safe dissection planes are followed, permanent frontalis muscle palsy is highly unlikely. Conspicuous scalp scarring and alopecia can occur if the scalp incision is closed under tension; however, this can be minimized by placing the tension at the deeper galeal level to allow a tension-free closure at the hair-bearing scalp level. Making incisions parallel to the hair follicles and limiting the use of electrocautery are also effective ways to avoid permanent hair damage (Fig. 17-11). Long-term alteration of scalp sensations such as itching, tingling, or numbness can occur and is a common source of complaints from patients. The majority of sensory changes resolves by 6 months but occasionally may persist as a source of irritation in some patients for up to 12 months. Sensory changes in the scalp are likely to occur in most patients undergoing an open brow lift 9,10 and this must be clearly communicated to the patient before surgery.

Fig. 17-11  Conspicuous scalp scarring and alopecia are minimized with strict adherence to meticulous wound closure without tension, carefully planned incisions parallel to the hair follicles, and limiting the use of electrocautery.

Chapter 17 

Open Brow Lift

237

When the swelling subsides approximately 3 to 6 months after surgery, revision surgery can be considered if the patient complains about brow asymmetry, widening of the scalp scar, remaining wrinkles, or areas of soft issue depression. Asymmetry of the brow level can exist before surgery, and this should be documented and discussed preoperatively. An aggressive lift on the lower side can improve the asymmetry, but it cannot guarantee that the brows will always be equal. A wide scalp scar can be revised by aggressively undermining the scalp at the subgaleal layer and suturing the galeal layer with tension, without putting tension on the hair-bearing part. Residual wrinkles or depressions can be improved with fillers, either with autologous fat or alloplastic materials such as hyaluronic acid.

Pearls for Success • Consider these patient selection standards to determine whether a patient is a good candidate for open brow-lift surgery: Is the patient more than 50 years of age? Does he or she have more than three of the six signs of an aging forehead? • When performing open brow-lift surgery, the surgeon should fi st use a supraorbital nerve block and infiltrate the scalp incision with a local anesthetic and an epinephrine solution. • The fascia adhesion should be completely released both at the supraorbital region and at the subgaleal level. • The forehead flap is redraped, the scalp is sutured with the tension on the galeal layer, and no tension is placed on the hair-bearing dermis layer. • Tissue glue can be applied to help prevent hematoma formation.

Refer ences 1. Leach JL Jr. Browlifting. Oper Tech Otolaryngol Head Neck 18:162-165, 2007. 2. Flowers RS, Ceydeli A. The open coronal approach to forehead rejuvenation. Clin Plast Surg 35:331-351; discussion 329, 2008. 3. Adamson PA, Johnson CM Jr, Anderson JR, et al. The forehead lift. A review. Arch Otolaryngol 111:325-329, 1985. 4. Kim YH, Cho BC, Lo LJ. Facial contouring surgery for Asians. Semin Plast Surg 23:22-31, 2009. 5. Ousterhout DK. Feminization of the forehead: contour changing to improve female aesthetics. Plast Reconstr Surg 79:701-713, 1987. 6. Knize DM. Anatomic concepts for brow lift procedures. Plast Reconstr Surg 124:2118-2126, 2009. 7. Knize DM. A study of the supraorbital nerve. Plast Reconstr Surg 96:564-569, 1995. 8. Marchac D, Sándor G. Face lifts nd sprayed fibrin glue: an outcome analysis of 200 patients. Br J Plast Surg 47:306-309, 1994. 9. Riefkohl R, Kosanin R, Georgiade GS. Complications of the forehead-brow lift. esthetic Plast Surg 7:135-138, 1983. 10. Guillot JM, Rousso DE, Replogle W. Forehead and scalp sensation after brow-lift: a c mparison between open and endoscopic techniques. Arch Facial Plast Surg 13:109-116, 2011.

K23345_Pu_c17 18_Open Brow Lift_r4_cl_225-238.indd 237

4/2/2015 5:00:12 PM

K23345_Pu_c17 18_Open Brow Lift_r4_cl_225-238.indd 238

4/2/2015 5:00:12 PM

18 Classic Face Lift

F

Dung H. Nguyen, Fu-Chan Wei

acial   rejuvenation is an increasingly popular cosmetic surgery procedure in the Asian population. It is important to consider the cultural and anatomic differences in Asian patients in the surgical planning to achieve satisfactory aesthetic results. The senior author (F.-C.W.) has developed a modifi d dual-plane face-lift echnique that gives consistent and long-lasting results for the lower face and neck in Asians. In this chapter we present the key technical points and surgical tips of this technique.

Anatomic and Cultural Considerations In general, Asians show fewer signs of facial aging than individuals of Western descent. The differences in skin characteristics and facial structure account for the perception of prolonged youthfulness. Asian skin has a thicker dermis with a higher collagen content that retains better skin elasticity over time. 1-3 The darker skin pigmentation provides protection from harmful ultraviolet rays.4 The typical Asian patient also tends to avoid prolonged direct sunlight exposure, which helps to minimize the effects of photoaging. The midface contains more fat superfic al to the superfic al musculoaponeurotic system (SMAS) and has dense fibrous attachments between the superfic al and deep fascia.5 Collectively, these factors explain the limited rhytids and longer resistance to sagging seen in the aging Asian face. Structurally, the facial skeleton in Asians has wider bizygomatic and bimandibular widths but weaker malar bone projection and a smaller, recessed chin, which produces a more rounded and flatter contour. Shirakabe et al6 suggested that the Asian face resembles that of a baby, which further provides an unconscious illusion of youth. However, over time everything succumbs to the forces of nature, and the Asian face is no exception. As the dermis gradually thins and the skin-dermal attachments become attenuated, the effects of gravitational forces become even more pronounced in the Asian face because of the weaker skeletal support, greater amount of fat, and heavier soft issue. Therefore facial rejuvenation procedures must focus more on resuspension of the subcutaneous tissues. The cultural perception of beauty and youthfulness is an important consideration in surgical planning. The areas of concern and patient expectations are different in Asian patients. There is particular emphasis on correction of the nasolabial folds, jowls, and mandibular line, and a less aggressive neck lift is appropriate in most cases. Many patients desire an oval facial shape with a smooth mandibular line and soft neckline.7,8 Sharp mandibular angles, prominent cheek bones, and tight necklines are considered undesirable traits.9,10

239

240

Part III 

Rejuvenation Surgery of the Face

Indications The ideal patient for the modified dual-plane face lift has soft tissue descent in the lower face and neck, particularly in the jowl and cervicomandibular area. Th s procedure does not address the midface or directly correct platysmal bands, but it can readily be combined with a midface lift or platysmaplasty if needed. The main advantage of this technique is the ability to reposition the skin and superfic al fat independently in separate vectors as a two-layer SMAS-type face lift but with limited skin and SMAS dissection. This minimizes the incidence of skin flap necrosis and signifi antly reduces the operative time and complication rates. The lasting effects are from the durable high suspension of the thick SMAS flap.

Preoperative Assessment Precise preoperative assessment and markings are critical to the subsequent execution of the surgery (Fig. 18-1). A thorough preoperative discussion with the patient is mandatory to establish realistic postoperative expectations. The entire face is assessed for areas of soft issue descent and the degree of skin redundancy. The patient should be informed that this procedure does not address brow ptosis, midface descent, or platysmal bands. The patient is marked in the upright sitting position. A preauricular and pretragal incision is preferred. The incision is extended superiorly into the temporal scalp. Inferiorly, the incision continues behind the ear onto the mastoid skin just above the conchomastoid groove and then into the posterior hair-bearing scalp at the midear level. At the lobule tip, a short extension is made along the mandibular line toward the chin. The length of this incision is the predicted skin lift that will be achieved, which is usually 1.5 to 3 cm in most patients. Hatch marks are made at 1.5 to 3 cm intervals along the preauricular incision (a-d). Counterpoints are also made at 90 degrees and at 1.5 to 3 cm anterior to the preauricular incision (bʹ-dʹ). Another mark (aʹ) is made on the extension line from the lobule tip, also 1.5 to 3 cm from the tip. The 1.5 to 3 cm mark is chosen as an estimate of the amount of skin excision to achieve an adequate lift, based on our experience. At closure, the corresponding pairs of marks are matched up, especially the vertical ones. Th s

dʹ

cʹ

d 1.5 cm c 1.5 cm b

4 cm

bʹ 1.5 cm 1.5 cm a

aʹ

Fig. 18-1  Preoperative markings. Points a through d are at 1.5 cm intervals. The move from points bʹ through dʹ indi-

cates the vector of lift or the skin flap. The distance from point a to aʹ (1.5 cm in this patient) is the predicted amount of skin lift, nd the vertical distance between points b through d and bʹ through dʹ is the predicted amount of skin excision. The markings on the face, neck, and retroauricular region defi e the area of subdermal skin dissection.

Chapter 18 

241

Classic Face Lift

ensures an even elevation of the skin flap in the same vector. The extent of skin dissection is indicated by a line drawn about 4 to 5 cm anterior to the preauricular incision. Another line drawn straight down from the posterior hairline incision is used to mark the extent of the posterior neck dissection. Before completion of this step, the position of the lobule tip is marked with methylene blue through the deep dermis with a 25-gauge needle to prevent malposition of the earlobe at the time of skin closure. Similar markings are repeated on the other side of the face.

Surgical Technique The incisions and planned dissection area on each side are injected with 30 to 40 ml of 0.5% lidocaine with epinephrine 1:200,000; 10 minutes is allowed for the injectate to take effect to minimize intraoperative bleeding. The skin flaps are elevated in the plane just beneath the dermis with a needle-tip Bovie under direct vision to keep the flaps thin and even. There is no risk of skin necrosis because of the limited extent of dissection (maximum 4 to 5 cm). To facilitate identifi ation of the dissection plane, the skin flap is retracted vertically with skin hooks while the surgeon uses the thumb and index fi ger of the nondominant hand to straddle the skin flap. With repeated downward and spreading motion, the surgeon provides traction and countertraction forces at the area of dissection to defi e and maintain the dissection plane (Fig. 18-2, A). Th s maneuver gives the surgeon precise control of the dissection plane and is easy to perform because of the limited length of dissection. Skin flaps of uniform thickness are elevated to the anterior and posterior marked lines and inferiorly as far as possible under direct vision. The strategic use of the overhead lights to illuminate the skin flap from directly above and into the wound prevents flap buttonholes during dissection. Careful attention is required during posterior auricular skin elevation to stay just beneath the dermis to avoid injury to the great auricular nerve. Blunt dissection with a straight face-lift scissors is used to complete the neck dissection in areas that cannot be visualized. Th s is achieved by advancing the scissors forward at different angles while the tip is kept slightly open and pointing up toward the skin (Fig. 18-2, B). Th s technique frees the skin from the underlying platysma and

A

B

Fig. 18-2  A, The thumb and index fi ger of the nondominant hand provide traction and countertraction forces at the area of dissection to defi e and maintain the dissection plane. B, Blunt dissection of the neck is achieved by advancing the face-lift scissors forward at different angles while the tip is kept slightly open and pointing up toward the skin.

Continued

242

Part III 

Rejuvenation Surgery of the Face

C

D

E

F

G

H

1-2 cm

I

J

Fig. 18-2, cont’d  C and D, Skin flap elevation shows the extent of dissection in the plane immediately beneath the dermis of the face and neck. E, Markings for sub-SMAS dissection. F, A straight face-lift cissors is used to elevate the SMAS by spreading motions of the tip while the scissors is advanced forward. G, A high SMAS lift. ote the thick SMAS flap in the Asian patient. The vertical lift should be greater than the lateral lift H, A 1 to 2 cm wide strip of lateral SMAS is excised to reduce the bimandibular width of the face. I, The amount of skin excised anteriorly is modest. J, The amount of skin excised posteriorly is modest.

K23345_Pu_c18 19_Classic Face Lift_r3_cl_239-246.indd 242

4/2/2015 5:02:34 PM

Chapter 18 

Classic Face Lift

prevents inadvertent injury to the deep neurovascular structures in the lower face and neck. Liposuction may be used at this time if there is signifi ant submental lipodystrophy. Dissection of the neck is complete after adequate skin mobility is achieved (Fig. 18-2, C and D). Complete neck dissection is not necessary. Sub-SMAS dissection begins with infiltration of 0.5% lidocaine with epinephrine 1:200,000 in the plane between the superfic al and deep fascia of the face and neck. A transverse incision is made in the SMAS over and parallel to the zygomatic arch. It is then angled inferiorly to continue anterior to the ear and along the inferior border of the mandible (Fig. 18-2, E). A straight face-lift cissors is used to elevate the SMAS and emphasize the full layer above the parotid gland. The dissection plane is developed with spreading motions of the tip while the scissors is advanced forward (Fig. 18-2, F). Bridging fibers between the SMAS and parotid fascia are divided. The SMAS dissection does not extend to the anterior border of the parotid gland. Th s is important, because the SMAS becomes thin and attenuated anterior to the middle portion of the parotid gland and therefore tends to tear during SMAS suspension. The thicker the SMAS flap, the more durable and long-lasting results that can be achieved after SMAS suspension. The platysma seen in the inferior part of the elevated SMAS flap is also divided to release its pulling-down effect, which causes jowling. Traction forces, mainly vertical and much less lateral, are applied on the SMAS to ensure smoothing of the nasolabial fold, better defin tion of the cervicomental angle, and reposition of the soft tissues of the cheek and neck. The redundant SMAS superiorly and laterally is excised (Fig. 18-2, G). The superior cut edges of the SMAS are reapproximated and fi ed to the deep fascia with 3-0 Dexon interrupted horizontal mattress sutures. A 1 to 2 cm wide strip of superfic al fascia is also excised along the lateral border of the mandible to reduce the bimandibular width of the face. Fatty tissue in this region can be further trimmed if needed (Fig. 18-2, H). The lateral cut edges of the SMAS flap are reapproximated only in the upper part down to the earlobe but not further inferior to avoid the appearance of a flattening wide face. The skin is carefully lifted and redraped to smooth out the lower face and neck contour. Areas of tethering can be corrected by extending the subdermal dissection for several millimeters. The redundant skin, usually measured 1.5 to 3 cm, is then excised conservatively with a No. 15 blade (Fig. 18-2, I and J). A temporal extension incision is also made to remove the residual standing cone. The preoperative markings on the skin edges are properly matched up and reapproximated with interrupted intradermal 4-0 or 5-0 Dexon sutures and running 5-0 or 6-0 nylon or Surgilon sutures. Particular attention is made not to distort the position of the earlobe or to place tension on the closure to prevent the pixie ear deformity. The scalp incision is closed with skin staples. No coagulation is applied on the scalp edges close to the hair follicles to prevent injury. Hemostasis may be achieved with skin staples alone. No drains or local application of fibrin glue are necessary.

Postoperative Care Postoperatively, a pressure dressing is applied to the patient for 24 hours. In our practice, we avoid placing drains. The patient usually stays overnight in the hospital and is allowed to shower the day after surgery. The sutures and staples are generally removed 1 week postoperatively. Scar massage is recommended, but massage in the vertical direction near the earlobe should be avoided, because it may cause a pixie ear deformity.

243

244

Part III 

Rejuvenation Surgery of the Face

Results Most of our patients are very satisfi d with the outcome of their classic face lift, especially for the improvement of jowls and marionette lines. However, the improvement of the nasal fold is not as satisfactory. A complication such as hematoma or skin flap necrosis is rare. A pixie ear deformity can be a problem, but it can be treated by repositioning the earlobe. If the patient develops a hypertrophic scar, scar revision may be required.

Fig. 18-3 Th s 67-year-old woman had a lower face and neck lift. Postoperative photos 1 month after the procedure show a more youthful oval face shape with improved nasolabial folds, mandibular outline, cheek fullness, and neck contour.

K23345_Pu_c18 19_Classic Face Lift_r3_cl_239-246.indd 244

4/2/2015 5:02:34 PM

Chapter 18 

Classic Face Lift

245

Fig. 18-4 Th s 65-year-old woman had a total face lift. Postoperative photos show a more youthful face.

K23345_Pu_c18 19_Classic Face Lift_r3_cl_239-246.indd 245

4/2/2015 5:02:35 PM

246

Part III 

Rejuvenation Surgery of the Face

Discussion Above all, successful facial rejuvenation of the Asian patient requires a clear understanding of the anatomy of the Asian face and the effects of gravity on the soft tissue components with aging. The proposed surgical technique is designed to maximally lift he lower face and neck through a modifi d dual-plane technique with limited skin and SMAS dissection to minimize wound complications and risks of nerve injury. When this procedure is executed properly, the cosmetic results are long-lasting and natural, and the incidence of complications with this technique is very low. Precise dissection in the correct tissue plane under direct vision and good preoperative infiltration of a local hemostatic agent not only avoid an uneven or irregular facial skin contour after redraping, but also minimize the incidence of postoperative hematoma, obviating the need to use a drain. Limited skin dissection in patients with a thick dermis eliminates the concern of skin flap necrosis. Facial nerve injury is also unlikely, because the SMAS dissection stays above the deep fascia and does not extend beyond the anterior border of the parotid gland. Injuries to the great auricular nerve and neurovascular structures of the neck are also not possible because most of the neck dissection is done immediately beneath the dermis. The most common complication is widened or hypertrophic scars, which may be minimized with meticulous wound closure without tension.

Pearls for Success • It is essential to select the appropriate patients and establish realistic postoperative expectations. • The surgeon should maintain even thickness of the skin flap by vertical retraction of the flap and by providing traction and countertraction forces at the area of dissection to defi e and maintain the dissection plane. • The skin and SMAS dissection should be limited to behind the anterior border of the parotid to minimize injury to the facial nerve branches and to avoid attenuating the SMAS. • It is important to anchor the thick SMAS securely to the deep fascia to ensure long-lasting lifting results. • There should be modest skin excision to minimize tension on closure. • The surgeon should not cauterize the scalp to prevent injury to the hair follicles and postoperative alopecia.

Refer ences 1. Lee Y, Hwang K. Skin thickness of Korean adults. Surg Radiol Anat 24:183-189, 2002. 2. Shirakabe Y. The Oriental aging face: an evaluation of a decade of experience with the triangular SMAS flap technique in facelifting. Aesthetic Plast Surg 12:25-32, 1988. 3. Lee Y, Hong JJ. Multiplane face lift ith the subperiosteal dissection for orientals. Plast Reconstr Surg 104:237244; discussion 245-246, 1999. 4. Berardesca E, de Rigal J, Leveque JL, et al. In vivo biophysical characterization of skin physiological differences in races. Dermatologica 182:89-93, 1991. 5. Sykes JM. Management of the aging face in the Asian patient. Facial Plast Surg Clin North Am 15:353-360, vi-vii, 2007. 6. Shirakabe Y, Suzuki Y, Lam SW. A new paradigm for the aging Asian face. Aesthetic Plast Surg 27:397-402, 2003. 7. Bergeron L, Chen YR. The asian face lift. Semin Plast Surg 23:40-47, 2009. 8. Onizuka T, Hosaka Y, Miyata M, et al. Our mini-facelift for Orientals. Aesthetic Plast Surg 19:49-58, 1995. 9. Morris DE, Moaveni Z, Lo LJ. Aesthetic facial skeletal contouring in the Asian patient. Clin Plast Surg 34:547556, 2007. 10. Soh J, Chew MT, Wong HB. An Asian community’s perspective on facial profile attractiveness. Community Dent Oral Epidemiol 35:18-24, 2007.

K23345_Pu_c18 19_Classic Face Lift_r3_cl_239-246.indd 246

4/2/2015 5:02:35 PM

19 Short-Recovery Face Lift

M

Su

Yukio Shirakabe, Terumi Shirakabe, Katsunori Niitsuma

any Asian patients prefer noninvasive procedures to face-lift surgery. With the increasing number of noninvasive alternatives available, including botulinum A toxin, injectable fillers, lasers, phototherapy, and radiofrequency therapy, the number of face-lift operations has decreased since the mid-1990s. Asians tend to shy away from face-lift surgery because of postoperative swelling and bruising, discomfort, a longer downtime or recovery period, and the occasional need for hospitalization; however, they understand that face-lift surgery is typically more effective and durable than any of the noninvasive alternatives. The other deterrents to face-lift urgery are the telltale signs that result from it, including ugly scars and hairless areas in the temporal region, the change of the sideburn position, and the loss of space between the ear and the sideburns, each of which is very noticeable on Asians, especially those who often wear their hair pulled back. These problems are intolerable for Asian patients, who defin tely do not want their face-lift surgery to be recognized by others. Based on more than 30 years of experience performing face-lift surgery, we have modifi d the conventional face lift in an effort to avoid the swelling and other telltale complications without compromising the overall results. Th s modifi d technique has minimized downtime and produced wonderful results that cannot be achieved through noninvasive procedures. Th s modifi d technique avoids creating a temporal incision and thus prevents temporal undermining, which can cause the most severe postoperative swelling. With this modifi d technique, the incision is made in front of and behind the sideburns and in front of and behind the auricle. Temporal skin redundancy as a result of superfic al musculoaponeurotic system rhytidectomy (SMASectomy) is improved by tightening the redundant skin and orbicularis oculi muscle through an infrabrow excision instead of through conventional temporal undermining. Th s results in a dramatic reduction in postoperative swelling; thus it allows a quicker recovery and return to activities of daily living.

Evolution of Standard Face-Lift Surgery in Japan To better understand this modifi d technique, one needs to appreciate the history of face lifts in Japan and the differences between face lifts in Asians and whites.

247 K23345_Pu_c19_Short Recovery Face Lift_r7_cl_247-262.indd 247

4/3/2015 12:08:46 PM

248

Part III 

Rejuvenation Surgery of the Face

C A

Fig. 19-1  Wide-skin undermining by González-Ulloa.1

E F9

F

B

At the malar rhytidectomy, tracing contours the highest portion of the temporal region and from these curves downward at an angle of 90 degrees, as shown by point C in the E area. Th F-F9 line is the pilot line, which runs from the commissure of the eyelids to 2.5 cm above the auricular sulcus. Th s is the guideline traced to allow for the evaluation of the amount of upward traction to be obtained with the anterior flap and symmetry in stretching the length of the incisions, posterior and anterior (points A and B).

Fa ce-L ift Sur ger y in the 1970s

In Europe and the United States in the 1970s, face-lift surgery with extensive undermining, as reported by González-Ulloa1 (Fig. 19-1), was very popular. In Japan, however, extensive undermining was rarely performed. In 1977 we reported extensive undermining to tighten the skin on the entire face.2 Th s technique was effective, but it required an extensive downtime or a long hospitalization averaging 8 days, and the patient had to wear a dressing. In addition, after the patient’s dressing was removed on postoperative day 4, his or her face was swollen like a large ball.

Fa ce-L ift Sur ger y in the 1980s

In the 1980s, the SMAS face-lift technique was developed, which limited the extent of skin undermining and dramatically reduced swelling and downtime. Th ough the development of this technique, face-lift surgery gradually became more popular. With the introduction of tissue glue, face-lift patients no longer required dressings. At the American Society for Aesthetic Plastic Surgery (ASAPS) meeting in 1986, we presented an effective face-lift technique using three procedures: augmentation with a SMAS graft, tightening by SMAS lifting, and reduction by suction-assisted lipectomy3 (Fig. 19-2). At the same meeting in 1986, we presented a face-lift technique for Asian patients using a triangular SMAS flap method combined with liposuction4 (Fig. 19-3) for which we received the Walter Scott Brown Award. Since that time, face-lift surgery has become more popular in Japan.

Fa ce-L ift Sur ger y in the 1990s

New face-lift echniques were introduced in the 1990s. For example, extended SMAS dissection was presented in 1995 by Stuzin et al,5 lateral SMASectomy was introduced in 1997 by Baker,6 and the composite rhytidectomy was presented in 1998 by Hamra.7 These techniques aimed to raise deeper tissues. The results lasted longer, but the techniques were so complicated that a detailed knowledge of facial anatomy was required to perform them. In the late 1990s, a variety of noninvasive facial treatments became available and started to challenge the use of invasive face-lift surgery.

Chapter 19 

A

249

Short-Recovery Face Lift

B

C

Graft

Fig. 19-2  The face-lift echnique that we presented in 1986.3 A, Augmentation with pedicle roll or free graft B, Tight-

ening. C, Reduction with liposuction.

A

B

Fig. 19-3  Shirakabe triangular SMAS flap method combined with liposuction.4 A, Triangular SMAS flap. B, Liposuction above the platysma muscle.

Fa ce-L ift Sur ger y in the 2000s

In the first half of the 2000s, face-lift surgery continued to grow in popularity. An antiaging and rejuvenation boom boosted the number of face-lift urgeries. At the same time, less-invasive and noninvasive procedures, including botulinum A toxin injection, injectable fillers, lasers, and radiofrequency therapy, started to compete with face lifts by emphasizing that they required little to no downtime.

Fa ce-L ift Sur ger y in 2010 and Beyond

In 2010, noninvasive facial treatments were yielding better results than those achieved previously. In Japan, for the fi st time, the number of noninvasive rejuvenation procedures outpaced the number of face-lift operations. Japanese patients who did not like the telltale signs of surgery preferred noninvasive treatment; therefore the number of invasive face-lift operations began decreasing. After 2010, to encourage patients to request face-lift urgery rather than noninvasive treatments, surgeons started to develop procedures that required shorter downtime than noninvasive alternatives.

250

Part III 

Rejuvenation Surgery of the Face

Problems Associated With the Incision and Undermining in the Temporal Region In traditional face-lift urgery, the surgeon starts an incision on the hair-bearing scalp or along the hairline in the temporal region and continues from the preauricular region to the postauricular region. In addition, subcutaneous undermining is performed up to the lateral canthus to tighten the temporal region. The temporal incision and undermining sometimes cause the following problems, which are very noticeable on Asians with black hair: • Ugly scars and baldness in the temporal region (Fig. 19-4, A) • Loss of the sideburns and elevation of the hairline (Fig. 19-4, B) • Skin loss between the preauricular region and the sideburns (Fig. 19-4, C) • Frontalis muscle paralysis caused by damage to the temporal nerve8 • Swelling and bruising in the temporal, cheek, and eyelid regions (Fig. 19-4, D and E) The problem noted in Fig. 19-4, D and E—swelling and bruising in the temporal, cheek, and eyelid regions after temporal undermining—always appears immediately after surgery, which leads people to think that face-lift surgery results in the patient’s having a swollen face. If this issue is resolved, downtime can be reduced, and comfortable and convenient face-lift urgeries will be available. Th s problem is often caused by treatment of excess skin in the temporal region resulting from the lateral SMASectomy. Therefore, instead of raising the excess skin laterally toward the temporal hairline, the surgeon should cut the excess

A

B

D

C

E

Fig. 19-4  Temporal problems. A, An ugly scar in the temporal region. B, Loss of the sideburns. C, Reduced space in the

preauricular region. D and E, Swelling and bruising in the temporal, cheek, and eyelid regions after temporal undermining.

Chapter 19 

251

Short-Recovery Face Lift

skin through an infrabrow excision and pull up a part of the lateral supraorbicularis oculi muscle medially toward the eyebrow. Th s technique makes it possible to correct the skin redundancy in the lateral canthus caused by the lateral SMASectomy without undermining the temporal region, thus avoiding the swelling and bruising caused by undermining in the temporal region.

Indications Th s technique cannot be used for patients with hypomyotonia or regular users of blood anticoagulant. However, this technique can be used for patients who have normal blood test results and are mentally, emotionally, and physically healthy, regardless of their sex or age. It is especially appropriate for patients who do not want their face lift o be recognized by others and patients who need second or subsequent face lifts. In my practice, a total of 45 of 143 patients have received second or subsequent face lifts. The only limitation of this technique is that it cannot improve the quality of the skin itself.

Preoperative Procedure Mar king an Incis io n Line and Determining Und ermining

The surgeon should mark the incision line in front of and behind the auricle and decide the extent of undermining. A lazy S line is placed along the lower border of the sideburns to the auricle (Fig. 19-5, A and B). A gentle C-curved line is then made both in front of and behind the earlobe (Fig. 19-5, C). The placement of the two C-curved lines helps avoid not only a “dog-ear” formation at the base of the earlobe but also hypertrophic scar formation. In the postauricular area, the C-curved line runs 5 mm above and parallel to the auriculotemporal sulcus and rotates 90 degrees to the hair side at the posterior eminence of the triangular fossa, and a V-shaped line is horizontally placed up to the hairline (Fig. 19-5, D). Th s V-shaped incision, which ends at the hairline without extending into the hair-bearing area or along the hairline, also prevents a dog-ear deformity and avoids formation of a hypertrophic scar.

A

B

C

D

Fig. 19-5  The incision line around the auricle and the extent of undermining. A and B, A lazy S line along the sideburns. C and D, A gentle C-curved line around the auricle, and a V-shaped line in the postauricular area.

252

Part III 

A

Rejuvenation Surgery of the Face

B

1-2 fingers 3-4 fingers

Feathering area

Undermining area

SAL area

Fig. 19-6  The skin undermining area and the suction-assisted lipectomy area.

The skin undermining area is two fi gerbreadths from the sideburns, three to four fi gerbreadths from the tragus, and three to four fi gerbreadths from the earlobe (Fig. 19-6).

Per fo rming a Dolp hin-S hap ed Infrabr ow Excis io n Line

Upper blepharoplasty through an infrabrow excision has some advantages.9 The amount of skin or muscle to be removed can be estimated before surgery. The scar can be hidden under the lower end of the brow and will be nearly invisible 3 months after surgery. However, the spindle-shaped excision often causes some slanting wrinkles laterally at the medial canthus and leads to a drooping scar at the lateral canthus, which can often make this scar noticeable. In 2007 we modified the spindle-shaped excision to avoid its disadvantages. We changed the lower line of the spindle shape at the medial canthus side to a gentle curve parallel to the contour of the upper eyelid. Th s modifi d design helps prevent tension and slanting wrinkles produced by the spindle-shaped excision. The modifi d line was named the dolphin-shaped excision, because the shape looks like a swimming dolphin (Fig. 19-7). The steps for performing a dolphin-shaped infrabrow excision are as follows: 1. Draw the upper line of the spindle shape along the lower end of the eyebrow. Start the excision line at the point where the direction of the eyebrow growth begins to change from upward to downward. In a patient with mild ptosis of the upper eyelid, the line should start a little more laterally. 2. Draw the lower excision line. With the patient in a sitting position, push the upper cheek up gently, taking the redundant skin between the thumb and fi gers to correct the drooping upper eyelid. Then draw the lower line of the spindle shape to determine the amount of skin to be removed. Only the lower line on the medial side is changed to a gentle curve parallel to the contour of the upper eyelid rim. The dolphin-shaped excision line is complete. The amount of skin under the lateral canthus should be a little smaller than usual, because a part of the orbicularis oculi muscle has been excised and sutured.

Chapter 19 

Short-Recovery Face Lift

Fig. 19-7  A dolphin-shaped infrabrow excision line.

Fig. 19-8  A 23-gauge by 60 mm lateral quadruple-hole cannula with a curved tip.

Fig. 19-9  An injection of a local anesthetic

for a face lift

Injecting a Lo cal Anes the tic

A local anesthetic is given to the patient through a 23-gauge by 60 mm lateral quadruple-hole cannula with a curved tip10 (Fig. 19-8). I (Y.S.) intravenously infuse 0.08 to 0.15 kg of midazolam (Dormicum) before surgery, and add it as needed. In face-lift surgery, minimizing intraoperative bleeding is the most important step to minimize swelling. To do this, skin undermining should be performed as close to the dermal layer as possible. An accurate injection of a local anesthetic works like hydrodissection, facilitating undermining by the scalpel and thus minimizing the bleeding. Th s 23-gauge by 60 mm lateral quadruple-hole cannula with a curved tip is very useful. The cannula is inserted horizontally between the dermal and fat layers (Fig. 19-9). While the cannula is withdrawn horizontally, the anesthetic solution is injected evenly in all directions. The only discomfort that the patient has is a feeling of pressure. Ample time should be taken to inject the anesthetic into both sides, from the cheeks to the lower neck. After the anesthetic is injected into both sides, the epinephrine has already begun to work on the first side that was injected; therefore undermining can be performed with minimal bleeding.

253

254

Part III 

Rejuvenation Surgery of the Face

Surgical Technique Skin Incis io n and Und ermining

An incision is made with a No. 15 blade scalpel along the line from the sideburns to the postauricular hairline. The scalpel is also used for the fi st 1 cm of undermining. With face-lift scissors, undermining is performed at the sharp skin undermining area. A gauze pad is inserted into each treated area. After undermining is complete, the inserted gauze pads are removed one by one. Hemostasis is carefully confi med for all of the treated areas, especially the postauricular hairline, which bleeds easily and therefore requires careful hemostasis. Quick and careful hemostasis must be repeated throughout the surgery to prevent postoperative hematoma, swelling, and discomfort.

Lipos uctio n and Fea ther ing

Immediately after fin shing sharp undermining, the surgeon performs liposuction and feathering on the border with the sharply undermined area in the zygomatic and buccal regions using a 2.0 mm diameter cannula. Feathering is a procedure that creates multiple tunnels in a honeycomb pattern, enabling smooth transitions between treated and untreated areas. In the neck region, fat accumulated on the platysma muscle is treated by liposuction and feathering. The platysma muscle is elevated together with the skin, without being separated from the skin. Neck liposuction is effective for Asians, whose faces look bigger because their necks are often shorter and thicker compared with those of whites. Thorough neck liposuction should be performed to make the neck look slimmer and longer by tightening the platysma muscle.

Lateral

Super fici al Muscul oap oneur otic System Rhy tid ect omy

To start a lateral SMASectomy, a surgeon draws a gentle S line with a width of 8 to 15 mm on the SMAS, from the platysma muscle to the preauricular region, and then to the zygomatic region. A thin layer of the SMAS is removed. To tighten the skin around the nasolabial fold and the angulus oris, it is more effective to avoid undermining the anterior SMAS. A 3-0 absorbable suture (we use 3-0 Dexson) is placed at the inner part of the platysma muscle (Fig. 19-10). The platysma muscle is elevated laterally. The elevated muscle is plicated, making certain that the sagging in the middle of the neck improves. The SMAS that is continuous with the platysma muscle after passing the earlobe is plicated parallel to the nasolabial fold. The

A

B

C

10 mm

Fig. 19-10  Lateral SMASectomy. A, SMAS design. B, SMAS suture (cephalic). C, SMAS suture (posterior).

Chapter 19 

Short-Recovery Face Lift

upper part of the SMAS is lifted toward the zygomatic region and anchored to improve cheek sagging. Th s lateral SMASectomy signifi antly improves sagging in the cheek region (Fig. 19-11).

Excis io n and Sutur ing of Excess Skin

When the surgeon puts excess skin on the auricle, he or she must exercise caution to avoid tension with the skin flap. The surgeon then makes a skin incision down to the earlobe base to expose the earlobe. A temporary suture is made at the earlobe base. The skin overlapping the postauricle is trimmed away along the auriculotemporal sulcus. The remaining skin flap is gently pulled up toward the supraauricular area. Then the excess skin is removed along the C-curved line that was drawn preoperatively to avoid a dogear along the hairline. Th s C-curved line is very useful to prevent not only a dog-ear formation but also extensive scarring. The preauricular region is then treated. The temporary suture at the earlobe base is removed. The skin flap overlapping the tragus is cut off along the top of the tragus. Then the excess skin overlapping the sideburns is gently lifted and removed along the lazy S incision line without causing tension. Wound closure is performed with a 5-0 absorbable buried suture (we use a PDS 5-0 suture) and a continuous skin suture using a nylon thread (we use a 5-0 black suture) (Fig. 19-12).

A

B

Fig. 19-11  SMASectomy to improve sagging of the cheek. A, The facial skin flap is pulled in the direction that the arrow is pointing. B, The postauricular flap is pulled to cover the auricle.

Fig. 19-12  Suturing in the preauricular region.

255

256

Part III 

Rejuvenation Surgery of the Face

Box 19-1  Advantages of the Dolphin-Shaped Infrabrow Excision • The avoidance of temporal undermining minimizes swelling in the temporal, eyelid, and cheek regions, which are the areas that become most swollen. • A dolphin-shaped infrabrow excision also makes it possible to prevent many of the other complications in the temporal region that are caused by standard face-lift surgery. • Th s type of infrabrow excision also makes it possible to preserve the positions of the sideburns and hairline in the temporal region, so patients can undergo repeat face-lift surgery. • Good surgical results are obtained with a dolphin-shaped infrabrow excision. The results are the same as those of standard face lifts and neck lifts, with fewer complications. • The downtime after having surgery using the dolphin-shaped infrabrow excision technique compared with that of a traditional face lift is dramatically reduced.

Dolp hin-S hap ed Infrabr ow Excis io n

Skin sagging resulting from a SMASectomy at the temple and the lateral canthus is improved by lifting up the lateral supraorbicularis oculi muscle using a dolphin-shaped infrabrow excision. Instead of raising the sagging skin laterally using an incision in the hair-bearing area or hairline in the temporal region, as in a standard face lift, the surgeon pulls the orbicularis oculi muscle medially toward the brow, which can minimize swelling in the temple. Box 19-1 lists the advantages of this type of excision. Upper blepharoplasty using a dolphin-shaped infrabrow excision is performed in the following order: 1. The skin is excised according to the preoperative design to expose the orbicularis oculi muscle (Fig. 19-13, A and B). 2. The orbicularis oculi muscle at the lower edge of the excision is pinched with a forceps and pulled up medially to determine the amount of skin to be removed, which depends on the degree of temporal sagging (Fig. 19-13, C and D). 3. An incision is placed in the orbicularis oculi muscle on the outer side of the lower edge of the excision line, the muscle flap is pulled up, and redundant muscle is excised and sutured, without causing tension in the temporal area (Fig. 19-13, E). 4. After common buried sutures (6-0 PDS) are placed, a continuous 7-0 black nylon suture is placed (Fig. 19-13, F).

Chapter 19 

A

Short-Recovery Face Lift

257

B

C

D

E

F

Fig. 19-13  Upper blepharoplasty using a dolphin-shaped infrabrow excision. A, Skin excision. B, Exposure of the or-

bicularis oculi muscle. C and D, The surgeon checks the muscle redundancy by evaluating the amount of redundant skin and muscle at the lateral canthal area that was made by the lateral SMASectomy. E, The incision line in the orbicularis oculi muscle. F, Final suturing in the infrabrow.

K23345_Pu_c19_Short Recovery Face Lift_r7_cl_247-262.indd 257

4/3/2015 12:08:55 PM

258

Part III 

Rejuvenation Surgery of the Face

Results We performed this technique on 143 patients (121 women and 22 men) between the ages of 40 and 90. Unlike standard face-lift procedures, which cause swelling and bruising and require extensive downtime, this technique causes almost no swelling and bruising, requires minimal downtime, and produces results as good as standard face-lift rocedures. Our patients were prepared for swelling, bruising, and a long downtime. However, after the surgery, they reported little to almost no postoperative swelling or bruising; therefore they did not have any restrictions in their activities of daily living.

A

B

C

D

E

F

G

H

Preoperative

2 days postoperatively

5 days postoperatively

1 month postoperatively

Fig. 19-14 Th s 56-year-old woman had a face lift nd a neck lift hrough infrabrow-excision upper blepharoplasty. Because of the cheek lift, the orbicularis oculi muscle was elevated in the lower eyelid region, which caused a light jugal line after surgery. To avoid this problem, we combined a skin-muscle flap upper blepharoplasty with this surgery.

K23345_Pu_c19_Short Recovery Face Lift_r7_cl_247-262.indd 258

4/3/2015 12:08:58 PM

Chapter 19 

259

Short-Recovery Face Lift

A

B

C

D

E

F

G

H

Preoperative

2 days postoperatively

5 days postoperatively

1 month postoperatively

Fig. 19-15 Th s 43-year-old woman presented with complaints of sagging in her face and neck at the lateral canthi, and especially around the mouth and the mental and submaxillary regions (Fig. 19-15, A and E). Upper blepharoplasty combined with a SMASectomy and an infrabrow excision was performed. Eight units of Botox Vista were injected into the mental region. On postoperative day 2, swelling and bruising were not very noticeable (Fig. 19-15, B and F). The patient was allowed to take a shower on day 2 and to wash her hair on day 3. The sutures on the lower brows were removed on day 5 (Fig. 19-15, C and G). All of the sutures were removed on day 8. Good progress is shown 1 month after surgery (Fig. 19-15, D and H).

260

Part III 

Rejuvenation Surgery of the Face

A

B

C

D

E

F

G

H

Preoperative

5 days postoperatively

8 days postoperatively

1 year postoperatively

Fig. 19-16 Th s 67-year-old woman complained of sagging in her entire face, especially in the lower third. A face lift and neck lift with an infrabrow excision blepharoplasty was performed. Th s infrabrow excision was made slightly above the usual position, because she wanted to erase her eyebrow tattoo. Her postoperative progress was the same as that of the patient shown in Fig. 19-15.

Chapter 19 

Short-Recovery Face Lift

261

In a patient who undergoes multiple face lifts and whose sideburns are shortened, hair grafts from the lower parts of the sideburns can be transplanted. A lazy S incision is placed horizontally at a suitable position, taking the patient’s face length, width, shape, and desire into consideration. Hair remaining in the lower part of the sideburns should be pulled up and moved to the front of the tragus. If a patient does not want the remaining hair, the hair can be removed 1 month after surgery.

Management of Complications The potentially serious complications of this modifi d technique include nerve damage, skin necrosis, and postoperative asymmetry. To avoid nerve damage, the surgeon must fully understand the anatomy of the facial nerves before performing this type of surgery. Skin necrosis can be prevented by avoiding excessive tension on the skin. The same surgeon should operate on both sides of the face to avoid postoperative left right asymmetry. To minimize complications, such as swelling and bruising, hemostasis is carefully carried out for all of the treated areas during surgery. Quick and careful hemostasis must be repeated and achieved in each stage of the surgery. After the entire undermining is complete, the gauze pads that were inserted are removed one by one. Utilizing a dolphin-shaped infrabrow excision helps to minimize swelling in the temporal region and to make the scars unnoticeable.

Discussion We have performed this modifi d conventional face-lift technique for more than 160 patients since August 2007. Th s technique does not require making an incision in the temporal hair-bearing area or hairline, and it does not require any undermining in the temporal area.

Pearls for Success • Avoid making incisions in the temporal region to prevent many complications, including ugly scars and hair loss in the region, sideburn loss, hairline elevation, and skin loss. • Do not make any incisions in the temporal hair-bearing area to minimize swelling and bruising. • Prevent the formation of dog-ear and hypertrophic scars by making a lazy S incision along the sideburns, a gentle C-curved incision in front of and behind each earlobe (two C-curved incisions in total), and a V-shaped line incision behind the auricle. • Use a local anesthetic with a 23-gauge by 60 mm lateral quadruple-hole cannula with a round tip. Th s helps to minimize intraoperative bleeding and postoperative swelling with face-lift surgery. • Minimize swelling and bruising through careful and quick hemostasis in each treated area. • Perform liposuction and feathering in the neck, which are very useful to make the neck look longer and younger, especially for Asians. • Tighten the temporal excess skin that results from the lateral SMASectomy by implementing a dolphin-shaped infrabrow excision. Th s helps minimize swelling in the temporal region and makes the scars unnoticeable.

K23345_Pu_c19_Short Recovery Face Lift_r7_cl_247-262.indd 261

4/3/2015 12:09:02 PM

262

Part III 

Rejuvenation Surgery of the Face

Refer ences 1. González-Ulloa M. The aging face: elimination of wrinkles and other problems. In González-Ulloa M, ed. Aesthetic Plastic Surgery, vol 1. St Louis: Mosby, 1988. 2. Shirakabe Y. Rhytidectomy. J Jpn Soc Aesth Plast Surg 1:83, 1977. 3. Shirakabe Y. The Oriental aging face: an evaluation of a decade of experience with the triangular SMAS flap technique in facelifting. Aesthetic Plast Surg 12:25-32, 1988. 4. Shirakabe Y. Suction assisted rhytidectomy in the face and neck. Presented at the Congress of the Nineteenth Annual Meeting of ASAPS, New Orleans, LA, 1986. 5. Stuzin JM, Baker TJ, Gordon HL, et al. Extended SMAS dissection as an approach to midface rejuvenation. Clin Plast Surg 22:295-311,1995. 6. Baker DC. Lateral SMASectomy. Plast Reconstr Surg 100:509-513, 1997. 7. Hamra ST. Composite rhytidectomy. Plast Reconst Surg 90:1-13,1992. 8. Seckel BR. Facial Danger Zones: Avoiding Nerve Injury in Facial Plastic Surgery. St Louis: Quality Medical Publishing, 1994. 9. Hayashi H, Fujimori R. Effects of infrabrow face lift. J Jpn Soc Aesth Plast Surg 25:114-118, 2003. 10. Shirakabe Y. A new painless micro-cannula for extensive local anesthesia with a bulbous tip that has four peripheral holes. J Jpn Soc Aesth Plast Surg 33:8-18, 2011.

K23345_Pu_c19_Short Recovery Face Lift_r7_cl_247-262.indd 262

4/3/2015 12:09:02 PM

20 Multimodal Surgical Approaches to the Aging Face

T

Shih-Heng Chen, Hung-Chi Chen, Che-Wei Chang, Chih-Hsuan Chen, Yueh-Bih Tang Chen

he   quest for rejuvenation of the aging face is a popular trend affecting all racial ethnicities, including Asians. Skoog1 was the fi st to describe deep tissue repositioning for the aging face in 1968. Thereafter, a rapid revolution in techniques occurred through the 1990s and 2000s,2-10 and the face lift became the mainstay of facial rejuvenation. However, an increased understanding of facial anatomy and planes11-15has led to a new defin tion of facial aging, which is deflating as well as loosening. In addition, because of advances in fillers and new technologies,16-17 an aging face can be rejuvenated with the use of multiple modalities, in addition to a face lift 18-20 In this chapter, we present our multimodal surgical approaches for facial rejuvenation. In addition, the characteristics of facial aging in Asians and the indications for combined or ancillary procedures are discussed.

Anatomy and Pathophysiology Compared with the skin of people of European extraction, the skin of Asians is stronger, with a thicker dermis. The facial skeleton is wider, but the anteroposterior diameter is relatively shorter. The nose is usually flat and short with relative hypoplasia at the nasion. As people age, the most common sign of aging is drooping of the eyebrows, which results in overhanging of the upper eyelid skin. Hollowing of the eyelids with progressive enophthalmos and ptosis also develops. Typically it may occur differentially. With the continuous effect of gravity, lower eyelid bags will appear and progressively increase. Facial aging may also be exacerbated by progressive resorption of the facial skeleton, notably at the maxilla and chin area. Therefore a prominent tear trough groove, laxity at the jowls, flattening of the face, retrusion of the chin, and prominence of the nasolabial folds are the usual complaints when patients present requesting facial rejuvenation. With progressive deterioration of eyesight, the periorbital muscles are overused as the person squints, which results in corrugator wrinkling, transverse lines at the nasal root and dorsum caused by procerus contraction, transverse wrinkling of the forehead, and radiating rhytids in the crow’s-feet region. Other common complaints include hollowing of the temporal area resulting from gravity, decreased temporal

263

264

Part III 

Rejuvenation Surgery of the Face

muscle bulk caused by the loss of molar teeth, bone resorption, and contraction of the orbicularis oculi muscles, with inadvertent twitching. Other manifestations of aging include seborrheic keratosis, cylindroma, verrucae, nevi, hyperpigmented patches, spider angioma, telangiectasia, epidermal inclusion cysts, dermatofibroma, and xanthelasma.

Chara cter is tics of Fa ci al Aging in Asians Frontal Aging

Transverse forehead lines appear as a result of the thinning and loosening of the skin with hyperactive contraction of the frontalis muscles as they work to lift he eyebrows and open the upper eyelids. Downward displacement of the eyebrow is caused by the constant action of the orbicularis oculi, corrugators, and procerus muscles (Fig. 20-1). Temporal hollowing is another sign of aging, which is caused by a decrease in mastication power with the loss of the molar teeth. Th s may result in a loss of muscle bulk of the temporal and/or masseter muscles (Fig. 20-2). Periorbital aging is more pronounced in Asians than in whites. Because visual acuity decreases as people age, the orbicularis oculi muscle contracts to enhance vision. Thereafter, crow’s-feet are more noticeable. The common signs of aging are blepharochalasis, crow’s-feet, corrugator frown lines, transverse lines caused by procerus contraction, and eyelid bags. Patients most commonly complain of lower eyelid bags, significant tear trough deformities, and progressive enophthalmos with or without ptosis, which may occur differentially on each eye (Fig. 20-3).

Fig. 20-1  Frontal aging. Note the transverse forehead lines and the effects of the constant action of the orbicularis oculi, corrugator, and procerus muscles to improve eyesight.

Fig. 20-2  Temporal hollowing.

Chapter 20 

Multimodal Surgical Approaches to the Aging Face

Patients most frequently request correction of their eye bags. As a result of gravity, the intraorbital soft tissue progressively sags, with weakening of the orbital septum of the lower eyelid. Bulging of the lower eyelids with delineation of the arcus marginalis also contributes to asymmetry and a tired appearance of the eyes (Fig. 20-4). The tear trough deformity may be signifi ant, with lengthening of the orbicularis oculi muscles and loosening of the skin, which is exacerbated by the progressive resorption of maxillary and orbital bones. Ptosis may occur because the levator palpebrae muscle weakens as a result of fatty degeneration, along with an enlargement of the bony orbit as bone is resorbed and a decrease in fat volume of the upper eyelid caused by gravity and/or body weight change. Backward and downward displacement of the globe may cause ineffective dragging of the upper eyelid. With differential volume change, many elderly patients pre­ sent with varying degrees of enophthalmos and ptosis (Fig. 20-5).

Fig. 20-3  Periorbital aging.

Fig. 20-4  Pronounced tear trough arcus marginalis, and lower eyelid bags.

Fig. 20-5  Eyelid ptosis and enophthalmos.

265

266

Part III 

A

Rejuvenation Surgery of the Face

B

Fig. 20-6  A, This patient has premaxillary depression caused by bone resorption. B, This patient has a decrease in nasal height and length caused by bone resorption.

With aging, bone resorption may be noticeable at the orbit, premaxillary area, and upper and lower jaws (Fig. 20-6). The jawbones may be inwardly displaced, and pursing of the lips may lead to perioral radiating lines. There may also be retrusion of the chin. Aging of the lower face and lower neck usually presents with prominence of the nasolabial folds and jowls and laxity of the neck skin with platysmal bands.

Indications for Facial Rejuvenation Patients seeking facial rejuvenation usually have one or more of the following complaints: • Drooping of the eyebrows, resulting in overhanging of the upper eyelid skin • Hollowing of the eyelids with progressive enophthalmos and ptosis • Lower eyelid bags; with the progressive effects of gravity, lower eyelid bags will appear, with the resorption of the orbital bone and weakening of the orbital septum. • Progressive resorption of the facial skeleton, notably at the maxilla and chin • A prominent tear trough groove, laxity of the jowls, and flattening of the face • Retrusion of the chin, prominence of the nasolabial folds, and the appearance of platysmal bands • Corrugator wrinkling, procerus-affected transverse lines at the nasal dorsum, forehead wrinkling, and crow’s-feet; with progressive deterioration in eyesight, the periorbital muscles are overused, and these are the typical results. • Hollowing at the temporal area resulting from a loss of muscle bulk of the temporalis muscle, gravity, and bone resorption • Contraction of the orbicularis oculi muscle Patients seeking facial rejuvenation want to look younger and expect to have a refreshed, natural appearance from their procedure. Some patients want a major and remarkable change, whereas other patients desire only subtle changes. In Asian patients a combination of methods is usually used (Table 20-1). During the preoperative assessment, all possible treatment options should be discussed with the patient. Informed consent should be obtained before proceeding with the treatment plan. Postoperative satisfaction with the result varies, depending on the socioeconomic and psychological status of the patient. The surgeon must ensure that the patient has realistic expectations and discuss the anticipated result with the patient before the procedure, including what can and cannot be corrected through surgery and the possible complications associated with cosmetic surgery. The preoperative assessment is of paramount importance to avoid patient dissatisfaction and medical malpractice litigation.

Chapter 20 

267

Multimodal Surgical Approaches to the Aging Face

Table 20-1  All Selected Procedures for Facial Rejuvenation Frontal Aging

Periorbital Aging

Bone Resorption

Jowls

Botox injection

111

1111

—

—

Fat grafting

111

11

1111

1111

11

111

11111

1111

11111

11111

11111

11111

Face lift

111

1111

111

11111

Neck lift

—

—

1111

11111

Fillers Forehead lift

1, Occurrence; —, not performed.

Surgical Technique A face lift, or rhytidectomy, is a cosmetic surgery procedure that removes excess skin with or without tightening of subcutaneous tissues on the patient’s face and neck. The skin is then redraped, and the excess skin is removed. The most often requested procedure for facial rejuvenation in our practice is lower blepharoplasty, followed by upper blepharoplasty, and usually both. Th s is followed by a forehead lift which is sometimes combined with a face lift. Midline highlighting with augmentation of the nose and chin signifi antly enhances the rejuvenation effect. Midline highlighting consists of (1) lengthening the nose and the columella, (2) heightening the nasal tip, dorsum, and nasion, (3) lifting up the alar base and the medial aspect of the maxilla, and (4) adding length and projection to the receded chin. Botox injections are benefic al to eliminate residual wrinkles. Various types of lasers or photorejuvenation devices, such as Thermage, radiofrequency with a diode laser, and Fraxel fractional laser, are benefic al ways to tighten the skin and clarify the unsightly skin surface and texture. In addition, soft issue fillers, such as autologous fat grafts, Perlane, Restylane SubQ, Juvéderm, and Juvéderm Voluma, are often used for facial rejuvenation with considerable short-term and long-term benefits. For rejuvenation of the upper face, lower blepharoplasty is the most common procedure, because it can be performed with local anesthesia. If upper blepharoplasty is done at the same time, the patient will have optimal results. A local anesthetic with 2% lidocaine and 1/100,000 epinephrine is used for upper and lower blepharoplasty. An infraorbital nerve block is also employed for lower blepharoplasty to facilitate the midface lift During surgery, transblepharoplasty myotomy of the corrugator and procerus muscles is usually carried out through the medial aspect of the upper blepharoplasty incisions on the right side. Sometimes patients may want an isolated temporal lift. A orehead lift sing an endoscopic minimal access approach is currently popular. However, this technique cannot effectively correct the problems of periorbital aging. A thread lift ay only offer a superfic al result, with the complications of scarring, uneven skin, extrusion, and pain. Therefore it is not the method of choice.

For ehead Lift and Blep har opl a st y

Temporal elliptical excision of the skin down to the level above the deep temporal fascia is extensive; the length and amount of the excision depend on the severity of forehead skin redundancy and central convergence. The patient is prepared on the operating table, and local anesthesia and sedation are induced with 1% lidocaine with 1:100,000 epinephrine.

K23345_Pu_c20 21_Multi Surg Aging Face_r4_cl_150323.indd 267

4/2/2015 5:13:31 PM

268

Part III 

Rejuvenation Surgery of the Face

The forehead lift begins along the deep temporal fascia down to the entire forehead, medially to the nasal root and nasal dorsum, and to the nasal tip with the use of a dissector. The corrugators are partially severed; the procerus is transected so the nose can be lifted up and stretched, thereby causing the severity of the frown lines to disappear or decrease. Usually the nasal root can be augmented with soft tissue from the temporal subcutaneous tissue and fascia, which might otherwise be discarded. Along the deep temporal fascia, the surgeon reaches the lateral orbital wall and superior orbital rim; the periosteum can be opened to easily lift up the eyebrow and tighten the wrinkled skin of the crow’s-feet. The dissection can then proceed downward to the zygomatic arch and enter the premaxillary area, even to the upper lip. Thus the upper face and midface can be lifted in 10 minutes. One vacuum drain is left in place, and the wound is closed with 2-0 strong sutures; the proximal superfic al temporal fascia is brought up to the distal temporal fascia and muscle, ensuring that the lift is tight enough. Similar procedures are done on both sides. Scoring is made at the midportion of the forehead. The skin is closed with wide Oppose skin staples, which cause the least destruction to hair follicles and hair growth. The entire procedure can be completed within 1 hour. The vacuum drain is removed 2 days later. Patients were happy with their result after subsidence of the swelling and ecchymosis. Upper blepharoplasty is performed by removing redundant skin, performing a partial myectomy of the orbicularis oculi muscle, correcting the ptosis and enophthalmos with fat or cartilage grafting at the orbital fl or, and tightening of the orbital septum of the lower eyelid. Lower blepharoplasty is performed through a subciliary incision with a minimal transverse lateral extension. Dissection proceeds down to the inferior orbital rim. Strengthening of the orbital septum is performed only to remove the overfl wing fat. The excess fat can be used to fill the tear trough and premaxillary depression through the subperiosteal pocket. A strip myectomy along with the overlying skin is performed with the patient’s mouth fully open and the eyes looking upward. After this, the lower eyelid skin should lie comfortably at the subciliary incision line. Tightening of the skin-muscle flap of the lower eyelid to the lateral orbital wall with lateral canthopexy should be performed after the excess skin-muscle complex is removed. A midface lift d wn to the nasal ala and upper lip can be achieved through a subciliary incision of the lower eyelid. A subperiosteal midface lift is always accessible through lower or upper blepharoplasty, temporal lift, or forehead lift incisions. A lower face and neck lift can be performed with elevation and tightening of the superfic al muscular aponeurotic system and plication of the parotid fascia. Lipoplasty with a small-caliber liposuction cannula can be performed on the submandibular and submental jowls and supranasolabial fold. The sucked-out fat can be used to fill some of the unwanted depressions. A common complaint is platysmal bands on the neck, which can easily be divided through small, concealed neck incisions. Sliding genioplasty or chin augmentation can be performed to enhance a retruding jawline. Secured anchorage in the deep temporal fascia, helical crus, tragal groove, mastoid fascia, and periosteum should also be done.

Aur icul ar Bout onnièr e Fa ce Lift

For excessive sagging of the lower face, the auricular boutonnière face lift provides the most effective lift with the least operative time, especially in patients who had previous foreign-body injection at the midface and lower face and secondary face lifts (Fig. 20-7, A).

Chapter 20 

269

Multimodal Surgical Approaches to the Aging Face

The incision is made circumferentially around the ear; at the preauricular area, the incision goes behind the tragus and along the crease down to the ear lobule–cheek refl ction (Fig. 20-7, B). The posterior incision is 1 cm higher above the crease. The dissection is made above the parotid fascia; tension is applied at the edge of the skin toward the surgeon to avoid injury to the facial nerve branches. If there is some palpable foreign body above the nasolabial fold, a small liposuction cannula can be used to evacuate some of the foreign body and smooth the lump. A 4 to 5 cm incision is then made parallel to the anterior auricular line, 2 to 3 cm anterior and 1 to 2 cm inferior to the helical crus (Fig. 20-7, C). Afterward, the buttonhole will be hinged onto the ear. The buttonhole method will put support at the helical crus. Therefore it can eliminate the drawbacks of the gravity and dragging effect of a traditional face lift, with which recurrence of loosening and pixie-ear lobule formation are common problems. The tension is greatest at the helical crus and/or the temporal fascia; the preauricular skin flap is thinned so that it can be sutured inside the tragus. Suturing can be done at the upper and lower ends of the tragus, with fix tion into the cartilage so that it will not displace anteriorly with movement and pivoting (Fig. 20-7, D). A

B

First incision: Anterior Second incision: Posterior

Boutonnière incision pulled over tragus

C

D Pivot point

Area of posterior auricular redundant skin removed

Third incision: parallel to ear

Flap elevated and subcutaneous fat thinned, creating sling to hang behind ear

Sling fills defect posterior to ear

Preauricular skin advanced to first incision

Fig. 20-7  Auricular boutonnière face lift A, Full facial diagram of the boutonnière incision. B, Initial incisions. C, Th

surgeon should remove any redundant postauricular skin and fat over the skin flap before proceeding. D, Movement and pivoting of the ear.

270

Part III 

Rejuvenation Surgery of the Face

Th s procedure takes much less operative time than a traditional face lift, nd the ear lobule will not assume a pixie-ear appearance. The postauricular wound can be sutured continuously. Some excess skin at the postauricular area can be excised. The neck skin can also be tightened at the postauricular fascia and periosteum.

Chin Augment atio n

In profile, an ideal chin projects attractively and continuously from a beautiful jawline. In patients with severe chin retrusion, a sliding genioplasty with anterior repositioning can add to chin length. For a less severe case, a chin implant can be benefic al. For skin laxity of the jowls, hyaluronic acid injection or fat injection can be advantageous.

Ancill ar y Pr o ced ur es

The following ancillary procedures are complementary ways to smooth some imperfections: 1. Soft tissue augmentation is done with injection of fat, collagen, or hyaluronic acid. 2. Laser treatment can eliminate seborrheic keratosis, nevi, pigmentation, and xanthelasma. 3. Intense pulsed light, radiofrequency, and Fraxel fractional laser treatments can tighten skin of the lower eyelids, perioral area, cheeks, and jowls. 4. A chemical peel can smooth an uneven skin texture. 5. A botulinum toxin injection can correct the asymmetry and wrinkles that persist even after a surgical procedure. 6. Augmentation of the nose and/or chin may highlight the midline by stretching the neighboring skin and enhancing a rejuvenated appearance.

Results To achieve a satisfactory postoperative result, the patient and plastic surgeon must have a mutual understanding regarding what can and cannot be achieved through the planned surgery. Even if there is some residual imperfection, the aforementioned ancillary procedures can be used to minimize the flaw. Adherence to the basic principles of plastic surgery will produce consistent results. The revision rate is below 1%. Patient satisfaction can almost always be achieved.

K23345_Pu_c20 21_Multi Surg Aging Face_r4_cl_150323.indd 270

4/2/2015 5:13:32 PM

Chapter 20 

Multimodal Surgical Approaches to the Aging Face

271

Fig. 20-8 To achieve a refreshed and younger looking face, this 56-year-old woman had upper and lower blepharoplasty and augmentation of the nose to lengthen the nose and columella and to heighten the nasal tip, nasion, and dorsum. Postoperative images were taken 6 months after the procedure.

Combined Procedures When procedures are combined, the following questions must be answered to determine the order of the procedures: • What are the patient’s expectations from surgery? • What method of anesthesia induction does the patient prefer? • How much can the patient afford? • Does the patient want a major or minor change in appearance? • What is the patient’s psychological state?

K23345_Pu_c20 21_Multi Surg Aging Face_r4_cl_150323.indd 271

4/2/2015 5:13:33 PM

272

Part III 

Rejuvenation Surgery of the Face

If the patient wants a major change in appearance and can afford it, a multiple-procedure operation is preferable to meet his or her expectations. If the patient has hypertension and anxiety, a minor short procedure is recommended. It is advisable to perform a more comprehensive correction in a single operation, because the satisfaction rate will be much higher. If a prosthesis is to be placed during a multiple-procedure operation, the prosthesis procedure should be done fi st (for example, nasal augmentation or chin augmentation with an implant) to avoid infection. If the patient does not have a signifi ant medical problem, a 2- to 3-hour operation under general anesthesia is usually well tolerated. The combination of procedures include blepharoplasty (upper or lower or both), rhinoplasty, a forehead lift, a midface lift, a neck lift, and genioplasty. A combination of procedures will always achieve a more natural and favorable result.

Management of Complications No operation is without the potential for complications. In eyelid surgery, possible complications include asymmetry, signifi ant scarring, enophthalmos, and ptosis. Ectropion is an infrequent complication of lower eyelid surgery. Asymmetry of the eyebrows may occasionally occur. Facial nerve injury at the frontal, zygomatic, or marginal mandibular branches sometimes occurs. Formation of the pixie-ear deformity is another unfavorable result of face lift surgery. Knowledge of the exact anatomy of the related structures is the only way to avoid these complications. If facial asymmetry occurs from any of these causes, the use of a botulinum toxin injection can easily help balance the face.

Discussion In Asian patients, the major aesthetic concern is the eyes, especially the lower eyelids. Male patients are mostly concerned with lower eyelid bags, whereas women almost always complain about sagging upper eyelids with coverage of the supratarsal folds and a sunken eye appearance. Most patients usually have laxity of the forehead skin with rhytids of the transverse forehead, corrugator, and transverse procerus. In Asians, the skin and dermis are relatively thick, and thus laxity of the lower face and neck skin will usually not appear before the age of 70 years. Asian patients tend to prefer local anesthesia. Upper blepharoplasty is the most frequently requested procedure for women, and lower blepharoplasty is the most frequently requested procedure for men. If the patient needs more dramatic rejuvenation, then a minimally invasive forehead lift is usually recommended, which can be performed with a nerve block and local anesthesia with sedation. A forehead lift with a lower blepharoplasty can reach the premaxillary area to lift up the midface with satisfactory results. In patients with a depression at the alar base and upper part of the nasolabial folds, soft tissue transfer or fat grafting may enhance the aesthetic result. For a thin patient with signifi ant platysmal bands, a miniface lift and neck lift with division of the platysmal bands can achieve a satisfactory result. For patients with a retruding chin, a sliding genioplasty or a chin implant, either Medpor or silicone, placed subperiosteally can achieve a pleasing aesthetic result. For patients with a short and depressed nose, a forehead lift can lengthen the nose. Augmentation with soft tissue from the deepithelialized scalp or temporal fascia is a benefic al correction. For a more depressed nose, augmentation with an implant can highlight the midline and achieve satisfactory results.

K23345_Pu_c20 21_Multi Surg Aging Face_r4_cl_150323.indd 272

4/2/2015 5:13:33 PM

Chapter 20 

Multimodal Surgical Approaches to the Aging Face

273

Pearls for Success • The surgeon and patient must have a mutual understanding of what can and cannot be achieved through a facial rejuvenation procedure. The surgeon will then select the most suitable method for that specific patient. • The surgeon must be aware of any asymmetry of the patient’s face, including enophthalmos and ptosis. • The inherent surgical problems and the most effective means to resolve these should be explained to the patient. • The importance of midline highlighting should be emphasized to obtain a more desirable result. • Soft tissue augmentation with either fat grafting or Restylane injection at the perioral, lip, and alar base is an advantageous way to further improve skin texture and soften and smooth the jawline.

Refer ences 1. Skoog T. Plastic Surgery: New Methods. Philadelphia: WB Saunders, 1974. 2. Tessier P. [Subperiosteal face-lift] Ann Chir Plast Esthet 34:193-197, 1989. 3. Hamra ST. Composite rhytidectomy. Plast Reconstr Surg 90:1-13,1992. 4. Mendelson BC. Correction of the nasolabial fold: extended SMAS dissection with periosteal fix tion. Plast Reconstr Surg 89:822-833, 1992. 5. Owsley JQ. Lifting the malar fat pad for correction of prominent nasolabial folds. Plast Reconstr Surg 91:463-474, 1993. 6. Fuente del Campo A. Subperiosteal facelift: open and endoscopic approach. Aesthetic Plast Surg 19:149-160, 1995. 7. Ramirez OM, Pozner JN. Subperiosteal minimally invasive laser endoscopic rhytidectomy: the SMILE facelift Aesthetic Plast Surg 20:463-470, 1996. 8. Baker DC. Lateral SMASectomy. Plast Reconstr Surg 100:509-513, 1997. 9. Owsley JQ. Face lift. Plast Reconstr Surg 100:514-519, 1997. 10. de la Fuente A, Santamaria AB. Endoscopic subcutaneous and SMAS facelift without preauricular scars. Aesthetic Plast Surg 23:119-124, 1999. 11. Mitz V, Peyronie M. The superficial musculo-aponeurotic system (SMAS) in the parotid and cheek area. Plast Reconstr Surg 58:80-88, 1974. 12. Baker DC. Deep dissection rhytidectomy: a plea for caution. Plast Reconstr Surg 93:1498-1499, 1994. 13. Hamra ST. The deep-plane rhytidectomy. Plast Reconstr Surg 86:53-61, 1990. 14. Ivy EJ, Lorenc ZP, Aston SJ. Is there a difference? A prospective study comparing lateral and standard SMAS face lifts with extended SMAS and composite rhytidectomies. Plast Reconstr Surg 98:1135-1143, 1996. 15. Sullivan PK, Hoy EA, Mehan V, et al. An anatomical evaluation and surgical approach to the perioral mound in facial rejuvenation. Plast Reconstr Surg 126:1333-1340, 2010. 16. Bentkover S. The biology of facial fillers. Facial Plast Surg 25:73-85, 2009. 17. el-Domyati M, el-Ammawi TS, Medhat W, et al. Radiofrequency facial rejuvenation: evidence-based effect. J Am Acad Dermatol 64:524-535, 2011. 18. Little JW. Th ee-dimensional rejuvenation of the midface: volumetric resculpture by malar imbrication. Plast Reconstr Surg 105:267-285; discussion 286-289, 2000. 19. Baker DC. Minimal incision rhytidectomy (short scar face lift) with lateral SMASectomy: evolution and application. Aesthet Surg J 21:14-26, 2001. 20. Kernt B, Kernt M, von Finckenstein J. Submandibular neck lifting with platysma resection. Aesthetic Plast Surg 35:61-65, 2011.

K23345_Pu_c20 21_Multi Surg Aging Face_r4_cl_150323.indd 273

4/2/2015 5:13:33 PM

K23345_Pu_c20 21_Multi Surg Aging Face_r4_cl_150323.indd 274

4/2/2015 5:13:33 PM

21 Endoscopic Approach to Facial Rejuvenation

F

Jung Wu

or  more than a decade, there has been a tendency in all surgical fi lds to devise ways to minimize operative scars. Performing surgery with smaller incisions is achievable with the use of videoendoscopy. Videoendoscopy yields advantages in facial rejuvenation procedures of the frontal, malar, zygomatic, midface, and cervical areas.1-5 It provides excellent visualization of the operative field, allowing delicate dissection and suturing and enabling accurate hemostasis with preservation of the nerves, all within a closed technique. An increasing number of patients prefer minimally invasive surgical techniques, which signifi antly reduce postoperative pain, considerably shorten postoperative convalescence, and even decrease the overall cost. Therefore endoscopic surgeries are increasing in popularity. In this chapter, I introduce my preferred techniques for endoscopic brow lift, midface lift, and lower face and neck lift. The indications, important considerations, and management for each procedure are also discussed.

Anatomy Fa sci a and Land mar ks in the Temporal Ar ea

Accurate identifi ation of the various components of the forehead fascia and the spatial relationships between them is extremely important to make accurate dissection at the right plane and to avoid nerve injury, especially when one is performing dissection under the endoscope through small and limited incisions. However, fascial terminology is very confusing, with various names being used for the same structures. To avoid confusion, I will use the terminology used by Ramirez6,7 (Figs. 21-1and 21-2).

275

276

Part III 

Rejuvenation Surgery of the Face

Skin Subcutaneous fat (dense connective tissue) Epicranial aponeurosis or galea Periosteum Areolar (subgaleal) fascia (or innominate fascia) fuses with superficial temporal fat pad

Temporal fascia proper Deep temporal fascia (deep layer of deep temporal fascia)

Superficial temporal fascia (temporoparietal fascia, continuous with galea) Intermediate temporal fascia (superficial layer of deep temporal fascia)

Intermediate temporal fat pad

Superficial temporal fat pad

Deep fat pad (buccal fat pad)

Frontal branch of facial nerve

Zygomatic arch Periosteum

Superficial musculoaponeurotic system

Temporalis muscle Masseter muscle

Parotid fascia Parotid gland

Fig. 21-1  The layers of the temporal region.

Fascia in the temporal area consists of the superficial temporal fascia (temporoparietal fascia, previously called the temporoparietalis), the areolar (subgaleal) fascia (or innominate fascia), and the temporal fascia proper, which splits into two lamina—the intermediate temporal fascia, which is the superfic al layer of the deep temporal fascia, and the deep temporal fascia, which is the deep layer of the deep temporal fascia. Th inferior temporal septum is a loose band of attachments between the superfic al and the deep temporal fascia, close to or above the zygomatic arch, which has also been called the orbicularis-temporal ligament by Isse8 (Fig. 21-3). The zygomatic arch is an important landmark; dissection should be performed with care below this line, because vital structures such as the frontal branch of the facial nerve, which runs through the superfic al temporal fat pad, will be traveling on the roof of and parallel to the septum. In addition, the neurovascular bundles, such as the sentinel vein, temporal veins, and the zygomaticotemporal nerves, are inferior to the inferior temporal septum and usually close to and just above the upper border of the zygomatic arch.

Chapter 21 

277

Endoscopic Approach to Facial Rejuvenation

Temporal fascia proper

Frontalis

Temporalis muscle Frontal branch of seventh nerve

Deep temporal fascia

Plane of section

Intermediate temporal fascia

Innominate (subgaleal) fascia Intermediate fat pad Superficial temporal fascia

Deep temporal fat pad

Superficial temporal fat pad

Zygomatic arch Bichat’s fat pad

Frontal branch of seventh nerve Superficial musculoaponeurotic system

Masseter muscle Parotid gland

Fig. 21-2  The layers of the temporal region in relation to the masseter and the parotid gland.

Supraorbital ligamentous adhesion

Temporal ligamentous adhesion

Lateral brow thickening of periorbital septum

Temporalis muscle

Sentinel vein

Inferior temporal septum

Temporal branches of facial nerve Lateral orbital thickening of periorbital septum

Zygomaticotemporal nerve Periorbital septum

Fig. 21-3  The anatomy of the inferior temporal septum.

K23345_Pu_c21_Endo Facial Rejuv_r4_cl_0275-0316.indd 277

4/2/2015 5:17:55 PM

278

Part III 

Rejuvenation Surgery of the Face

Fig. 21-4  Retrograde dissection method for the zygomatic arch.

It is usually recommended that the intermediate temporal fascia be pierced approximately 1.0 to 1.5 cm above the zygomatic arch to avoid injury to the frontal branch.9 However, many patients have thick tissue around the arch, and piercing the intermediate fascia is not only dangerous but also a distinct possibility, especially when it is difficult to locate the upper margin of the zygomatic arch underneath it. Therefore I developed a safe retrograde dissection method for the zygomatic arch in which the bony part of the malar body is identifi d fi st, because it has the thinnest fascial and periosteal covering on it, and then the malar body can be easily felt and dissected by the elevators (Fig. 21-4). After the bony portion is identifi d, backward dissection and exploration of the malar and arch junction can then be performed easily. Continuous backward dissection can be done, and even the entire arch can be easily degloved subperiosteally, with the frontal branch safely preserved.

Impor t ant Ret aining Ligament s and Adhes io ns of the Mid f a ce

The retaining ligaments of the midface usually originate from the bone and insert into the overlying skin. Stuzin et al10 described two types of retaining ligaments. The first are the true osteocutaneous ligaments, which run from the periosteum to the dermis, such as the mandibular ligaments and the zygomatic ligaments. The second type is formed by the ligaments between the overlying dermis by fibrous septa and the underlying structures, such as the parotid and masseter, by coalescence of the superfic al facial fascia and the deep facial fascia, which are fi mly adherent to each other, similar to the masseteric cutaneous and parotid cutaneous ligaments (Fig. 21-5). These fi e structures are important in the maintenance of the facial soft tissue in its normal position. However, these ligaments relax with age and eventually become redundant; together with the loss of skin elasticity and volume loss of the soft tissue, especially the fat pads, these ligaments characterize an aging face. Successful elevation and rejuvenation of the midface depend on adequate release of these adhesions and retaining ligaments, especially around the periorbital, lateral brow, and whole cheek areas.

Ch a ra cter is tics of Mid f a ce Aging

An aging midface typically has flattening of the malar area, with accentuation of the nasolabial fold. These characteristics have multiple causes, mainly the loss of cheek projection or ogee curves as a result of ptosis

Chapter 21 

279

Endoscopic Approach to Facial Rejuvenation

and descent of the malar fat pad, and descent of the lid-cheek area with atrophy of soft tissues and inferior medial sliding of this tissue. Also, there is laxity of the skin, soft tissue, ligaments, and muscles, such as the zygomaticus major and minor and the levator of the upper lip, causing ptosis of the mouth corners and downward sliding of the arcus marginalis of the lower eyelid as a result of loosening and weakening of the structure that divides the orbital region and the midface (Fig. 21-6).

Subgaleal plane Superior temporal adhesion

Galeal plane

Temporal ligamentous adhesion Periorbital septum

Inferior temporal adhesion

Zygomatic ligament Masseteric ligament

Superficial musculoaponeurotic system (SMAS) plane

Sub-SMAS plane

Fig. 21-5  The retaining ligaments of the midface.

Fig. 21-6  Laxity of the orbicularis retaining ligament and the zygomaticocutaneous ligament contribute to the appearance of an aging face. Orbicularis retaining ligament Zygomaticocutaneous ligament

280

Part III 

Rejuvenation Surgery of the Face

A

B

C

D

Fig. 21-7  Th s woman’s midface has normal, youthful ogee curves.

Another possible change is reabsorption of the maxilla, which further decreases the projection of the cheek. I think that the rejuvenation of the midface should be an “en bloc” elevation of all of the descended tissues, including the tightening of not only the skin and shallow layers, but also the skin, subcutaneous tissue, retaining ligaments, soft and fatty tissues, fascia, and muscles except the bone. In addition to lifting of the descended tissues, restoration of the volume and projection of the cheek are also very important to restore the normal ogee curves that are characteristic of a young face (Fig. 21-7).

Ner ves

Motor Nerves Endoscopic face-lift procedures are primarily performed in the deepest planes of the face and usually are signifi antly below the plane of the facial nerve and its branches; therefore injuries to these nerves, except those in the frontal branches, are extremely rare. The temporal branch, which emerges from the upper border of the parotid gland beneath the superfic al musculoaponeurotic system (SMAS), is usually parallel and adjacent to the inferior temporal septum; it lies on the periosteum and crosses the middle third of the zygomatic arch, usually at the midpoint between the tragus and the lateral canthus (red line in Fig. 21-8). The temporal branch then enters the temporal fossa as multiple (usually two to four) fi e branches. After crossing the zygomatic arch, it runs through the substance of the superfic al temporal fat pad, pointing to the lateral eyebrow usually 1.5 cm lateral to the tail of the eyebrow (see Fig. 21-8). Finally, the temporal

Chapter 21 

281

Endoscopic Approach to Facial Rejuvenation

Temporal branch

Fig. 21-8  Nerves of the frontal branch.

Zygomatic branch

Lower buccal branch

Facial nerve

Marginal mandibular branch

Fig. 21-9  The marginal mandibular branch of the facial nerve.

Marginal mandibular branch

branch pierces the superfic al temporal fascia to innervate the deep surface of the frontalis muscles, whereas some branches go farther to innervate the orbicularis oculi and glabellar musculature. The marginal mandibular branch of the facial nerve is well protected by the parotid gland along its medial portion. After emerging from the parotid gland, it is protected by the SMAS-platysma layer. At this point, the marginal mandibular branch usually runs at or below the mandibular margin, and may extend 1 to 2 cm below the margin before crossing the facial blood vessels. When it crosses the facial blood vessels, it runs upward, usually to the point just above the mandibular margin (Fig. 21-9). Th s branch is deep to the platysma throughout its course, but it could be at risk where the platysma goes thin. To prevent nerve injury, the dissection should be performed above the platysma laterally and deep to the platysma centrally. Injuries to the buccal and zygomatic branches are rare; there are multiple communications and interconnections between the buccal and zygomatic branches, so an injury to one or more branches may not cause a noticeable defic t.

282

Part III 

Rejuvenation Surgery of the Face

Sensory Nerves The skin of the scalp and face are supplied by the sensory fibers of the trigeminal nerve (Fig. 21-10), with its fi st division, and the ophthalmic nerve, whose largest branch is the frontal nerve that enters the orbit through the superior orbital fissure and then divides into the supraorbital, supratrochlear, infratrochlear, lacrimal, and external nasal branches. The supraorbital nerve divides into a medial (superior) branch that innervates the central forehead up to 2 cm beyond the hairline, and the lateral (deep) branch, the major sensory nerve of the scalp, which innervates the scalp back to the parietal and lambdoidal suture line.9,11 The supraorbital nerve runs consistently in a 1 cm wide band between 5 and 15 mm medial to the palpable temporal ridge (Fig. 21-11).The supratrochlear nerve innervates the medial forehead, whereas the in-

Lesser occipital nerve (cervical ventral ramus 2)

Ophthalmic nerve

Greater occipital nerve (cervical dorsal rami 2 and 3)

Maxillary nerve Greater auricular nerve (cervical ventral rami 2 and 3) Mandibular nerve Cervical dorsal rami 3, 4, 5 Supraclavicular nerves

Transverse cutaneous nerve of neck (cervical ventral rami 2 and 3)

Fig. 21-10  The skin of the face and scalp contain the sensory fibers of the trigeminal nerve.

Expected innervation of deep branch Deep branch of supraorbital nerve Superficial branches of supraorbital nerve

Fig. 21-11  Location of the supraorbital nerve.

Chapter 21 

Endoscopic Approach to Facial Rejuvenation

fratrochlear nerve supplies the nasal dorsum and medial orbital rim. The skin of the midface is innervated by the maxillary division of the trigeminal nerve through the zygomaticotemporal, zygomaticofacial, and infraorbital branches (see Fig. 21-10). The zygomaticotemporal nerve exits the lateral orbital rim through a foramen into the temporal fossa and pierces the deep temporal fascia about 2 cm above the zygomatic arch near the sentinel vein to innervate the skin of the temple region.

Instrumentation It is important to use the right endoscopic system, the right instruments, and the right dissectors in the right place. Dissection with inappropriate instruments, the use of elevators with inadequate curvature, or dissection around the neurovascular bundle areas with sharp bone strippers always results in active bleeding, inadequate dissection, and overmanipulation of the soft tissue, or even nerve injury. If the dissection is carried down to the midface by passing through the zygomatic arch without an intraoral incision, dissectors with appropriate curves must be used. If intraoral incisions must be made, ordinary periosteal dissectors can be used for subperiosteal degloving dissection of the midface.

End osc opic Unit

The basic endoscopic unit consists of a camera, a xenon or LED light source, and a video monitor with an optional DVD or a digital recorder and a printer. Usually a rigid 4 or 5 mm arthroscope with a 30-degree down angle is preferred, introduced with a sleeve used for irrigation and protection of the shaft f the scope. A sleeve with a blunt, slightly elevated tip allows safe displacement or lifting of the tissue being dissected, whereas an angulated tip may partially block the operative fi ld. Two monitors are recommended: one to the right of the patient and one to the left, o the surgeon and the assistant each have their own monitor, allowing them to closely watch the surgery simultaneously in opposite directions (Fig. 21-12). If the endoscope is introduced into the midface cavity through an intraoral incision, a sleeve with an angulated tip is recommended, because the soft issue in the midface is much softer than the fascial tissue in the forehead area, and this angulated tip can prevent the soft tissue from falling down in front of the endoscope, which may block the operative view for both the surgeon and the assistant.

Fig. 21-12  Two monitors are recommended for surgery to allow the surgeon and assistant to watch the surgery simultaneously in opposite directions. Also, it is easier for the surgeon to work in all directions.

283

284

Part III 

Rejuvenation Surgery of the Face

End osc opic Instr ument s Elevators

Many of the periosteal elevators are made with a straight shaft nd blunt tips. Some periosteal elevators have a half curve or full curve; however, most of the curves are not task specific r ergonomic enough to fit with the skull bone. It is not wise to use a straight elevator for dissection on the human skull bone, which has so many curves that one can barely fi d a straight line or a flat platform on it. If a surgeon tries to accomplish the whole dissection procedure with only a few dissectors with limited curves, he or she may encounter some unreachable dead angles, regardless of whether the dissection is made horizontally or vertically. Therefore I designed a brand new set of six patented elevators, each of which has its own task-specific design (Fig. 21-13). To perform an endoscopic midface lift using only a temporal incision, I also designed task-specific dissectors that can carry the dissection from the temporal area down to the midface area without having to make an intraoral incision. Because the dissection in a lower face lift remains subcutaneous and superfic al to the SMAS, sharp dissection is needed; thus I recommend using standard face-lift scissors to aid the dissection. In addition to the ordinary surgical instruments, some quite delicate devices, such as angulated endoscopic scissors, punches, and graspers (Fig. 21-14), are needed to obtain a tangential approach rather than a straight approach. A malleable suction coagulator is recommended, so that bleeding vessels can be stopped at any

Fig. 21-13  Six patented elevators, each of which is designed for a specific task.

A

B

Fig. 21-14  A, Angulated endoscopic scissors and punches. B, Angulated endoscopic graspers are also needed to obtain the desired tangential approach.

Chapter 21 

Endoscopic Approach to Facial Rejuvenation

angle or curve. To dissect the supratrochlear and supraorbital nerves, an angulated nerve retractor is sometimes necessary, especially when coagulation around them is needed. Plastic port protectors are recommended to allow repeated insertion of the endoscope and instruments and to prevent hair follicle loss as a result of vigorous manipulation of the instruments around the skin edges of the incision.

Anesthesia The key ways to achieve a successful face lift are through adequate dissection and rigid, tension-free fix tion. A general anesthetic is usually recommended, because it can provide muscle relaxation so that the fixation of the descended tissues can be lifted up without any countertraction. Regardless of whether a local or general anesthetic is used, a local anesthetic with lidocaine and epinephrine is administered to decrease the depth required for the general anesthetic and to decrease oozing during the operation. Along the supraorbital rim and upper border of the zygomatic arch areas, 1% lidocaine with 1:50,000 epinephrine solution is usually used. For the scalp, forehead, and midface areas, 1% lidocaine with 1:200,000 epinephrine solution is used, and for the lower face and neck areas, 1% lidocaine with 1:300,000 epinephrine solution is used.

ENDOSCOPIC BROW LIFT Indications The indications for an endoscopic brow lift are essentially the same as those for the open approach. Endoscopic brow lift is an alternative choice for a patient with brow ptosis who has hooding of the upper eyelids, asymmetrical brow ptosis, deep forehead creases, and deep frown lines caused by hyperactive frontalis and corrugator muscles. However, if the open method is not suitable for a particular patient, endoscopic brow lift may be the appropriate choice. Because this is an alternative procedure, it is not indicated for all patients. Endoscopic brow lift has limitations for patients with signifi ant skin excess who may not be fully satisfi d with the result unless it is performed with other associated procedures.

Operative Technique The endoscopic brow lift uses many of the principles of the open subperiosteal approach.12-14 Before performing any clinical application of endoscopic techniques, the surgeon must be very familiar with the traditional techniques, the anatomy (especially the different planes of the fascia), the spatial relationship between the fascial planes, and the location of the nerves. The surgeon should create a bloodless view under the endoscope by exploring the blood vessels with blunt dissectors and ensuring coagulation before the vessels bleed. Once bleeding occurs, the scope will be fl oded with blood, and the procedure will become very difficult.

Mar kings

First, the surgeon marks the midline at the root of the nose, the approximate location of the supratrochlear nerve according to the in vivo study by Lorenc et al,15 which is an average of 1.7 cm away from each side of the midline along the supraorbital rim. The supraorbital nerve should be marked at an average of 2.7 cm away from each side of the midline along the supraorbital rim, according to Lorenc et al15; this location always has a deep branch pointing toward the temporal line of fusion. Then the margins of the lateral orbit, the zygoma, and the upper and lower margins of the zygomatic arch on both sides should be outlined. The frontal branch of the facial nerve is marked from the lower border of the earlobe, the point from which the

285

286

Part III 

Rejuvenation Surgery of the Face

Fig. 21-15  Markings for an endoscopic brow lift

0.5 cm 3 cm 1.5-2 cm

Fig. 21-16  Paramedian incisions and temporal incisions.

main trunk of the facial nerve emerges from the tympanomastoid fissure, and then it passes along the line midway between the lateral canthus and the tragus of the ear. Finally, the frontal branch extends toward the temporal crest, usually at a point approximately 1.5 cm lateral to the tail of the eyebrow (Fig. 21-15).

Incis io ns

The number of incisions varies; three to six incisions are recommended. However, I think four are sufficient (two paramedian incisions and two temporal incisions), because three incisions may cause inadequate or uneven traction of both of the eyebrows during the lifting, especially for a patient with asymmetrical eyebrows. The function of the central slit incision that has been typically described can be easily replaced by the paramedian incisions (Fig. 21-16), which are about 3 cm away from the central line and about 3 to 5 mm away from the hairline. The temporal incisions are marked below a line running tangent from the ala to the lateral canthus, which is less than 2 cm long, parallel to the temporal hairline, and approximately 1.5 to 2 cm away from the temporal hairline. If a temporal incision is made above this tangent line, the traction force down to the midface will be blocked by the lateral canthal area (see Fig. 21-16). With each incision approximately 1.5 to 2 cm long, there is suffici t width to introduce the scope and manipulate the instruments.

Chapter 21 

Endoscopic Approach to Facial Rejuvenation

Pr o ced ur e

1 . Right temporal incision: The right temporal incision is carried down to the top of the temporal fascia proper, which is rigid and whitish in appearance, after circumferential blunt dissection with a scissors after a port protector is introduced. The endoscope and a blunt dissector are then inserted into the same incision. The dissection should always be kept on the top of the temporal fascia proper to protect the frontal branch (Fig. 21-17). To create a bigger and optimally effective working space, the surgeon can dissect toward the temporal crest line fi st. When approaching the temporal crest line, the temporal fascia proper will be visible where it turns into the periosteum, which can be easily cut by a sharp bonestripping dissector. The subperiosteal dissection should remain at least 2 cm medial to the temporal crest line. The fascia should be cut and the periosteum undermined in the direction of the orbit along the temporal crest line until the intersection between the supraorbital rim and temporal crest line is reached. The temporal dissection continues until the temporal veins (the larger one usually being the sentinel vein) and the zygomaticotemporal nerves are identifi d along the lateral orbital rim and zygomatic arch. The dissection is carried down along the lateral orbital rim until the platform of the malar body is found, and then a retrograde dissection is performed toward the zygomatic arch. The frontal branch will be safe if the surgeon uses an angulated dissector that fits the plane of the arch and makes a “plane dissection” instead of a sharp, scratching dissection. 2 . Left temporal incision: The same procedures performed for the right temporal incision are performed on the left side. 3 . Right paramedian incision: Before the right paramedian incision is made, the periosteum must be undermined to avoid separation of the periosteum from the skin. Then subperiosteal dissection is performed up to the vertex. The dissection connects laterally with the temporal space. After a port protector is inserted, the endoscope is introduced. The dissection is carried down to the supraorbital rim area and stopped when the supratrochlear and supraorbital nerves appear. The surgeon incises the periosteum along the supraorbital rim, from temporal to temporal, to elevate the descended forehead and eyebrow, making certain that the eyebrow area is included at the upper part of the cut periosteum. The incision begins from the right side at the intersection point between the supraorbital rim and the temporal crest line with insertion of a curved endoscopic scissors through the right temporal incision. Cutting along the rim proceeds until the midline is crossed. Then the ends that were cut should be further separated with a curved dissector. At this point, the corrugator and procerus muscles can be resected. Superficial temporal fascia Superficial temporal fat pad Superficial musculoFrontal branch aponeurotic system of facial nerve Parotid gland

Temporal fascia proper Intermediate Deep temporal temporal fascia fascia

Zygomatic arch

Temporalis muscle

Masseter muscle

Fig. 21-17  Dissection begins with a temporal incision.

287

288

Part III 

Rejuvenation Surgery of the Face

Temporal fixation Paramedian fixations

Fig. 21-18  The superfic al temporal fascia is suspended and fi ed to the temporal fascia. All of the nerve fascicles should be identifi d, isolated, and protected before any muscle is removed. An endoscopic punch is usually used for the muscle resection. Thorough discussion with the patient must take place before surgery if resection of the muscle will be necessary. 4 . Left aramedian incision: The same procedures performed for the right paramedian incision are performed on the left side. 5. Fixation a. Temporal area: The superfic al temporal fascia is suspended and fi ed to the temporal fascia proper underneath at the higher position with strong suture materials such as 3-0 PDS or 3-0 Maxon sutures (Fig. 21-18). Two stitches are usually put in a square suturing manner to lower the chance of the tissue being cut through by a simple vertical suture. At this point, the descended temple and lateral eyebrow areas should be lifted up even with the nasolabial fold, which can be improved if the plane on the temporal area (under the superfic al temporal fascia) and the subperiosteal plane on the midface are connected and unifi d. b. Paramedian area: There are many kinds of fix tion methods at the paramedian area such as percutaneous screw fix tion, the subcutaneous absorbable screw with suturing method, simple suturing through cortical tunnels, Mitek Bioknotless anchors, and fix tion with an Endotine forehead device. If maximum suspension is required, as in a patient with severe brow ptosis or heavily folded skin, I recommend using the Endotine forehead device. The fix tion begins with hooking up the wound margins with skin hooks with full upward traction of the forehead skin, and then the location of the drill hole is marked at the upper end of the wound that is closest to the hairline (Fig. 21-19, A). In the process, it is important to hide the Endotine forehead device beyond the hairline, so that it cannot be seen on the forehead skin. Then a drill hole is made on the outer table of the skull with a size- and depth-specific drill bit (Fig. 21-19, B). The Endotine forehead device (Fig. 21-19, C) is then inserted into the hole with the fix tion tines facing upward (Fig. 21-19, D and E). A click sound can usually be heard during the insertion; the surgeon must make sure there is no loosening so that the

Chapter 21 

A

289

Endoscopic Approach to Facial Rejuvenation

B

C

D

E

Fig. 21-19  A, Making a mark with the drill hole under the traction of the skin hooks. B, A drill hole is made. C, Endotine forehead device. D and E, The Endotine forehead device is inserted. A small click should be heard.

K23345_Pu_c21_Endo Facial Rejuv_r4_cl_0275-0316.indd 289

Continued

4/2/2015 5:18:04 PM

290

Part III 

Rejuvenation Surgery of the Face

F

G

H

I

Fig. 21-19, cont’d  F and G, The scalp is pulled superiorly. H and I, The device is engaged. device is securely inserted. Then the scalp is pulled superiorly with full traction by the skin hooks (Fig. 21-19, F and G). The device should be overlapped by the pulling scalp, and the device should be engaged by direct digital pressure on the tines so that the overlying periosteum and galea are impaled by them (Fig. 21-19, H and I). Th s device can usually be palpable for several months and will dissolve completely within 1 year. 6. Drainage: A small suction drain is recommended only if there is obvious oozing. The drain can be kept in place for 2 to 3 days.

Postoperative Care To prevent edema, taping the forehead and temporal areas with adhesive Micropore tape can be considered but is not essential; the tape is usually removed 3 to 5 days after surgery. If there is a drain, it is removed 2 to 3 days postoperatively. Ice packs are recommended for the fi st 72 hours after surgery, followed with warm packs for at least several days. Prophylactic antibiotics can be administered as necessary. The sutures on the scalp are usually removed 7 to 10 days after surgery, whereas staples and screws, if any, should be left in place for 10 to 14 days. A headband can be used as needed to control edema and to help with fix tion.

Chapter 21 

Endoscopic Approach to Facial Rejuvenation

291

Results I have performed nearly 2000 total or subtotal endoscopic facial rejuvenations, with different combinations using the forehead lift, midface lift, nd lower face lift. atient satisfaction has been extremely high. For patients more than 40 years of age, the procedures must always be combined with an endoscopic midface lift and a brow lift. For patients more than 50 years of age, an endoscopic forehead lift should not be performed by itself; rather, it should be combined with a midface lift and even a lower face lift.

Fig. 21-20 Th s 50-year-old woman presented with brow ptosis, eyebrow asymmetry, static and dynamic forehead lines, deep frown lines, hooding of the upper eyelids, and brow tail ptosis. Her main concerns were the deep frown lines and brow tail ptosis, which made her face look sad. I only performed an endoscopic brow lift, with near-complete removal of the corrugator. After surgery, the areas that most concerned the patient were improved, and she was very satisfi d with the result. Further correction of the depressed central forehead and frown lines with filler was recommended, but she did not want these additional corrections. She is shown preoperatively and 1 year postoperatively.

K23345_Pu_c21_Endo Facial Rejuv_r4_cl_0275-0316.indd 291

4/2/2015 5:18:07 PM

292

Part III 

Rejuvenation Surgery of the Face

Fig. 21-21 Th s 53-year-old woman, who had undergone upper blepharoplasty years earlier, presented with typical brow ptosis with hooding of the upper eyelids, eyelid tail ptosis, and asymmetry of the eyebrows and double eyelids. I performed an endoscopic forehead lift n her and corrected her brow ptosis as well as the asymmetry of her eyebrows and double eyelids. She was happy with the results. She is shown preoperatively and 1 year postoperatively.

Management of Complications There are usually no major complications if the procedures are performed carefully and step by step under the endoscope. The neurovascular bundles can be well protected under the magnifi d view.

For ehead Par es thes ia, Dyses thes ia, and Anes thes ia

Almost every patient has a variable degree of forehead paresthesia, dysesthesia, and anesthesia in the forehead and scalp. These symptoms are usually not permanent, and the patient will typically recover within several months if there was no nerve injury during the operation. Desensitization by frequent tapping of the lesion area with the pads of the fi gers (3 to 5 minutes, every 1 to 2 hours) can usually shorten the period of recovery, and taking oral B-complex vitamins may help.

K23345_Pu_c21_Endo Facial Rejuv_r4_cl_0275-0316.indd 292

4/2/2015 5:18:08 PM

Chapter 21 

Endoscopic Approach to Facial Rejuvenation

Pr ur itus

Actually, pruritus is another kind of paresthesia; usually recovery occurs within several months. Pruritus is managed the same as a paresthesia: desensitization and taking oral B-complex vitamins may provide relief of the symptoms and shorten the recovery period.

Mot or Ner ve Injur y

One of the most dreaded complications of an endoscopic forehead lift is frontal nerve injury. Frontal nerve injury and temporary neurapraxia are reported to occur in approximately 0.4% of patients.16 Using modern techniques and modifi d instruments, I have no record of permanent motor nerve injury in any of my patients.

Al opeci a

Alopecia may be caused by direct injury of the hair follicles along the incisions by vigorous manipulation of instruments and by stress or tension at the fix tion point area. Alopecia can be prevented by inserting an endoscopic access device (the Guyuron Endoscopic Access Device17) or a port protector. Internal fix tion with the Endotine Forehead device has been reported to not be associated with the alopecia that is seen with the use of percutaneous screw or staple techniques.18 I have found no alopecia present around the Endotine fix tion sites in any of my patients, probably because there is less stress or tension on the point of fix tion and the tension force is separated and divided by the five tines on the device. Only a few of my patients with marginal alopecia along the temporal or paramedian incisional scars needed revisions.

Recur r ent Br ow Pt os is

Recurrent brow ptosis is usually caused by insuffici t dissection, especially in the area of the lateral orbital ligaments. Recurrent brow ptosis can be avoided by adequate dissection and rigid fixation. None of my patients needed secondary surgery for correction of recurrent brow ptosis.

Excess ive Br ow Ele vatio n

Very few of my patients (less than 0.1%) have complained of excessive elevation of their eyebrows. A normal young eyebrow position should be at the level of the frontal bone prominence, regardless of the patient’s race. If the eyebrows are higher than this prominence, the brows are generally considered to be excessively high. Because some patients may be startled or distressed to see their elevated, younger-looking eyebrows after surgery, the surgeon should thoroughly discuss and demonstrate the planned level of eyebrow correction with the patient preoperatively. It also helps to tell the patient that sometimes the brows will appear to be high while the surrounding tissues are still swollen, and it may take a few months for the brow position to look normal again. Secondary surgical correction is usually not required.

Discussion I have found that endoscopic brow lift lone yields excellent results when performed on patients in their late thirties or early forties. For patients over age 40, an endoscopic brow lift s only recommended concomitant with a midface lift; for patients over age 50, all of the total face-lift procedures should be combined for rejuvenation. The surgeon should clearly communicate this to the patient before surgery, so that the patient’s expectations for correction are realistic.

293

294

Part III 

Rejuvenation Surgery of the Face

There are different opinions among surgeons regarding the plane of dissection that should be used for endoscopic forehead lifting and brow lifting. I prefer the plane of dissection presented by Ramirez,19 because a subperiosteal dissection from anterior to posterior preserves the integrity of the areolar tissue at the galeal-periosteal interface. Th s type of subperiosteal dissection is important in preserving the normal gliding mechanism of the occipitalis-frontalis complex, the only muscle complex that elevates the brow; therefore a stable and dynamic brow position is preserved. In a conventional brow lift, artial resection or scoring of the frontalis muscle is almost the standard procedure; however, this will actually weaken the only muscle capable of elevating the eyebrow. In addition, during resection or scoring of the muscle, the small branches of the supraorbital or supratrochlear nerve may be transected and eventually result in formation of a painful neuroma, which is extremely difficult to treat.19 In a patient with forehead creases, these lines usually improve several months after surgery; this is probably a result of a decrease in frontalis hyperactivity, because factors that forced elevation of the eyebrow have been removed. Any forced traction without adequate dissection will eventually result in early relapse. The key ways to prevent early relapse are to perform adequate dissection and rigid fix tion. Especially around the lateral orbital area, dissection should be performed with care, because any residual dense fibers or adhesion bands may result in inadequate lateral brow lifting and early relapse. The surgeon should avoid using single-point fix tion or suturing, because the tissue around the point of fix tion sustains a high stress of tension force, which may tear or break the tissue itself and eventually result in relapse of the lifted tissue.

Pearls for Success: Endoscopic Brow Lift • Direct piercing of the intermediate temporal fascia is not recommended. “Retrograde dissection” provides a safe dissection of the zygomatic arch. • All blunt dissection should be done and advanced in a continuous horizontal plane. Multiple penetrations or tunnels should never be created separately. • Instruments should be task specific. The area of the neurovascular bundles should always be dissected with blunt, slender dissectors. • A malleable suction coagulator can stop a bleeding vessel at any angle or curve. • A port protector can avoid hair follicle loss resulting from vigorous manipulation. • The key to achieving a successful face lift s through adequate dissection and rigid, tension-free fix tion. • The use of a general anesthetic is recommended, because it can provide muscle relaxation so that fix tion of the descended tissues can be lifted without countertraction. • To create a bloodless endoscopic view, it is essential to expose the blood vessels with blunt elevators, ensuring that coagulation occurs before the vessels bleed. • Resection of the corrugator muscle should be conservative; total resection is not recommended. Isolation of the nerve fascicles should be performed before any resection of the muscle fibers. • Unifying the different planes of the temporal and midface areas can result in improved nasolabial folds. • Any forced traction without adequate dissection will eventually result in early relapse. • Single-point fix tion or suturing should be avoided, because it sustains a high stress of tension force, eventually resulting in breakdown of the tissue and early relapse.

Chapter 21 

Endoscopic Approach to Facial Rejuvenation

ENDOSCOPIC MIDFACE LIFT Indications The indications for endoscopic midface lift re essentially the same as for the open approach. An endoscopic midface lift is an alternative for a patient with flattening of the malar area caused by the loss of soft tissue and fat, sagging of the malar bags, moderate to signifi ant tear trough deformity, periorbital hollowing, elongation of the lid-cheek junction, a prominent nasojugal groove, an accentuated and deepened nasolabial fold, ptosis of the eyebrow tail, ptosis of the lateral corner of the eyelid, ptosis of the mouth corner, or dynamic and static periorbital wrinkles. The transtemporal endoscopic midface lift an be combined with an endoscopic forehead lift or a lower face lift

Operative Technique Incis io ns

Only two temporal incisions are necessary for an endoscopic midface lift hat is performed alone. The temporal incisions are marked below a line running tangent from the ala to the lateral canthus, approximately 1.5 to 2 cm away from and parallel to the temporal hairline. Each incision can be 1.5 to 2 cm long; thus each incision is wide enough for the introduction of the scope and manipulation of instruments. It is important to know that if a surgeon makes a temporal incision above this tangent line, the traction force down to the midface will be blocked by the lateral canthal area (see Fig. 21-16). If an intraoral incision is necessary, it is placed at the buccogingival sulcus area and at the level approximately 1 cm above the alveolar bone, starting from the vertical tangent line of the nasal notch of the piriform aperture and approximately 2 cm lateral from this line (Fig. 21-22).

Pr o ced ur e

If an endoscopic forehead lift is to be combined with an endoscopic midface lift, the dissection in the forehead region is exactly the same as in the forehead lift.

2 cm

1 cm

Fig. 21-22  An intraoral incision is made in the buccogingival sulcus area.

295

296

Part III 

Rejuvenation Surgery of the Face

Transtemporal Endoscopic Midface Lift Without an Intraoral Incision 1 . Right temporal incision: The beginning of the dissection is the same as that for an endoscopic forehead lift, and the dissection is carried down to the midface through the right temporal incision. Four margins should be completely released (Fig. 21-23, A), including superiorly, the infraorbital rim along with the lateral orbital rim; medially, the margins along the nasal notch of the piriform aperture; inferiorly, the premaxilla just above the alveolar bone; and laterally, at least the anterior two thirds of the zygomatic arch and buttress of the maxilla. All of the margins must be completely released; otherwise, it is difficult to perform en bloc mobilization and elevation of the whole midface around the soft tissues. I have designed some dissectors that allow complete release of the margins in this manner (Fig. 21-23, B). Part of the insertion of the masseter muscles should be detached with the coagulator against the bony side; any adhesion at the junction between the inferior border of the zygomatic body and the buttress of the maxilla should be released to complete the detachment. Together with the complete elevation of the periorbital adhesion, the detachment provides a wider space for further insertion of the scope and thus better visualization of the midface cavity. Thorough undermining of the whole periosteum and the structures under the lower eyelid is important, so that the depression in this area is corrected as the skin and underlying tissues are lifted and redraped. During dissection of the inferior orbital rim area, care should be taken around the infraorbital nerve region, which is usually approximately 1 cm below the infraorbital rim in the midpupillary line (Fig. 21-23, C ). Finally, the dissection is carried down to the gingival groove, and it is ready for fix tion (Fig. 21-23, D). 2. Left emporal incision: The same procedures that were performed for the right temporal incision are performed on the left side.

A B Infraorbital rim

Anterior two thirds of zygomatic arch Buttress of maxilla Piriform aperture

Fig. 21-23  A, The four margins to be released. B, Dissectors designed to release all margins.

Chapter 21 

Endoscopic Approach to Facial Rejuvenation

C D

Fig. 21-23, cont’d  C, Model demonstrating dissection of the inferior orbital rim area. D, The gingival groove.

Transtemporal Endoscopic Midface Lift With an Intraoral Incision 1. Right temporal incision: The procedures for the transtemporal endoscopic midface lift with an intraoral incision are exactly the same as the procedures without an intraoral incision with one exception: the superior, medial, and lateral margins of the maxilla are left for dissection through the intraoral incision. 2. Left emporal incision: The same procedures that were performed for the right temporal incision are performed for the left temporal incision. 3. Intraoral incision: Before making the incision, the oral cavity is thoroughly rinsed with a 1:1Betadine– normal saline solution to lower the chance of wound infection. Infiltration with 1% lidocaine with 1:80,000 epinephrine solution is performed around the incision area. The intraoral incision is made at the buccogingival sulcus at a level approximately 1 cm above the alveolar bone. The intraoral incision starts from the vertical tangent line of the nasal notch of the piriform aperture and is carried laterally away from this point (see Fig. 21-22). Usually 2 cm long is wide enough for the subperiosteal dissection. When the incision is carried more laterally, care must be taken around the orifice of the Stensen’s duct, which is at the opposite side of the second premolar area. A deep incision is made directly against the bone, and stripping of the periosteum is performed with ordinary bone strippers. The margins mentioned should be completely released (see Fig. 21-23, A). Part of the insertion of the masseter muscles should be detached with the coagulator against the bony side; after complete release of any retaining ligaments or adhesions, it is ready for fix tion. The advantage of an intraoral incision is that adequate and thorough dissection can be ensured without any dead angles. 4 . Fixation: There are several kinds of midface fix tion methods. Currently, the most popular methods include cable sutures, barbed sutures, and Endotine midface devices. I have been using the Endotine midface device since 2003; it is now my favored method of fix tion, elevation, and suspension of the malar fat pad. a. Reference point and line of fix tion: Based on my experience performing surgery on more than 1000 patients, I conclude that there is a reference point of fix tion that can be used as a coordinate of fix tion. It is approximately 1 cm medial to the intersection point between the vertical tangential line of the lateral canthus and the horizontal line of the nasal alar angle. Th s point is adjustable along the reference line of fix tion, which parallels the line between the lateral canthus and the nasal alar angle

297

298

Part III 

Rejuvenation Surgery of the Face

(Fig. 21-24, A and B). The point of fix tion should be made according to the thickness, projection, and volume of the midface tissues, and even the height of the cheek bone should be considered. For a patient with flattened cheeks or tissue atrophy, the point of fix tion should be lower along the reference line of fix tion so that a greater volume of tissue can be lifted up. For a patient with a prominent cheek bone or thicker but descended tissues, the point of fix tion should be higher along the line; thus less tissue can be lifted up and the cheek will be less prominent. To achieve a symmetrical appearance of the midface, the point of fix tion on each side may differ. b. Fixation of Endotine midface device without an intraoral incision: The Endotine midface device has five tines that can impale the periosteum and overlying soft tissues. Traction and fix tion of the device’s leash can elevate and suspend the malar fat pad and the surrounding tissues; therefore the Endotine midface device restores the volume of the cheek and thus the ogee curves. It has a deployment system to protect the implants and tines during insertion. With its insertion sheath, the device is inserted through the temporal incision (Fig. 21-24, C through E). After the correct spot of fix tion is reached, the device is deployed through a simple trigger release on the back of the insertion sheath to engage the tines to the periosteum and overlying soft tissues. Engagement is accomplished by direct digital pressure on the tines, allowing them to impale the overlying periosteum and soft tissues. The insertion sheath is then removed through the temporal incision (Fig. 21-24, F and G). The leash is sutured to the temporal fascia proper with two horizontal matrix sutures of 3-0 PDS or 3-0 Maxon under tension at the temporal incision after the desired elevation is reached, and the excess leash is then trimmed off (Fig. 21-24, H through J). Extra suspension force is still needed to elevate the descended temple and lateral eyebrow. The superfic al temporal fascia is then suspended and fi ed to the temporal fascia proper underneath at the higher position with 3-0 PDS or 3-0 Maxon sutures (see Fig. 21-18). Two stitches are applied, usually in a square suturing manner. c. Fixation of an Endotine midface device with an intraoral incision: Insertion of the Endotine midface device with an intraoral incision is the same as it is for fixation without an intraoral incision, except the engagement is assisted by direct pressure of the surgeon’s finger, inserted through the intraoral incision (Fig. 21-24, K). If the device is positioned incorrectly, reengagement of the device is very easy through the intraoral incision, although it is difficult for the manipulation without the intraoral wound. The rest of the fix tion of the device with an intraoral incision is the same as that without an intraoral incision. The intraoral wounds are usually closed with 4-0 chromic catgut by layers with interrupted sutures.

A

B

Reference line of fixation Reference point of fixation 1 cm

Fig. 21-24  A and B, The reference line and point of fix tion.

Chapter 21 

299

Endoscopic Approach to Facial Rejuvenation

D C

E

F

G

H I

Fig. 21-24, cont’d  C, The tines of the Endotine midface device. D and E, The device with its insertion sheath is inserted through the temporal incision. F and G, Removal of the device. H and I, The leash is sutured.

K23345_Pu_c21_Endo Facial Rejuv_r4_cl_0275-0316.indd 299

Continued

4/2/2015 5:18:11 PM

300

Part III 

Rejuvenation Surgery of the Face

J

K

Fig. 21-24, cont’d  J, The excess leash is trimmed. K, The surgeon places direct pressure through the intraoral incision with a fi ger.

Postoperative Care Suction drains are usually unnecessary if hemostasis is adequate; they are only indicated if there is obvious oozing. To prevent edema, taping of the temporal and midface areas with adhesive Micropore tape can be considered but is not essential; the tape is usually removed 3 to 5 days later. If there is a drain, it is removed 2 days after surgery. Ice packs are recommended for the fi st 72 hours, followed by warm packing for at least several days. Prophylactic antibiotics and postoperative oral antibiotics can be used as needed. Stitches or staples on the scalp are usually removed 7 to 10 days after surgery. An elastic and compressive face garment can also be used to control edema and help fix tion.

Results For patients less than 40 years of age, a pure endoscopic midface lift an be performed for selected patients with satisfactory results. For patients more than 40 years of age, it is not recommended to perform this lift y itself, because many older patients may also have brow ptosis. Endoscopic brow lift hould be performed together with other surgeries.

K23345_Pu_c21_Endo Facial Rejuv_r4_cl_0275-0316.indd 300

4/2/2015 5:18:12 PM

Chapter 21 

Endoscopic Approach to Facial Rejuvenation

301

Fig. 21-25 Th s 50-year-old woman presented with typical brow ptosis, hooding of the upper eyelids, brow tail ptosis, an aging midface with infraorbital hollowing, loss of ogee curves, and multiple atrophic changes. After a combined endoscopic forehead and midface lift, these areas were improved, her brow ptosis was corrected, the eyelids recovered without the need for upper blepharoplasty, the infraorbital hollowing improved, and the ogee curves were restored. Filler injections were recommended for her multiple atrophic and depressed areas, but she was satisfi d with the result. She is shown preoperatively and 1 year postoperatively.

K23345_Pu_c21_Endo Facial Rejuv_r4_cl_0275-0316.indd 301

4/2/2015 5:18:14 PM

302

Part III 

Rejuvenation Surgery of the Face

Fig. 21-26 Th s 47-year-old woman presented with an aging forehead and midface with asymmetrical cheek thickness and redundancy, which are evident on the preoperative photograph with her head down. After an endoscopic brow and midface lift ere performed, her brow ptosis, hooding of the upper eyelids, brow tail ptosis, loss of ogee curves, and even her asymmetrical cheek height and tissue redundancy were all improved. She was satisfi d with the results. She is shown preoperatively and 1 year postoperatively.

K23345_Pu_c21_Endo Facial Rejuv_r4_cl_0275-0316.indd 302

4/2/2015 5:18:15 PM

Chapter 21 

Endoscopic Approach to Facial Rejuvenation

Management of Complications Usually there are no major complications if the procedures are performed carefully and step by step under the endoscope. The neurovascular bundles can be well protected under the magnifi d view.

Par es thes ia, Dyses thes ia, and Anes thes ia

Most patients have a variable degree of paresthesia, dysesthesia, and anesthesia in the temporal and midface areas after surgery. These sequelae are usually not permanent and will resolve within several months if there is no nerve injury during the operation. Desensitization by frequent tapping of the lesion area with the pads of the fi gers (3 to 5 minutes, every 1 to 2 hours) can usually shorten the period of recovery, and taking oral B-complex vitamins may help.

Pr ur itus

Pruritus is actually another kind of paresthesia, from which a patient usually recovers within several months. Management of pruritus is the same as that for paresthesia, with desensitization and the use of oral B-complex usually helping to relieve the symptoms and shorten the recovery period.

Mot or Ner ve Injur y

One of the most severe complications of a transtemporal endoscopic midface lift s frontal nerve injury. Frontal nerve injury and temporary neurapraxia are reported to occur in approximately 0.4% of cases.16 Using modern techniques and modifi d instruments, I have encountered no permanent motor nerve injury in my patients.

Al opeci a

Alopecia may be caused by direct injury to the hair follicles along the incisions through vigorous manipulation of the instruments and stress or tension at the fix tion point. Vigorous manipulation of the instruments can be prevented by inserting an endoscopic access device (the Guyuron Endoscopic Access Device17) or a port protector.

Asymmetr y of the Mid f a ce

Asymmetry of the midface is obviously a result of fix tion of the midface at an inappropriate point. The point of fix tion should be made according to the thickness, projection, and volume of the midface tissues, and even the height of the cheek bone should be considered. To achieve a symmetrical appearance of the midface, the points of fixation on each side may differ. In some patients, if the surgeon tries to fix both sides at the same point and the same level, asymmetry of the midface may eventually result if the sides have different tissue thickness or cheekbone height, in which case a readjustment may be necessary.

Ear l y Rel aps e of the Mid f a ce

Early relapse is usually a result of force traction of the midface with inadequate dissection, especially around the four previously described margins. Revision of the dissection is necessary, even with intraoral incisions.

303

304

Part III 

Rejuvenation Surgery of the Face

Discussion The aging face is usually characterized by gravitational soft tissue descent, loss of elasticity of all tissues, and loss of bony and soft issue volume as a result of atrophy during the aging process. The conventional open approach has achieved better results than tightening of the aging face; however, the open approach provides a limited ability to correct the central oval of the face, especially ptotic midface tissues and nasolabial folds. Various approaches have been recommended for repositioning the ptotic midface, including transtemporal, transpalpebral, and transbuccal; the barbed sutures method; lateral access from the preauricular face-lift incision; and endoscopic temporal and oral approaches.4,20,21 The endoscopic temporal approach for the midface lift has many advantages. It provides a safe plane of dissection along the temporal fascia proper in the temporal area and can easily connect with the subperiosteal plane down into the midface through a safe “retrograde dissection” along the zygomatic arch, a method that I invented. It can easily be combined with the endoscopic forehead lift when necessary. The point of fix tion should be made according to the thickness, projection, and volume of the midface tissues, and even the height of the cheek bone should be considered. All margins on the midface should be completely released, including the infraorbital rim, along with the lateral orbital rim superiorly, the margins along the nasal notch of the piriform aperture medially, the premaxilla just above the alveolar bone inferiorly, and at least the anterior two thirds of the zygomatic arch and buttress of the maxilla laterally. Any forced traction without adequate dissection and any residual ligamentous adhesions or bands will eventually result in early relapse. Adequate dissection and rigid fix tion are the key ways to prevent early relapse from occurring.

Pearls for Success: Endoscopic Midface Lift • Rejuvenation of the midface should involve en bloc elevation of all of the descended tissues. • Restoration of the volume and projection of the cheek is important to restore the normal ogee curves, which are characteristic of a youthful midface. • Instruments should be task specific. The area of the neurovascular bundles should always be dissected with blunt and slender dissectors. • General anesthesia is recommended, because it can provide muscle relaxation, so that the fix tion of the descended tissues can be lifted up without any countertraction. • Direct piercing of the intermediate temporal fascia is not recommended. “Retrograde dissection” provides a safe dissection of the zygomatic arch. • The point of fix tion should be made according to the thickness, projection, and volume of the midface tissues, and even the height of the cheek bone should be considered. • A successful face lift can be achieved through adequate dissection and rigid, tension-free fixation. • Any forced traction without adequate dissection will eventually result in early relapse.

Chapter 21 

Endoscopic Approach to Facial Rejuvenation

ENDOSCOPIC LOWER FACE AND NECK LIFT Indications The indications for an endoscopic lower face and neck lift re essentially the same as those for the open approach, except that this procedure is not ideal for a patient with excessive skin redundancy; such patients also require skin resection. The endoscopic lower face and neck lift is an alternative choice only for a patient with less redundant skin or a patient who is not willing to accept traditional face-lift scars in the preauricular and postauricular regions. Furthermore, performing the endoscopic lower face and neck lift by itself is not recommended; rather, it should be combined with an endoscopic forehead lift or an endoscopic midface lift, or both, depending on the severity of the effects of aging on the patient’s face.

Operative Technique Endoscopic lower face and neck lift techniques are based on many of the principles of the open subperiosteal approach.12-14 To perform a safe and successful endoscopic procedure, the surgeon must have a thorough understanding of the local anatomy, the spatial relationship between the different planes of the fascia, and the locations of the nerves. Because there is a certain degree of adhesion between the SMAS and the subcutaneous layer, blunt dissection is not as easy in this region as it is between the superfic al temporal fascia and temporal fascia proper. Therefore I recommend using a combined method of the conventional face-lift echnique under the endoscope where blunt dissection is difficult. Here I will only describe the technique of the pure endoscopic lower face and neck lift without preauricular skin excision.

Mar kings

First, the mandibular margin, including the territory of dissection above and below the mandibular margin, should be outlined. The course of the frontal branch of the facial nerve should be marked. The mental nerve, which is the continuation of the alveolar nerve, exits the mental foramen on the mandible at the level of the second premolar and approximately 2 cm below the lower lip in the midpupillary line. The mental nerve should be preserved during the exposure (see Fig. 21-9).

Incis io ns

Moderate Lower Face and Neck Redundancy For a patient with early jowling and slight neck laxity where less dissection and less redraping of the skin are necessary, a 2 cm long postauricular incision just above the earlobe area is recommended; I call this a closed neck lift (Fig. 21-27).

Fig. 21-27  A postauricular incision just above the earlobe area.

2 cm

305

306

Part III 

Rejuvenation Surgery of the Face

2 cm 1 to 1.5 cm

2 cm

Fig. 21-28  An incision on the occipital scalp approximately 1 to 1.5 cm away from and parallel to the hairline and posterior to the mastoid process.

Severe Lower Face and Neck Redundancy For a patient with severe skin redundancy in the lower face and neck, the endoscopic lower face and neck lift hould not be performed alone; it should always be combined with skin resection. For a patient who does not want preauricular skin resection, an endoscopic lower face and neck lift hould be performed together with an endoscopic forehead lift and an endoscopic midface lift In addition to the postauricular incision, a 2 cm long incision on the occipital scalp approximately 1 to 1.5 cm away from and parallel to the hairline and posterior to the mastoid process is recommended (Fig. 21-28), because this location provides more space for redraping of the skin and prevents crowding of the skin around the earlobe.

Pr o ced ur e

Moderate Lower Face and Neck Redundancy 1 . After making a 2 cm long incision in the postauricular area, starting from the point at and above the earlobe area (Fig. 21-29, A and B), the surgeon starts the dissection using skin hooks and ordinary dissecting scissors (Fig. 21-29, C). 2. Once an endoscopic pocket is created, the endoscope is inserted, and a blunt elevator is used for dissection between the SMAS and the subcutaneous layer (Fig. 21-29, D and E). Below the mandibular line, the dissection is carried out between the platysma and the subcutaneous layer. Because this blunt dissection is not as easy as it is between the superfic al temporal fascia and the temporal fascia proper, a surgeon can combine the dissection with the conventional face-lift technique with the use of ordinary scissors under the monitoring of the endoscope where blunt dissection is difficult because of a strong connection between the layers (Fig. 21-29, F and G). Approximately three fi gerbreadths above and below the chin line is usually adequate for the range of dissection if the procedure is combined with an endoscopic midface lift or even an endoscopic forehead lift. If necessary, the dissection can be extended farther.

Chapter 21 

A

B

C

D

E

F

G

307

Endoscopic Approach to Facial Rejuvenation

Fig. 21-29  A and B, An incision is made in the postauricular area. C, The surgeon uses skin hooks and ordinary dissecting scissors to begin the dissection. D, The endoscope is inserted. E, The location of the scope can be viewed on a monitor. F, The dissection can be combined with a conventional face lift using an endoscope to monitor the technique. G, Bleeding can also be monitored with the endoscope.

Continued

K23345_Pu_c21_Endo Facial Rejuv_r4_cl_0275-0316.indd 307

4/2/2015 5:18:18 PM

308

Part III 

Rejuvenation Surgery of the Face

H

I

J

K

Fig. 21-29, cont’d  H, Insertion of the Endotine Ribbon. I, The device is removed from its protective cover. J, Th Rib-

bon is secured with 4-0 PDS or Maxon sutures to the fascial tissue below the mastoid process. K, Any redundant skin can be resected.

3. Fixation: A study by Boutros et al22 found that the biologic healing time for tissue to reattach to a new position is approximately 30 days under stable fix tion. Other studies have found that the healing time is 6 to 8 weeks. Any fix tion method that can last longer than this biologic healing time of 6 to 8 weeks can be used for fix tion. Although different kinds of fix tion can be performed, I prefer the Endotine Ribbon, which I have been using since 2006. After the skin flaps are dissected and hemostasis is confi med, the Ribbon is inserted with the tines facing downward. After the fix tion point is reached, which is usually approximately one fi gerbreadth below the mandibular margin or at the most movable part, the device is deployed from its protective cover. Although not essential, the distal end can be secured with 4-0 PDS or Maxon sutures to ensure full engagement of the tines. The tines are affixed to the underlying tissue with fi ger pressure, and then the descended tissues are lifted to the desired position by pulling up the leash with moderate tension. With 3-0 PDS or Maxon sutures, the device is secured to the fascia tissue under the mastoid process. Finally, the redundant skin can be resected as needed before the wound is closed (Fig. 21-29, H through K).

Severe Lower Face and Neck Redundancy 1. After making the postauricular incision and dissection, which are exactly the same as for a patient with moderate lower face and neck deformity, the surgeon makes an additional 2 cm long incision on the occipital scalp approximately 1 to 1.5 cm away from and parallel to the hairline and posterior to the mastoid process (see Fig. 21-28). 2. The dissection is initiated with skin hooks and ordinary dissecting scissors. 3. Once an endoscopic pocket is created, the endoscope is inserted, and a blunt elevator is used for dissection between the SMAS and the subcutaneous layer. Below the mandibular line, the dissection is carried between the platysma and the subcutaneous layer. The dissection can be combined with the

Chapter 21 

309

Endoscopic Approach to Facial Rejuvenation

conventional face-lift echnique with ordinary scissors under the monitoring of the endoscope where blunt dissection is difficult because of a strong connection between the layers. 4. Dissection continues until it connects with the pocket made through the postauricular incision. The two dissection areas are then connected with each other and are ready for fix tion (Fig. 21-30, A and B). If necessary, the dissection can be extended farther. 5 . Fixation: The procedures to correct severe lower face and neck redundancy are the same as those for moderate lower face and neck redundancy. If lifting of the descended mouth angle is inadequate, especially the marionette lines, an additional Ribbon can be added. The Ribbon is inserted approximately one fi gerbreadth above the mandibular line and approximately one fi gerbreadth away from the corner of the mouth (Fig. 21-30, C). After the fix tion point is reached, the device is deployed from its protective cover. Although not essential, the distal end can be secured with 4-0 PDS or Maxon sutures to prevent the distal Ribbon from springing up and thus ensuring full engagement of the tines. The tines are affixed to the underlying tissue with fi ger pressure, then the descended tissues are lifted to the desired position by pulling the leash with moderate tension (Fig. 21-30, D). It is important to prevent the device from passing right on top of the mastoid process or beyond it, since the device can be easily felt in this area because of the thin skin covering and the fact that the patient may feel uncomfortable when turning the head to the side. The device is secured with 3-0 PDS or Maxon sutures below the mastoid process, and the wound is closed with skin resection as needed (see Figs. 21-29, K, and 2130, D). Redraping of the redundant neck skin is performed at the occipital incision area by suturing the subcutaneous tissue to the SMAS and the fascial tissue underneath at the higher position (Fig. 21-30, E). Finally, the wound is closed with a 4-0 nylon suture.

A

C

B

A B

Fig. 21-30  A, Dissection continues until it connects with the pocket. B, The two dissection areas are then connected and are ready for fix tion. C, Location A is for a patient who needs additional lifting over the marionette line area and mouth angle. Location B is the usual Ribbon fix tion point for the lower neck lift.

Continued

310

Part III 

Rejuvenation Surgery of the Face

D

E

Fig. 21-30, cont’d  D, The tines are affixed to the underlying tissue with fi ger pressure. E, Redraping of the redundant neck skin.

Postoperative Care Suction drains are usually inserted for patients with obvious oozing at the wound site. If the procedures are combined with an endoscopic forehead and midface lift, taping with Micropore tape can be considered to prevent edema; the tape is usually removed in 3 to 5 days. If a drain is used, it is removed 2 days after surgery. The use of ice or cold pack compresses is recommended for the fi st 72 hours after surgery, followed by warm packs for at least several days. A prophylactic antibiotic and/or postoperative oral antibiotics can be administered as needed. Sutures or staples on the scalp are usually removed 7 to 10 days later. An elastic and compressive face garment can also be used to control edema and to help with fix tion.

Results The patient who would benefit from the endoscopic lower face and neck lift procedure is normally between 30 and 50 years of age, compared with the typical face-lift atient, who is normally between 45 and 65 years of age. The results are usually acceptable and may even be satisfactory to a patient who is not willing to accept traditional face-lift scars in the preauricular and postauricular areas.

K23345_Pu_c21_Endo Facial Rejuv_r4_cl_0275-0316.indd 310

4/2/2015 5:18:20 PM

Chapter 21 

Endoscopic Approach to Facial Rejuvenation

311

Fig. 21-31 Th s 77-year-old woman presented with an aging face with skin redundancy and multiple depression deformities. Skin resection was defin tely necessary, but she refused to have a conventional preauricular incision. Her choices were therefore limited, so an endoscopic total face lift was performed. She had an endoscopic brow lift, endoscopic midface lift, and endoscopic lower face and neck lift through postauricular incisions with limited skin resection, and two Ribbons were inserted on each side. The results were acceptable to the patient. She is shown preoperatively and 1 year after surgery.

K23345_Pu_c21_Endo Facial Rejuv_r4_cl_0275-0316.indd 311

4/2/2015 5:18:22 PM

312

Part III 

Rejuvenation Surgery of the Face

Fig. 21-32 Th s 55-year-old woman had undergone a temporal face lift lsewhere years earlier. Now she wanted to have a face lift with no additional scars on her face. An endoscopic lower face and neck lift alone would not effectively improve her redundancy; therefore I performed an endoscopic brow and midface lift together with an endoscopic lower face and neck lift. The patient was satisfi d with the results and did not wish to undergo any additional treatment, although I recommended filler injection for the multiple depressed areas. She is shown preoperatively and 1 year postoperatively.

Management of Complications Usually no major complications occur if the endoscopic lower face and neck lift s performed carefully and step by step under the endoscope. The neurovascular bundles can be well protected under the magnifi d view. Complications and their management are the same as those associated with an open lower face and neck lift

K23345_Pu_c21_Endo Facial Rejuv_r4_cl_0275-0316.indd 312

4/2/2015 5:18:24 PM

Chapter 21 

Endoscopic Approach to Facial Rejuvenation

313

Hemat oma

Hematoma can occur in any surgery, including an endoscopic lower face and neck lift, especially if the dissection is extensive. However, the endoscope provides the advantage of facilitating the location of bleeding vessels. Complete hemostasis can be achieved by using a malleable suction coagulator.

Fa ci al Ner ve Injur y

Any dissection superfic al to the zygomaticus muscles will also be superfic al to the facial nerve branches; therefore the dissection between the platysma and the subcutaneous layer or between the SMAS and the subcutaneous layer are safer and are superfic al to the facial nerve branches. The marginal mandibular branch is usually the branch at risk during dissection. It is deep to the platysma throughout its course, but it could be at risk as the platysma goes thin. To prevent nerve injury, the dissection should be performed above the platysma laterally and deep to the platysma centrally. During an open face lift, the auriculotemporal nerve is often injured or divided, because it courses with the superfic al temporal artery. The mental nerve, which is the continuation of the alveolar nerve, exits the mental foramen on the mandible at the level of the second premolar and approximately 2 cm below the lower lip in the midpupillary line, and innervates the chin and the lower lip. The mental nerve should be preserved during open or endoscopic exposure.

Ear l y Rel aps e of the Lower Fa ce and Neck

Early relapse is usually caused by force traction of the lower face and neck with inadequate dissection. When any forced traction occurs without adequate dissection, any residual ligamentous adhesions or bands will eventually result in early relapse. The key ways to prevent early relapse from happening are through adequate dissection and rigid fix tion.

Discussion Various approaches have been tried to achieve an incisionless lift. The use of barbed sutures, barbed threads, or contour threads are techniques involving stretching, grabbing, and tightening of the skin without dissection and addressing the underlying structures. However, disappointments such as extrusion, fracture, unusual dimpling, and a high infection rate are not uncommon. Longevity is directly proportional to the range of dissection. The larger the range of dissection, the longer the results will persist. The tines of the Ribbon engage, fix te, and elevate the platysma in the neck, producing sharp improvement in the cervicomental angle or the SMAS in the cheek, minimizing the jowl. An endoscopic lower face and neck lift can even be used as an adjunct to open procedures, because it provides additional elevation of the fascia or platysma. The endoscopic lower face and neck lift s only an alternative choice for a patient with less redundant skin or a patient who is not willing to accept traditional face-lift scars in the preauricular and postauricular regions. It is not recommended that an endoscopic lower face and neck lift e performed by itself; rather, it should be combined with an endoscopic forehead lift, n endoscopic midface lift, r both, depending on the severity of the effects of aging on the patient’s face. Thorough discussion with the patient before surgery is essential. The surgeon must tell the patient that this endoscopic procedure in the lower face and neck is just an alternative method to correct the problem and that it has a limited effect for a patient with severe lower face and neck skin redundancy.

K23345_Pu_c21_Endo Facial Rejuv_r4_cl_0275-0316.indd 313

4/2/2015 5:18:24 PM

314

Part III 

Rejuvenation Surgery of the Face

Pearls for Success: Endoscopic Lower Face and Neck Lift • A combined method of a conventional face-lift technique under the monitoring of the endoscope is recommended where blunt dissection is difficult. • A malleable suction coagulator can achieve complete hemostasis at any angle on the face. • The key ways to achieve a successful face lift are through adequate dissection and rigid, tensionfree fix tion. • Longevity is directly proportional to the range of dissection. The larger the range of dissection, the longer the results will persist. Any forced traction without adequate dissection will eventually result in early relapse. • The endoscopic lower face and neck lift is only an alternative choice for a patient with less redundant skin or for a patient who is not willing to accept traditional face-lift cars in the preauricular and postauricular regions. It is recommended that this procedure should not be performed alone; rather, it should be combined with an endoscopic forehead lift an endoscopic midface lift or both, depending on the severity of the aging face. • Thorough discussion with the patient before performing the endoscopic procedure in the lower face and neck is essential. The surgeon must tell the patient that this procedure is just an alternative method to correct the problem and that it has a limited effect for a patient with severe lower face and neck skin redundancy.

Refer ences 1. Vasconez LO, Core G. Endoscopic techniques of coronal lifting [videotape #463-A]. Birmingham: University of Alabama–Birmingham Division of Plastic Surgery, 1992. 2. Isse N. Endo-facial Training Seminar. Newport Beach, CA, June 1993. 3. Ramirez O. Endo-facial Training Seminar. Newport Beach, CA, June 1993. 4. Saltz R, Casagrande C, Saciloto A. Rejuvenation of the midface. In Nahai F, Saltz R, eds. Endoscopic Plastic Surgery. St Louis: Quality Medical Publishing, 2008. 5. Toledo LS. Videoendoscopy and liposculpture of the face and neck. Endoscopic Plast Surg 3:85-94, 1996. 6. Ramirez OM. Endofacelift: subperiosteal approach. In Ramirez OM, Daniel RK, eds. Endoscopic Plastic Surgery. New York: Springer Verlag, 1995. 7. Ramirez OM. The subperiosteal rhytidectomy: the third-generation face-lift. Ann Plast Surg 28:218-232; discussion 233-234, 1992. 8. Isse NG. Endoscopic facial rejuvenation: endoforehead, the functional lift. ase reports. Aesthetic Plast Surg 18:21-29, 1994. 9. Daniel RK. Endoforehead: subperiosteal approach. Endoscopic Plast Surg 2:46-67, 1996. 10. Stuzin JM, Baker TJ, Gordon HL. The relationship of the superfic al and deep facial fascias: relevance to rhyti­ dectomy and aging. Plast Reconstr Surg 89:441-449; discussion 450-451, 1992. 11. Webster RC, Gaunt JM, Hamdan US, et al. Supraorbital and supratrochlear notches and foramina: anatomical variations and surgical relevance. Laryngoscope 96:311-315, 1986. 12. Ramirez OM, Maillard GF, Musolas A. The extended subperiosteal face lift: a defi tive soft- issue remodeling for facial rejuvenation. Plast Reconstr Surg 227-236; discussion 237-238, 1991. 13. Ramirez OM. The subperiosteal rhytidectomy, the third-generation face-lift. Ann Plast Surg 28:218-232; discussion 233-234, 1992. 14. Ramirez OM, Fuente del Campo A. Facial rejuvenation: subperiosteal brow and face lift. nstructional Course Series, vol 6. Plastic Surgery Educational Foundation. St Louis: Mosby–Year Book, 1993. 15. Lorenc ZP, Ivy EJ, Aston SJ. The course and relations of sensory nerves of the forehead: study in vivo. Presented at the Twenty-sixth Annual Meeting of the American Society of Aesthetic Plastic Surgery, Boston, MA, 1993. 16. Ramirez OM. Subperiosteal endoscopic techniques in facial rejuvenation. In Achauer BM, Eriksson E, Guyuron B, Coleman JC III, eds. Plastic Surgery: Indications, Operations, and Outcomes. St Louis: Mosby, 2000.

K23345_Pu_c21_Endo Facial Rejuv_r4_cl_0275-0316.indd 314

4/2/2015 5:18:24 PM

Chapter 21 

Endoscopic Approach to Facial Rejuvenation

315

17. Guyuron B. Forehead rejuvenation. In Achauer BM, Eriksson E, Guyuron B, Coleman JC III, eds. Plastic Surgery: Indications, Operations, and Outcomes. St Louis: Mosby–Year Book, 2000. 18. Stevens WG, Apfelberg DB, Stoker DA, et al. The endotine: a new biodegradable fix tion device for endoscopic forehead lifts. Aesthetic Surg J 23:103-107, 2003. 19. Ramirez OM. Endoscopic full facelift. Aesthetic Plast Surg 18:363-371, 1994. 20. Sasaki GH. Comparison of open and endoscopic forehead lifts: a reliminary evaluation by questionnaire response. Presented at the Endoscopy in Plastic Surgery: A Consensus Multidisciplinary Symposium, Birmingham, AL, July 1994. 21. Saltz R. Endoscopic temporal-incision only midface lift is enhanced by endotine technique. Aesthetic Surg J 25:80-83, 2005. 22. Boutros S, Bernard RW, Galiano RD, et al. The temporal sequence of periosteal attachment after elevation. Plast Reconstr Surg 111:1 942-1947, 2003.

K23345_Pu_c21_Endo Facial Rejuv_r4_cl_0275-0316.indd 315

4/2/2015 5:18:24 PM

K23345_Pu_c21_Endo Facial Rejuv_r4_cl_0275-0316.indd 316

4/2/2015 5:18:24 PM

22 Neck Rejuvenation

O

David S. Kung

ften   the neck is the fi st area in which signs of aging are noticed. Sagging skin, deep horizontal lines, bulging vertical bands, and hanging jowls are all areas of concern among Asian patients. The attractive neck shared among all Asian cultures is portrayed in a long fl wing silhouette from chin to sternum with smooth overlying skin bounded by well-defi ed mandibular borders. Each region of the neck can be treated independently or conjointly, with multiple treatment options, including traditional neck-lift urgeries, combination face-lift procedures, and the newer minimally invasive procedures. Desired results typically include elimination of vertical bands or cords at the front of the neck from separation of the platysma muscle; obtaining a flat plane under the chin, with no soft issue bulges from fat, muscle, or salivary glands; creating a natural, aesthetically pleasing cervicomental angle formed by the neck and lower jaw; tightening of the neck skin; and undetectable or minimally visible scars. These can be obtained despite the challenges of thicker, less mobile skin, as typically seen in the Asian patient. In this chapter neck rejuvenation is discussed in detail, with emphasis on the importance of an Asian patient-centered approach to evaluation and treatment.

Anatomy of the Neck With a growing number of options available for neck rejuvenation, the challenge is greater than ever to match the best possible procedure with the needs and desires of the patient. Often a patient presents with multiple deformities of the neck, further complicating the process. The key factor is anatomy. The neck anatomy encompasses the anterior borders of the trapezius muscles laterally, the supraclavicular region inferiorly, and the inferior border of the mandible superiorly. Other important structures include the submandibular gland, the digastric muscles, and the submental fat pad. The platysma muscle, a common focus of neck rejuvenation, originates from the fascia overlying the pectoralis and deltoid muscles, inserting in multiple points above the angle of the mandible.1 Multiple nerve structures in the neck require familiarity and practice to avoid nerve damage during rejuvenation procedures (Fig. 22-1).

317

318

Part III 

Rejuvenation Surgery of the Face

Marginal mandibular nerve Submandibular gland

Great auricular nerve

Hyoid bone

Common carotid artery

Thyroid cartilage

Jugular vein

Thyroid gland

Fig. 22-1  Anatomy of the neck.

Rohrich et al2 wrote in detail about neck anatomy, and specifi ally about the platysma region. Vistnes and Souther3 noted: “Posterior fibers intertwine with the depressor anguli oris, mentalis, risorius, and the orbicularis oris before inserting at the level of the commissures. Central fibers insert directly into the periosteum of the mandible. Along its course, partial decussation of the muscle fibers is seen in approximately 61% to 75% of the population.” And de Castro4 stated: “When the muscle decussates from hyoid to chin, a supportive sling is fashioned for the submental area. When the decussation of the platysma is absent, the free medial edges can be responsible for an anterior neck deformity, which appears as two vertical bands.” The superfic al cervical fascia is a thin layer of subcutaneous connective tissue that lies between the dermis and the deep cervical fascia. It divides to envelop the platysma. The marginal mandibular branch of the facial nerve (the nerve of facial expression) is covered by platysmal fibers as it runs along the inferior border of the mandible.5 The cervical branch of the facial nerve affects the deep surface of the platysmal muscle and can easily be injured without realizing it. The marginal mandibular nerve is superior to the mandibular border. The great auricular nerve can be identifi d at a point approximately 6.5 cm inferior to the bony external auditory canal in the midtransverse belly of the sternocleidomastoid. The external jugular vein is 0.5 cm anterior to the nerve.6

Indications Th ee common problems present themselves during evaluation of the neck anatomy: 1. Excess skin: Loose, sagging skin, including skin folds, which cause deep wrinkles. Surgical removal may be considered.

Chapter 22 



Neck Rejuvenation

2. Excess fat: Visible excess volume, such as a double chin, or fullness of the submental fat pads. Liposuction independently or in combination with other procedures is an effective approach for fat removal. 3. Muscle laxity: Loose muscles in the neck, predominantly of the platysmal muscle. The platysma is actually a pair of superfic al muscles directly under the skin that stretch from the clavicle to the upper face. These are naturally separated at the midline, but with anatomic variations possible, aging causes the muscles to relax, allowing the overlying skin to sag. The result is banding, vertical cords, or a noticeable “turkey wattle.” Banding can also develop from skeletonization of the anterior “strap” muscles. There are four pairs of broad, flat, straplike muscles; these cervical muscles form a supportive triangle, including the sternocleidomastoid muscle, considered the key to the neck.

Preoperative Assessment Visually, the face is a composite, with areas that complement, accentuate, or detract from one another. The neck must be viewed as a component of the overall face, and any aesthetic neck surgery should blend with and improve the facial construct as a whole. Initial patient evaluation for neck rejuvenation, then, should include structural hard and soft issue evaluations, not just of the neck but of the entire face, with a concentration on balance in the lower face, including the chin, jaw, cheeks, and nose. Analysis of soft tissue volume, surface contour, skin laxity, lines, and angles can be aided by analytical tools, such as the Steiner analysis,7 a well-established guide to the measurement of angles in the lower face, specifi ally the skeletal relationship between the maxilla and mandible. Although inherent biases are found in any analysis, multiple authors have described the “ideal” relationships between the neck, chin, jawline, and nose. Marquardt’s analysis models8 build on various multiples of Phi, also known as “the golden ratio,” or “the divine proportion.” Phi is actually a mathematical ratio of 1.618:1 that seems to appear recurrently in beautiful things in nature as well as in other things we perceive as beautiful. One can apply the golden ratio theory to the human form, because the face and neck offer multiple examples of its rules of proportion. Ellenbogen and Karlin9 also described the cervicomental angle as the angle formed by the intersection of two lines: vertically from the glabella of the forehead to the pogonion; and horizontally, from the menton to the deepest point between the submental area and the neck, called the cervical point. They included the “ideal” cervicomental angle in their five-point description of characteristics of a youthful, aesthetic neck: 1. A distinctive inferior mandibular border from menton to angle, with no jowl overhang 2. Subhyoid depression 3. Visible thyroid cartilage 4. Visible anterior border of sternocleidomastoid muscle, distinct from mastoid to sternum 5. A cervicomental angle ranging from 105 to 120 degrees (90 degrees from the sternocleidomastoid to the submental line) Sommerville et al10 described the ideal cervicomental angle more specifi ally by sex: 126 degrees for males and 121 degrees for females. During the initial patient evaluation, in addition to assessing skin laxity and the amount and position of platysmal fat, the surgeon should note the presence of malpositioned or ptotic submandibular glands. A

319

320

Part III 

Rejuvenation Surgery of the Face

neck with excessive fat can hide deformities, such as ptotic glands, which may become more visible with neck rejuvenation. As with consultation for any aesthetic surgical procedure, the patient’s goals, expectations, and medical history are integrally important to the evaluation, analysis, and recommendation of appropriate treatment options. In addition, patient tolerance should be considered. For example, varying levels of discomfort accompany different procedures, including swelling, pain, and visible bruising. And there are different lengths of recovery and risks of complications associated with all procedures, such as a more traditional neck-lift procedure (cervicoplasty with platysmaplasty), or a neck lift combined with a face lift, compared to less-invasive “trampoline-type” suspension neck lifts

Surgical Technique: Overview Excess Fat : Lipos uctio n

The removal of excess fat through liposuction can be a successful treatment on its own, particularly for patients with good skin tone and very little sagging skin. Evaluation will show some fatty tissue under the chin and on the neck. Generally, the procedure is performed with small-diameter blunt-tipped cannulas to avoid creating irregularities. The procedure is often done with manually powered cannulas under low suction for better control, improved accuracy, and a smoother contour. Liposuction may be performed as a fi st step for a patient who wants the opportunity to evaluate the results before considering additional procedures. When a patient desires a more comprehensive approach to neck augmentation and multiple problems are evident, including excess fat, excess and/or sagging skin, and muscle laxity, liposuction may be combined with a choice of neck-lift procedures.

Excess Skin: Sur gical Removal

When the benefits of more comprehensive neck rejuvenation are desired, the predominant factor in determining the appropriate procedure is the amount of excess skin, which can result from the presence or loss of excess fat or from previous surgery. An excessive amount of loose, sagging skin will need to be removed surgically, through cervicoplasty. For a mild to moderate amount of excess skin, a suture suspension technique may produce the desired results.

Muscle La xit y and Skin Tens io ning: Neck-L ift Pr o ced ur es

Both open and closed neck-lift procedures are discussed next, with emphasis on trends toward combining neck lift with face lift, when desired and appropriate, and new minimally invasive techniques, particularly the “trampoline” neck lift

Anes thes ia

For open surgical procedures, general anesthesia is preferred. The primary reason, beyond patient comfort, is the number of blood vessels in the neck and the potential for signifi ant blood loss during dissection. General anesthesia can decrease bleeding through better control of a patient’s overall hemodynamics. When general anesthesia is not possible or is avoided by preference, local infiltration can be performed with spinal catheters in combination with intravenous sedation. Nerve blocks are not as effective in this area. The tumescent technique works well: sterile solution is mixed with local anesthetic, bicarbonate, and epinephrine. Th s technique numbs tissue and decreases bleeding, which assists with dissection.

K23345_Pu_c22 23_Neck Rejuv_r5_cl_317-334.indd 320

4/3/2015 8:19:25 AM

Chapter 22 

Neck Rejuvenation

Box 22-1  What an Isolated Neck Lift Can and Cannot Do It can: • Eliminate excess jowl fat overhanging the jawline • Tighten and lift skin • Include platysmaplasty: tightening of the platysma muscles • May require general anesthesia • Last 3 to 7 years, depending on skin elasticity and support It cannot: • Improve the labiomandibular fold—the sag just below the corner of the mouth, beside the lower lip and chin • Resolve the problem of excessive hanging skin

OPEN NECK-LIFT PROCEDURES Multiple options for open neck rejuvenation procedures have been described in the literature. Yet information about these procedures can be confusing. Particularly misunderstood is the difference between cervicoplasty, in which the surgeon trims excess skin and lifts emaining skin into place, and platysmaplasty, which alters the platysma muscles (also called platysmal plication). In many cases these procedures are performed together.

Isolated or Formal Neck Lift Th s is well described by Joel Feldman,11 a pioneer in face-lift nd neck surgery and author of Neck Lift, a landmark book that provides step-by-step details about specific neck-lift procedures. An isolated neck lift increases defin tion of the jawline and eliminates the jowl. It is most useful for younger patients who want rejuvenation of the neck, but either do not need or do not want a complete face lift. See Box 22-1 for what the isolated neck lift can and cannot do.

Steps in Traditional Open Neck Lift 1. Anesthesia: The subcutaneous tissues in the submental and cervical regions are infiltrated with tumescent solution in the form of 30 ml of 1% lidocaine mixed with 1 ml of epinephrine (1:1000) in 1 L of Ringer’s lactate, to help minimize blood loss and maintain a relatively clean operating fi ld during dissection (Fig. 22-2). 2. Access: Both a standard preauricular and postauricular incision is made with a No. 15 blade (Fig. 22-3). 3 . Dissection: Wide medial and lateral neck undermining is performed to free fibrous attachments of the superfic al platysmal fascia from the dermis. (Th s assumes that the patient has skin laxity and poor platysmal muscle tone.) Dissection is performed under direct vision with fiberoptic lighting and countertraction. The cheek and submandibular regions are extensively undermined. The skin flaps are joined in the midline submental region. NOTE: 3 mm of subcutaneous fat should be left on all skin flaps to avoid skin irregularities, adhesions, and dimpling. Care should be exercised in sculpting excess platysmal fat, because this will be a primary determinant of the postoperative appearance of the neck.

321

322

Part III 

Rejuvenation Surgery of the Face

Fig. 22-2  Subcutaneous infiltration of the submental and cervical regions with tumescent solution prior to an open neck-lift procedure.

Fig. 22-3  The preauricular and postauricular incisions commonly used in open neck-lift procedures. Dissection begins with freeing the fibrous attachments of the superfic al platysmal fascia from the dermis.

4 . Plication: Lateral platysmal plication is performed by placing multiple 4-0 Mersilene sutures from the muscle to the sternocleidomastoid fascia. If recurrent banding is present from the free medial platysmal muscle margins, a medial plication is performed through a 1 to 2 cm submental crease incision. The inferomedial fibers of the platysma are incised up to 1 to 2 cm, followed by reapproximation of the free medial edges with interrupted 4-0 Mersilene sutures. No removal of muscle is necessary. If the midline decussation is intact, imbrication of the muscle is performed to tighten the muscular sling and sharpen the cervicomental angle. Th s medial imbrication provides a smooth submental contour. 5 . Skin excision and closure: Excess skin is removed and the skin flap redraped without tension. Closure is then performed in layered fashion with the subdermal and subcuticular sutures of choice.

Corset Platysmaplasty Corset platysmaplasty (platysmal plication) is a procedure fi st described and popularized by Feldman.11 The inner edges of the flat, elastic platysma muscles are linked to the overlying skin by fi e connective tissue fibers. With aging, the muscles lose elasticity and tone, causing the relaxed skin-muscle complex to sag,

Chapter 22 

Neck Rejuvenation

Box 22-2  What Corset Platysmaplasty Can and Cannot Do It can: • Correct neck cords • Improve the shape of the jawline • Improve neck contour in transverse dimension • Require general anesthesia • Last 3 to 7 years, depending on skin elasticity and support It cannot: • Correct jowling (which is best addressed by a lower face lift • Eliminate the ear scars associated with face and neck lift

leaving visible vertical cords, often referred to as a “turkey wattle” or “turkey gobbler” neck. By joining the two edges of the muscles together at the midline, they create a single sheet of platsyma. The vertical cords or bands should no longer be visible. Once the muscles are tightened in the midline below the chin, lateral traction on the platysma then creates a sling that elevates the soft tissues below the jawline. Access is through a small horizontal incision hidden under the chin. The procedure is often combined with a lower face lift. eneral anesthesia is preferred. See Box 22-2 for what corset playmaplasty can and cannot do.

Combined Neck and Face Lift The combined neck and face lift s the most popular open procedure today to rejuvenate the neck. The typical candidate has lost too much tone and elasticity to get the desired results with a neck lift lone, or he or she simply seeks more extensive facial rejuvenation. The procedure combines the benefits of platysmaplasty, and cervicoplasty if necessary, with other procedures that improve the overall facial appearance. For example, to improve the labiomandibular fold at the time of a neck lift, a l wer cheek lift s performed. Th s leaves the upper cheek and its nasolabial fold nearly as is. To improve both the nasolabial and labiomandibular folds, a full cheek or full face lift is performed with the neck lift

Minimal Access Cranial Suspension (MACS) Lift Minimal access cranial suspension (MACS) lift s a frequently performed combination face and neck lift (Fig. 22-4). A relatively simple procedure, it produces elegant results and has a reduced recovery time compared with more invasive open procedures. Most appealing is the advantage of a combined procedure—the ability to suspend the midface and neck at one time—which is achieved without telltale visible signs of a traditional face lift; there is no scar behind

323

324

Part III 

Rejuvenation Surgery of the Face

30°-45°

Fig. 22-4  Access and extent of soft issue dissection in a MACS lift.

e dashed lines illustrate the plicating suture loops used to elevate the midface and neck. A third plicating suture loop can be placed in the lateral orbital region in an extended MACS lift

the ear, no retracted earlobe, and no elevated hairline. A short scar in the crease in front of the ear, behind the tragus, provides a superior-anterior approach. Local anesthesia with intravenous sedation is standard for patient comfort. Recovery typically takes 1 to 2 weeks.

Submental Lipectomy With Platysmal Plication Submental lipectomy with platysmal plication, sometimes called a modified neck lift, is a surgical procedure that combines the removal of localized fat deposits under the chin (surgical lipectomy) with a tightening of the platysma muscle (platysmal plication). Together, this combination procedure can result in a more well-defi ed neckline and jaw. The procedure can extend to removal of deep fat, and to the platysma muscle, and can include tightening of deeper weakened muscles, such as the anterior belly of the digastric muscle. It is performed through a small incision under the chin.

Gland Removal Gland removal is a controversial issue in neck rejuvenation. Excessive neck volume or a signifi ant bump from a low-lying submaxillary or submandibular salivary gland can be a major concern, particularly in male patients. Some surgeons advocate the removal of the salivary gland to alleviate a disturbing visible bump, but this is controversial. Others believe that normal anatomy should not be removed to attain aesthetic results. Because the complications associated with gland removal can be signifi ant (such as salivary cysts or nerve damage), I prefer suspension of the salivary gland rather than removal. Th s can be performed during an open or closed neck rejuvenation procedure, uing suspension sutures through the capsule of the salivary gland.

K23345_Pu_c22 23_Neck Rejuv_r5_cl_317-334.indd 324

4/3/2015 8:19:27 AM

Chapter 22 

Neck Rejuvenation

325

Postoperative Care To decrease swelling, ice and cool compression should be alternated for the first 72 hours postoperatively. Primary surgical dressings should be removed and replaced with compression bandages within 3 days, when maximum swelling is likely to have occurred. Switching to warm heat compresses at this time can help reduce bruising. Compression dressings are important for decompressing “dead space” created by neck-lift rocedures. They are best left in lace (removed for wound cleaning, sleeping, showering) for 1 week, or until a postoperative examination can be done to evaluate healing. Some surgeons recommend the natural supplements bromelain and Arnica montana for their association with reducing swelling. Drains can be placed during surgery and will be monitored by the patient until removed within one week. Patients should be instructed at the time of discharge regarding what to watch for in the postoperative period. Basic incision line care will include cleaning suture lines twice a day, followed by application of antibiotic ointment.

Results

A

B

C

D

Fig. 22-5 Th s 27-year-old woman of Philippine descent presented with the complaint of a “double chin” with excess fat. Examination revealed mild submental lipodystrophy with minimal skin excess. Submental liposuction was performed under local anesthesia through tumescent infiltration of 1% lidocaine mixed with 8.4% sodium bicarbonate. At 12 months, contour improvement is seen in the submental region, with a defi ed mandibular lower border. In the lateral view, a flatter submental plane is seen, with a defi ed cervicomental angle.

K23345_Pu_c22 23_Neck Rejuv_r5_cl_317-334.indd 325

4/3/2015 8:19:29 AM

326

Part III 

Rejuvenation Surgery of the Face

A

B

C

D

Fig. 22-6 Th s 45-year-old woman of Vietnamese descent complained of laxity in the lower third and lateral canthal regions of her face. Examination revealed mild midface ptosis in conjunction with lateral canthal depression. An extended MACS lift f the face and neck was performed, with placement of a lateral orbital plicating suture loop. She is seen 24 months postoperatively, with improved contour in the submental region and a defi ed lower border of the mandibular area. The lateral orbital canthal region has also remained elevated compared with its preoperative position.

K23345_Pu_c22 23_Neck Rejuv_r5_cl_317-334.indd 326

4/3/2015 8:19:30 AM

Chapter 22 

A

C

Neck Rejuvenation

327

B

D

Fig. 22-7 This 59-year-old woman of Chinese descent requested cervical recontouring to reduce her “thick neck.” Examination showed moderate fat excess, with a blunted cervicomental angle. Cervicoplasty with submental lipectomy and medial platysmal plication was performed under general anesthesia. Twelve months postoperatively, photographs refl ct a signifi antly improved submental contour, with a more defi ed cervicomental angle.

Management of Complications In addition to the risk of infection, serious complications can include nerve damage, blood clots, skin necrosis, numbness, and muscle asymmetries. For example, damage to the marginal mandibular nerve can cause asymmetry in the lower lip. Other complications include the following: • Irregular contours of the neck, related to uneven suspension. To correct, the procedure must be revised, reopening the surgical area so resuspension of the neck is possible with appropriate vectors. • Recurrence of skin laxity as a result of gravity, loss of suspension, and aging. Here again, correction is through resuspension. • Overresection of submental fat. Th s results in a long-term depression in the midline of the submental region. Correction involves cervicoplasty with platysmaplasty and/or fat grafting.

K23345_Pu_c22 23_Neck Rejuv_r5_cl_317-334.indd 327

4/3/2015 8:19:31 AM

328

Part III 

Rejuvenation Surgery of the Face

CLOSED NECK-LIFT PROCEDURES Minimally invasive techniques are requested today because of their reduced risks, abbreviated recovery time, and minimal scarring. Some of these procedures have been performed for more than a decade; others, while only a few years old, already offer promising long-term results that could change the future of neck rejuvenation. For patients who do not have a sharp transition between the submental area below the jawline and the anterior neck (the cervicomental angle), these procedures can quickly and effectively provide a dramatic improvement in their profile.

Suture Suspension Neck Lift More traditional suture suspension procedures use self-retaining, permanent sutures or absorbable bands to lift nd hold skin in place, the goal being the creation of a well-defi ed, sharp cervicomental angle. There are two common techniques in using sutures in this manner: cabling and plicating. In both, a permanent suture is passed subcutaneously across the anterior neck, at the level corresponding to the depth of the angle between the submental area and anterior neck. Cabling relies on connecting two points to each other and often will fail once the suture loses tension. However, cabling is the easier suspension to place. Plicating sutures hold planes of tissue together like an accordion and can produce long-term results once the tissue planes have fused as a result of scarring. Therefore the results do not rely on the suture holding tension for the long term. By contrast, the results of suture suspension typically last only up to 1 year, depending on the patient.

Cabling

The suture or band is fi st anchored into the mastoid fascia, the deep soft issues behind the earlobe. It is then passed into the neck and looped into the subcutaneous plane to pull up on the neck. The technique usually involves placing sutures into both sides of the neck. Alternatively, a single suture that is anchored on each side can be used to span the entire neck to suspend tissue and reestablish the cervicomental angle.

Plica ting

Most effective in the anterior neck, planes of muscle can be plicated in the midline to establish a new submental plane. Th s is often performed in conjunction with submental lipectomy as part of an open approach.

Trampoline Platysmaplasty A technique invented by Gregory Mueller and colleagues,12 the percutaneous trampoline platysmaplasty (TPP) accomplishes skin tensioning in a trampoline-like suspension pattern in which a surgical thread is woven back and forth across the jawline, then exits and is tightened like a shoelace at the mental crease. The procedure (FDA approved in 2009), commonly referred to as the trampoline neck lift, takes less than an hour and is very effective for long-lasting correction of the visible cords or bands associated with a loose platysma muscle.

Chapter 22 

Neck Rejuvenation

A study at the American Society of Aesthetic Plastic Surgeons (ASAPS) conference in May 2011reported on 105 patients who underwent trampoline platysmaplasty, either with a face lift or alone. The investigators concluded: “The TPP is effective and durable in properly selected patients. It works well as a stand-alone procedure and with face lifts. t also offers younger patients a less-invasive option to improve neck contours inherited through genetics. With almost 3 years of follow-up, the results appear to be long lasting.”

Fiber optic Per cu t aneo us Tramp oline Pl at ysmapl a st y

Fiberoptic percutaneous trampoline platysmaplasty is a state-of-the-art technique that uses the ImplicitGuide (iGuide, Implicitcare) surgical suture system. The fiberoptic-guided TPP creates a tensioning matrix anchored to the retaining ligaments of the skin. With numerous procedures using this minimally invasive technology, I find that the TPP is capable of achieving results comparable to a traditional neck lift in elected patients, with the following advantages: • Minimal scarring • Local anesthesia • Rapid recovery (1 week versus 3 months) • Low risk of infection • Low risk of complications such as nerve damage, blood clots, and numbness A unique fiberoptic light–tipped guide rod allows the surgeon to see through the skin exactly where the instrument is positioned as it moves (Fig. 22-8). Th s TPP can easily be performed with concurrent liposuction and with a local anesthetic. Immediate on-the-table results are evident. The fiberoptic light aids signifi antly in avoiding damage to nerves and other anatomy. It also ensures proper positioning of the suspension sutures. Other complications, such as irregularities in contour and infection, are largely avoidable with proper training, practitioner diligence, and appropriate patient postoperative care. The procedure can usually be completed in 30 to 45 minutes.

Fig. 22-8  Instruments used to perform fiberoptic-guided TPP including, from left: lancet, tissue punch, two fiberoptic wands with sutures attached, and a marking guide.

329

330

Part III 

Rejuvenation Surgery of the Face

Steps for a Fiberoptic-Guided Percutaneous Trampoline Platysmaplasty 1. Preoperatively, a facial marking guide is used to make appropriate markings on the skin of the mandible where the trampoline points will be anchored under the skin (Fig. 22-9, A). 2. The first pass of a small blunt-tipped cannula provides anesthetic infiltration to the entire submental region. Liposuction can then be performed with a handheld 4 or 5 mm cannula (Fig. 22-9, B). 3. Next, following the markings, a fiberoptic wand is passed under the skin, encircling the retaining ligaments underneath the skin with a 4-0 polyester suture. As an added aid, with each pass of the suture wand, the fiberoptic light will disappear if the instrument is deep to a nerve or muscle. Th s allows the surgeon to maintain the suture in a subcutaneous plane as a trampoline-like suture lattice is constructed (Fig. 22-9, C). 4. Finally, through two tiny puncture sites, both ends of the suture exit next to each other in the mental crease. They are tied, the suture lattice is tensioned, the submental skin is redraped, and the knot is buried (Fig. 22-9, D).

Postoperative Care Immediately after a TPP, the patient should wear a light surgical compression bandage for 24 hours. The puncture sites should be kept clean and typically will be closed up and barely visible within 1 week. Elevation of the head while asleep is helpful, but not critical to success.

A

B

C

D

Fig. 22-9  Steps in performing a fiberoptic-guided TPP. A, Placement of the marking guide that positions the trampo-

line points for the TPP. B, Passage of a blunt-tipped cannula for anesthetic infiltration. C, Construction of the trampoline suture lattice with fiberoptic guidance. D, The endpoint in the construction of the suture lattice. As these suture ends are tied, the lattice is tensioned and the overlying skin is redraped.

Chapter 22 

Neck Rejuvenation

331

Results

A

C

B

D

Fig. 22-10 Th s 59-year-old woman of Chinese descent desired noninvasive neck rejuvenation. Preoperative examination showed mandibular jowling with cervical lipodystrophy and a blunted cervicomental angle. A TPP was performed with submental liposuction using tumescent infiltration. In a 45-minute procedure, the fiberoptic-guided iGuide surgical suture system was used to create a tensioning matrix anchored to the retaining ligaments of the skin. The procedure was performed per the step-by-step list given earlier. Liposuction was performed through standard 2 mm blunt-tipped handheld cannulas. The results could be seen almost immediately. At 12 months postoperatively, photographs reveal her improved submental contour, with improved defin tion of the mandibular border and a sharper cervicomental angle, although skin excess remains. No scars are visible.

K23345_Pu_c22 23_Neck Rejuv_r5_cl_317-334.indd 331

4/3/2015 8:19:34 AM

332

Part III 

A

C

Rejuvenation Surgery of the Face

B

D

Fig. 22-11 Th s 71-year-old woman of Chinese descent was dissatisfi d with the appearance of her neck and requested noninvasive neck rejuvenation. She was willing to trade her skin excess for the benefits of a closed procedure. Examination showed gross skin laxity in the submental region with minimal lipodystrophy. A fiberoptic-guided TPP was performed with tumescent infiltration using 1% lidocaine with 8.4% sodium bicarbonate. After liposuction was performed with 2 mm handheld cannulas, a suture matrix was created with the iGuide surgical suture system, as described earlier, tensioning the retaining ligaments of the skin. Her results were visible immediately after surgery (Fig. 22-11,D). At 12-month follow-up, the frontal photograph shows improvement in her submental and cervical skin contour, with an improved cervicomental angle and mandibular border defin tion (Fig. 22-11,B). No scars were visible.

Chapter 22 

Neck Rejuvenation

Management of Complications Complications with neck rejuvenation procedures include the following: • Contour irregularity, which usually subsides within 10 days of the procedure. • Infection, the incidence of which is low. Mueller et al13 reported 3 of 105 consecutive cases over a 5-year period beginning in October 2007 that required suture removal. • Suture failure, which can occur if the suture breaks or loses tension. Th s is usually evident in the operating room and is extremely rare.

Discussion Neck rejuvenation among Asian patients can be challenging, yet extremely gratifying. Under constraints of thicker skin with less mobility, achieving desirable and long-lasting results often involves a multi-planar approach. Combined with a patient-centric approach, today’s armamentarium of open and closed techniques to neck rejuvenation has stood the test of time regarding patient satisfaction. Although increasing demand for less scarring and faster recovery among Asian patients will undoubtedly fuel new discovery, the principles highlighted in this chapter will remain the standard for what is to come.

Pearls for Success • The surgeon should not underestimate the importance of both patient examination and consultation. Not all patients’ necks will age the same way. In discussing expectations, one must consider the individual’s anatomy, with an awareness of structural changes that have occurred, such as a weakening of neck support, and anticipation of further effects of aging. • In traditional neck-lift rocedures, overaggressive excision of the submental fat pad should be avoided. The common cause of a submental concavity, it is associated with an overdone result. The surgical goal is a flat plane, neither concave nor convex. • When removing excess fat from the platysma region, one must be mindful that this is a careful sculpting process that will defi e the ultimate appearance of the neck. • If the neck is not suspended with uniform force and vector between the face and neck, the result can be an odd appearance to the neck, such as multiple irregularities and eccentric lines running in different directions. Care must be exercised not to pull too strongly in a lateral direction without applying even tension across the lower face. • Achieving the “ideal” cervicomental angle can be a pitfall if it results in a cervical submental point that is too deep or sharp.

333

334

Part III 

Rejuvenation Surgery of the Face

Refer ences 1. Brennan HG, Koch RJ. Management of aging neck. Facial Plast Surg 12:241-255, 1996. 2. Rohrich RJ, Rios JL, Smith PD, et al. Neck rejuvenation revisited. Plast Reconstr Surg 118:1251-1263, 2006. 3. Vistnes LM, Souther SG. The platysma muscle. Anatomic considerations for aesthetic surgery of the anterior neck. Clin Plast Surg 10:441-448, 1983. 4. de Castro CC. The anatomy of the platysma muscle. Plast Reconstr Surg 66:680-683, 1980. 5. Dingman RO, Grabb WC. Surgical anatomy of the mandibular ramus of the facial nerve based on dissection of 100 facial halves. Plast Reconstr Surg Transplant Bull 29:266-272, 1962. 6. McKinney P, Katrana DJ. Prevention of injury to the great auricular nerve during rhytidectomy. Plast Reconst Surg 66:675-679, 1980. 7. In memory of Cecil Steiner. Angle Orthod 59:311-312, 1989. 8. Marquardt Beauty Analysis. Huntington Beach, California. Available at www.beautyanalysis.com. 9. Ellenbogen R, Karlin JV. Visual criteria for success in restoring the youthful neck. Plast Reconst Surg 66:826-837, 1980. 10. Sommerville JM, Sperry TP, BeGole EA. Morphology of the submental and neck region. Int J Adult Orthod 3:97106, 1988. 11. Feldman JJ. Neck Lift. St Louis: Quality Medical Publishing, 2006. 12. Mueller GP, Aston SJ, Leaf N. A comparison of the tensile strength of the retaining ligaments along the lateral jaw line to the medial platysma borders: determining clinical relevance in a percutaneous platysmaplasty. Presented at the ISAPS Twentieth Congress, San Francisco, Aug 2010. 13. Mueller GP, Leaf N, Sherrell JA, et al. The percutaneous trampoline platysmaplasty technique and experience with 105 consecutive patients. Aesthetic Surg J 32:11-24, 2012.

Part IV

Cosmetic Surgery of the Eyelid

K23345_Pu_c23p_Asian Eyelid_r4_cl_10pp.indd 335

4/3/2015 8:26:54 AM

K23345_Pu_c23p_Asian Eyelid_r4_cl_10pp.indd 336

4/3/2015 8:26:55 AM

23 Special Considerations in Cosmetic Surgery of the Asian Eyelid

A

David Daehwan Park

sians have traditionally lived in accordance with a Confucian morality, especially in China, Japan, and Korea, and thus they have tended to avoid cosmetic surgery. Surgery of the face or body brings disgrace to the good name of one’s father. Because of the more recent influence of Western culture, however, cosmetic surgery has become increasingly universalized and is now frequently performed in Asia. Psychological and social factors—namely, the potential for social recognition and/or social stability—may motivate a patient to seek cosmetic surgery. Cosmetic surgery may be viewed as a quest for beauty. Surgeons should be aware of these personal, social, and psychological factors when planning a surgery, and they should maintain suffici t communication with the patient to ensure that expectations are reasonable. Women, in particular, may seek cosmetic surgery to compensate for difficulties, for instance, a breakdown of romantic relationships or general frustration with their lives; therefore surgeons should closely evaluate psychological factors in these patients. Th s chapter summarizes the anatomy of Asian eyelids, common indications for Asian cosmetic eyelid surgery, preoperative evaluation, expectations after eyelid cosmetic surgery, and issues related to surgical complications.

Anatomic Structures and Aesthetic Considerations of Asian Eyelids Double Eyelid Folds

Double eyelid folds are formed from the levator palpebrae muscle, which originates superior to the orbit and is attached to the anterior surface of the tarsal plate. Thin fibers penetrate the orbicularis oculi muscle to exit from and adhere to the dermis anterior to the tarsal plate, so that the overlying skin region is depressed when the levator palpebrae muscle contracts.1 Asians lack the thin fibers that extend from the levator palpebrae muscle to the skin and thus generally do not have double eyelid folds. Fig. 23-1 shows the anatomic differences in the upper eyelid between Asians and Westerners. The anatomic differences between the eyelids of Asians and Westerners are listed in Table 23-1.

337

338

Part IV 

Cosmetic Surgery of the Eyelid

A

B

Fig. 23-1  Eyelid preferences. A, Asian preference; B, Western preference.

Table 23-1  Anatomic Difference in Upper Eyelid Anatomy Between Asians and Westerners Anatomic Feature

Eyelids of Asians

Eyelids of Westerners

Orbital fat, skin, orbicularis oculi muscle of eyelid

Relatively thick

Relatively thin

Bone surrounding orbital area

Does not protrude

Protrudes

Preseptal fat pad location

Preseptal and pretarsal

Pretarsal

Epicanthal fold

Present

Absent

Septum-levator function point

As low as the pretarsal plane

Above tarsus

Tarsal height

6.5 to 8.0 mm

9.0 to 10.5 mm

Medial lid crease origin

Medial canthus

Medial eyelid

Presence of crease

50%

100%

Because some people do not have double eyelid folds when they are born but acquire double folds with age,2 and in some people double folds are not present in the morning but appear in the afternoon, the preceding anatomic explanation that describes a congenital arrangement of upper levator palpebrae muscle fibers extending to the dermis to form double folds is not suffici t.3 Double eyelid folds are also determined by the thickness and volume of various anatomic components of the eyelids, in particular, orbital fat, central connective tissue, subcutaneous fat, and pretarsal fat. Some researchers attribute the lack of double eyelid folds in Asians not only to eyelid fat but also to the thickness of the orbicularis oculi muscle and skin.4 From an anatomic or morphologic and dynamic viewpoint, the reason for single eyelids in Asians is a flat, non-forward-protruding forehead and abundant subcutaneous fat under the upper eyelid. Th s is in contrast to the facial anatomy of Westerners, which is characterized by protruding bony structures surrounding the eyes, such as the supraorbital arch and zygomatic bone, and relatively small amounts of fat between these bones and the somewhat deeply set eyeballs, resulting in retraction of the associated skin, which forms the double eyelid folds.

The Role of the Upper Eyelid Double Fold

In many Asians, the single fold is suitable, but in some people with a single eyelid fold, the eyelid skin sags to the extent that the eyes are partially covered when the eyes are open, causing the eyes to appear thinner than what would be typical for the actual eye size. In these cases double eyelid fold surgery may improve the appearance of the eyelids, causing the eyes to appear larger and brighter.

Chapter 23 

Special Considerations in Cosmetic Surgery of the Asian Eyelid

Adipos e Tiss ue Ar ound the Eyes

The amounts of orbital fat, central connective tissue, and subcutaneous fat tissue greatly affect the beauty of the eyes. Too much adipose tissue can cause the eyelid to appear swollen and sleepy, whereas too little upper eyelid fat can make the eyes look older, similar to the appearance of an elderly person.

Epicanth al Fold

The presence of an epicanthal fold is common in people of Asian descent. Because this can make the region between the medial canthi look wide, it gives the impression that the eyes are small and childlike. Recently, the trend has been to perform double fold and epicanthoplasty at the same time. The epicanthal folds of Asians and whites are shown in Fig. 23-2.

The Wid ths and Types of Double Eyelid Folds

In general, the width of a double eyelid fold in Asians when the eye is open is approximately 20% to 30% (2 to 3 mm) of the width of the lid fissure. Therefore, if double folds are made too wide, the double fold lines and the lid fissure will likely appear separate from each other, possibly leading to a condition that looks like ptosis. Double eyelid folds are generally divided into infold and outfold types, and the type of double fold should be selected with care to ensure a good balance with the entire face.

Lower Eyelid

Compared with the upper eyelid, the lower eyelid is less mobile and thus less active. The changes associated with aging of the lower eyelid of greatest concern are components of skin/lid laxity, herniation of fat and bulging lower eyelid, deepening wrinkles on the midface, and so on. There are several methods available for rejuvenation of the lower eyelid. In contrast to the upper eyelid, special consideration of the lower eyelid structure is most important.

Asian

White

Preseptal fat Orbital septum Levator aponeurosis

Orbital septum Levator aponeurosis Tendrils from levator aponeurosis to skin

Fig. 23-2  The epicanthal folds of Asians and whites.

339

340

Part IV 

Cosmetic Surgery of the Eyelid

Common Indications for Asian Cosmetic Eyelid Surgery Upper Eyelid (Double Fold Opera tio n)

The double fold operation is the most widely performed among cosmetic surgery procedures in Asia. Between 40% and 60% of Asians do not have double eyelid folds; thus upper eyelid skin sagging, pseudoptosis that obstructs the visual fi ld, and/or Western influences all likely contribute to the high frequency of upper eyelid surgery among Asians. The goal of upper eyelid surgery is to make dermis of the upper eyelid skin adhere to the aponeurosis of the upper levator palpebrae muscle by direct connection or indirect scar formation, which causes the eyes to appear larger when they are open and gives them a bright expression. Th s surgery can also correct entropion, an inward folding of the upper eyelid. Removal of eyelid fat can be used as an auxiliary measure.

Lower Eyelid

In recent years, lower blepharoplasty has been performed with increasing frequency in Asians. There are several specific features of the lower eyelid (for example, the palpebral bag, tear trough deformity, and cheek ptosis) that surgeons should consider before surgery, and it is important to understand these specifi features and anatomy. Several methods are available to rejuvenate the lower eyelid and restore a youthful facial contour to the patient’s face.

Per io r bit al Rejuven atio n

Invasive and noninvasive methods are available for rejuvenating the periorbital structure. Before selecting a method, it is important to know which part of the patient’s outward appearance the patient would like to change, and what the patient expects from the surgery. Th s can be accomplished by giving the patient a mirror and having the patient point out the area of concern. After a rejuvenation procedure to eliminate sagging eyelids, patients may have not only cosmetic but also functional improvement.

Preoperative Assessment Upper Eyelid

Preoperative tests include eyesight tests, which should precisely test visual acuity bilaterally. These results will be helpful if complications, such as a decrease in visual acuity, occur postoperatively, and can prevent any misunderstanding about whether visual impairment existed before surgery or if it occurred after surgery. Ptosis and/or lateral asymmetry should be identifi d and explained to the patient. If the patient has ptosis, a general double fold operation will not improve the sleepy appearance: double eyelid fold operations in patients with ptosis yield poor surgical results, and the patient may blame the ptosis on the surgery itself. To test for ptosis, have the patient close his or her eyes, and then press the eyebrows to eliminate the action of the frontal muscle. Then have the patient open his or her eyes; this action will involve only the levator palpebrae muscle. (An additional evaluation method is summarized in Box 23-1.) The left and right eyes are generally not symmetrical. In cases of asymmetry, the patient should be advised of the condition and whether it can be corrected; asymmetry should be considered when planning the procedure. In addition, the patient should be evaluated for dry eye syndrome using Schirmer’s test, which mea-

Chapter 23 

Special Considerations in Cosmetic Surgery of the Asian Eyelid

Box 23-1  Preoperative Evaluation Medical History Diabetes • Hypertension • Others: hyperthyroidism, myasthenia gravis • Previous periorbital operation history

Eyelid Function Evaluation Amount of ptosis • Levator function • Others: Hering’s test, Bell’s phenomenon

Ophthalmologic Test Visual acuity, visual fi ld • Extraocular muscle function • Schirmer’s test • Slit lamp test

sures the degree of water absorption on filter paper in 5 minutes. Normal values are 15 to 30 mm, whereas values less than 10 mm are considered low secretion. If values obtained from Schirmer’s test are marginal or low, the patient should be referred to an ophthalmologist, or a slit lamp test should be conducted.

Lower Eyelid

It is important to test eyelid elasticity before operating on the lower eyelid to ensure that the appropriate surgical method is selected. Eyelid elasticity tests include two types: the pinch test to determine if changes in the lower eyelid are caused by the relaxation of the orbicularis oculi muscle (or by the relaxation of the skin), and the snap-back test to evaluate the necessity of horizontal shortening of the lower eyelid.

Expectations After Eyelid Surgery If a double eyelid fold operation is performed, in most cases the eyes will appear larger and brighter. With age progression of skin/lid laxity, herniation of fat and bulging lower eyelid and deepening wrinkles on the midface can occur. Lower blepharoplasty and periorbital rejuvenation attempt to reverse these changes and to restore the youthful contour of the face. Th oughout the periorbital rejuvenation, patients could have functionally good results, not only from cosmetic correction but also by removing obstacles to the visual fi ld resulting from sagging eyelids.

Management of Complications Complications that may be encountered during the immediate postoperative period include corneal exposure or dryness, chemosis, hemorrhage, and hematoma (Fig. 23-3), with ecchymosis and anterior hematoma or posterior hematoma and retrobulbar hemorrhage, cellulitis and abscess, inadvertent globe penetration, or eyelid slough (Box 23-2). In the intermediate postoperative period, complications may include orbicularis oculi muscle abnormality with hypertrophy or adhesions, lacrimal system dysfunction, dry eye, medial canthal deformity, diplopia and extraocular muscle movement disorder, and exposed keratinopa-

341

342

Part IV 

Cosmetic Surgery of the Eyelid

A

B

Fig. 23-3  A, Th s patient developed a hematoma after double fold surgery. B, Two months later, the hematoma has almost resolved.

Box 23-2  Complications Early Complications • Corneal exposure • Dryness • Chemosis • Hemorrhage • Hematoma • Ecchymosis • Retrobulbar hemorrhage • Infection (cellulitis, abscess)

Late Complications • Ptosis • Ectropion • Sunken eyelid • Asymmetry • Disappearance of double fold, high fold, lower fold • Inclusion cyst • Scar

Intermediate Complications • Orbicularis oculi muscle abnormality (with hypertrophy or adhesion) • Lacrimal system dysfunction (dry eye) • Medial canthal deformity • Diplopia • Extraocular muscle movement disorder • Exposed keratinopathy

thy from incomplete eyelid closure. In the late postoperative period, possible complications include ptosis, ectropion, sunken eyelid resulting from aggressive fat resection, asymmetries (Fig. 23-4), inclusion cyst (Fig. 23-5) or scarring, disappearance of double eyelid or shallowness, high fold (too much pretarsal show compared to normal) (Fig. 23-6), and lower fold (smaller pretarsal show compared to normal). After the lower eyelid operation, the complications described previously can appear; in addition, eyelid malposition (especially ectropion) and recurrence of the malar bag may be present. Eyelid malposition, especially ectropion (Fig. 23-7), results from senile ectropion, high myopia, or the protruding eyes of Graves oculopathy, excessive soft tissue injury of the lower eyelid.

Chapter 23 

A

Special Considerations in Cosmetic Surgery of the Asian Eyelid

343

B

Fig. 23-4  Asymmetry and its correction. A, Preoperative view; B, 6-month postoperative view.

A

B

Fig. 23-5  An inclusion cyst developed on this patient’s right upper eyelid. A, Preoperative; B, postoperative.

A

B

Fig. 23-6  High fold and its correction. A, Preoperative view; B, 16-month postoperative view.

A

B

Fig. 23-7  Patient with ectropion. A, Preoperative; B, postoperative.

K23345_Pu_c23p_Asian Eyelid_r4_cl_10pp.indd 343

4/3/2015 8:26:57 AM

344

Part IV 

Cosmetic Surgery of the Eyelid

Pearls for Success • The anatomic differences in the upper eyelid anatomy between Asians and Westerners include the presence or absence of double folds, volume of adipose tissue, presence of epicanthal fold, widths and types of double folds, and lower eyelid laxity. • For successful surgical outcomes, these differences should be considered. In many cases, cosmetic surgery creates a youthful and attractive appearance, but complications can arise easily, so surgery should be undertaken with care. • For satisfactory results of eyelid surgery, it is important that the contours of the upper and lower eyelids be harmonious. • Preoperative evaluation should be done carefully, to reduce risks of complications and increase the likelihood of satisfactory results.

Refer ences 1. Cheng J, Xu FZ. Anatomic microstructure of the upper eyelid in the oriental double fold. Plast Reconstr Surg 107:1665-1668, 2001. 2. Ishikawa T, Harii K. Double fold in adults: morphology and changes with aging. Plast Reconstr Surg 87:206, 1989. 3. Hiraga Y. Blepharoplasty in Orientals. Probl Plast Reconstr Surg 1:504, 1991. 4. Kobayashi K, Shirakabe T. Blepharoplasty in Orientals: nonincision technique. Probl Plast Reconstr Surg 1:496, 1991.

K23345_Pu_c23p_Asian Eyelid_r4_cl_10pp.indd 344

4/3/2015 8:26:57 AM

24 Upper Blepharoplasty David Daehwan Park

M

any techniques have been developed to produce double eyelid creases in Asians. In the past, incision techniques were commonly performed. Recently, nonincision techniques have become popular and are the procedure of choice for many Asian patients. Surgical techniques for upper blepharoplasty should not be complicated. Trauma to upper eyelid tissues needs to be minimized, with removal of the smallest amount possible of subcutaneous tissues and fat— in particular, orbital fat. In addition, surgeons need to avoid contact with the tarsal plate and the levator palpebrae muscle.

Types of Surgical Techniques Surgical techniques to form double eyelids can primarily be divided into two types: nonincision and incision. Incision methods involve an incision through the upper eyelid skin.

Nonincis io n Metho d

Nonincision upper eyelid surgery does not result in a visible scar over the eyelid. The two methods of suture placement are buried and nonburied. In the nonburied method, the suture is placed over the upper eyelid skin (Fig. 24-1). A

Levator aponeurosis

Skin

B

Fig. 24-1  Two types of nonincision double eyelid surgery. A, Buried suture method. Th dashed line represents the path of the suture. B, Nonburied suture method.

Upper lid fold

Tarsus

345

346

Part IV 

Cosmetic Surgery of the Eyelid

Nonincision Nonburied Suture Method The nonincision nonburied suture method is an easy, straightforward procedure; however, the sutures can become loose postoperatively. The suture can be passed directly through the tarsal plate, or it can be passed through tissue above the tarsal plate (Fig. 24-2).

Nonincision Buried Suture Method The nonincision buried suture method is the most frequently performed nonincision method (see Fig. 24-1). In Korea, this technique has been used in approximately half of all young people who have undergone eyelid surgery. With this method, two or three small incisions are made, and full-thickness, penetrating buried sutures are placed to induce adhesion. Although this method is a little more complicated than suturing the eyelid skin, it has advantages. Suture removal is not needed, and in patients who have epicanthal folds, an epicanthoplasty can be performed fi st, followed by a nonincision buried method, while the width of the double eyelids on the epicanthi are adjusted (Fig. 24-3 and Box 24-1).

A

B

Fig. 24-2  Two types of nonincision nonburied suture methods. A, The suture is passed directly through the tarsal plate. B, The suture is passed through tissue above the tarsal plate.

A

Levator aponeurosis

Skin

B

Upper lid fold

Tarsus

Fig. 24-3  A, Nonincision buried suture method. B, Epicanthoplasty with a nonincision buried method of double eye-

lid fold formation. The blue circles show the location of the small holes, and the dashed line represents the design of the epicanthoplasty.

Chapter 24 

Upper Blepharoplasty

Box 24-1  Nonincision Buried Suture Options for Double Eyelid Surgery • One buried suture is placed. • Two buried sutures are placed. • Th ee buried sutures are placed.

• Many buried sutures are placed. • Successive buried sutures are placed.

Fig. 24-4  Correction of an upward Mongoloid

canthal slant. In a nonincision buried double eyelid procedure, the desired outcome is to create double eyelids that are smaller on the sides of the lateral canthi than the sides of the medial epicanthi.

Box 24-2  Partial-Incision Double Eyelid Surgical Techniques • One small, single incision is made in the center of the upper eyelid. • One small, single incision is made on the lateral side, and two buried sutures are placed on the medial side. • One small, single incision is placed on the lateral side, and successive buried sutures are placed on the medial side.

In patients whose eyes slant upward at the lateral canthi (a Mongoloid slant), a nonincision buried double eyelid technique can be performed to improve the shape of the double eyelids. The double eyelid near the lateral canthus is made a little smaller than the double eyelid near the epicanthus (Fig. 24-4).

Incis io n Metho d

An incision method is appropriate in patients with thick, puffy eyelids. One of two types of incision may be employed, depending on the length of the incision: a full incision and a partial incision. Partial-incision double eyelid surgery is further divided into several types (Box 24-2). Similar to the nonincision method, the incision method has two subdivisions: the buried suture method and the nonburied suture method. Methods that do not use permanent, buried sutures usually result in removal of too much tissue and induce postoperative tissue adhesion.

Indications Nonincis io n Metho ds

Nonincision methods of upper blepharoplasty are easy to implement; thus they are frequently used. However, in patients with thick soft issue in their eyelids or a large volume of orbital fat, the double eyelid lines may not be permanent, and cysts or inclusion cysts can develop. Therefore these methods are most effective in patients with small upper eyelid muscles and minimal subcutaneous and orbital fat (Fig. 24-5).

347

348

Part IV 

Cosmetic Surgery of the Eyelid

Fig. 24-5  Typical patient for a nonincision method of upper blepharoplasty.

Fig. 24-6  Typical patient for an incision method of upper blepharoplasty.

The nonincision buried method, in particular, is often preferred, because the surgery is simple, short, and results in fewer scars. It is an appropriate procedure for patients who need to resume daily activities quickly and those who might wish to reverse the procedure later to restore their original eyelid shape.

Incis io n Metho ds

Incision methods are appropriate for patients whose upper eyelid skin has been extended, those whose upper eyelids have large amounts of fat, those who need distinct double eyelid lines for their occupation, those whose left and right eyelids are quite different because of traumatic scars, and those with scars from complications after radical nonincision reoperations on double eyelids. Most surgical techniques create permanent or temporary adhesion between the skin and the tarsal plate or between the skin and the levator aponeurosis. In patients whose upper eyelid skin sags signifi antly and those with excessive fat tissue, a combination of a buried method and an incision method produces the best results (Fig. 24-6).

Par ti al-I ncis io n Metho ds

Partial-incision upper blepharoplasty combines the advantages of incision and nonincision methods. It can be performed in eyelids of any orbital fat layer thickness but also implemented through surgical techniques so that good results can be obtained. With the partial incision technique, good results can also be obtained (see Fig. 24-7). It is preferable to incision methods if the entire eyelid has thick skin or a large amount of fat.

Preoperative Assessment The method of double eyelid formation is selected based on the surgeon’s preference and the following general patient features: the nature of the skin, the amount of subcutaneous orbital fat, the volume of the upper eyelid skin, and the patient’s preference.

Chapter 24 

Upper Blepharoplasty

The choice of a nonincision buried suture method or an incision method depends on assessment of the following patient factors: • The function of the levator palpebrae muscle • The amount of orbital and subcutaneous fat • The presence and degree of upper eyelid ptosis • The amount of upper eyelid skin • The function of the frontal muscle • The thickness of the eyelid in the area where a double eyelid will be formed Many complications can develop in patients who have upper eyelid ptosis preoperatively, even when a buried method is used (see Chapter 25). Therefore assessment of the amount and nature of upper eyelid skin is particularly important.

Preoperative Design The location and length of the double eyelid lines is designed preoperatively, regardless of the surgical technique to be used. For both the nonincision buried suture methods and the incision buried suture methods, the design should be made with the patient in a seated position. The patient’s position—seated versus supine—can signifi antly affect the location of the eyebrows, the orbital fat, and the function of the frontal and levator palpebrae muscles. Double eyelids can be divided into two types. The infold type of crease is not visible near the medial canthus, because the double eyelid line coincides with the lid margin. The double eyelid becomes wider toward the lateral canthus. The outfold type of double eyelid crease is visible at the medial canthal side and gradually becomes wider toward the lateral canthus. With the patient’s eyes closed, the most desirable double eyelid creases are determined using a forceps, loop wire, or lacrimal duct bougie to gently press on the upper eyelid skin until the eye opens (Fig. 24-7). After the completion of the preoperative markings, the surgeon should show the design to the patient to ensure that it is consistent with his or her desired result. As previously mentioned, the double eyelid width is closely related to the type of double eyelids produced. Double eyelids should look as natural as possible (Fig. 24-8). An appropriate relationship between the double eyelid lines is confi med when the eyes are closed and open. A

B

Fig. 24-7  Design of the fold line in nonincision double eyelidplasty. A, Using a loop wire. B, Using forceps.

349

350 A

Part IV 

B

Cosmetic Surgery of the Eyelid

C

D

Fig. 24-8  A and B, The level of the double eyelid is measured on the conjunctival and skin sides. C and D, The level of

needle insertion is compared on the conjunctival side and the skin side, with buried suture lines marked on the skin and conjunctiva. Th s patient has markings on the lower eyelid for fat removal through a lower blepharoplasty.

A

B

b

a d

c

Fig. 24-9  A, The level of the double eyelid line lies at or below the upper level of the tarsal plate. B, The difference of the double eyelid level between the opened and closed eye. (a, The height of the supratarsal double fold; b, the height from the eyebrow to the supratarsal double fold; c, the height of the tarsus; d, the height of the fold when the eye is open.)

Fig. 24-10  The width of the double eyelids when the eyes are open should be approximately 20% to 30% of the width of the eyelids when they are closed.

The height of the double eyelids when the eyes are closed is determined based on the distance from the eyelid margins to the double eyelid lines as well as the distance from the eyebrow to the double eyelid line (Fig. 24-9). In general, the width of the double eyelids is considered to be the most balanced if approximately 20% to 30% of this width is visible when the eyes are open (Fig. 24-10). In Koreans, the ideal height of a double fold when the eyes are open is 2 to 4 mm (Fig. 24-11). Generally, the height of the supratarsal fold is approximately 6 to 8 mm in Asians. The height of the tarsal plate that is fi ed to the dermis should be 1 to 2 mm higher than the height of the double eyelid line (Fig. 24-12). When necessary, incision lines may be marked on the center or the lateral side of the eyelid for fat or muscle band removal.

Chapter 24 

351

Upper Blepharoplasty

Fig. 24-11  The ideal height of the double fold is approximately 2 to 4 mm when the eyes are open. 2-4 mm

Fig. 24-12  The height of the double eyelid line is 1 to 2 mm smaller than the width of the tarsal plate. The red circle represents the buried suture.

More than 10 mm 3-5 mm

Skin excision

Muscle excision

6-8 mm

Fig. 24-13  Design of an upper blepharoplasty. A

B

C

D

Fig. 24-14  Depth of a double eyelid and range of movement. A, A static superfic al fold involves fix tion of the double

eyelid line to the tarsal plate, less dissection, and a nonburied suture. B, A static deep fold involves fold fix tion to the tarsal plate, extensive dissection, and a buried suture. C, A dynamic superfic al fold requires fix tion of the line to the levator aponeurosis, less dissection, and a nonburied suture. D, A dynamic deep fold requires fix tion of the line to the levator aponeurosis, extensive dissection, and a buried suture.

For incision buried suture methods, I recommend that the easiest surgical method be selected to minimize the skin incision and tissue excision and to achieve the most natural appearance (Fig. 24-13). In most Asian patients, fix tion of double eyelid lines to the levator aponeurosis results in dynamic double eyelids. Very little of the double eyelid lines will be visible when the eyes are closed, but a large portion will be seen when the eyes are open. On the other hand, if double eyelid lines are fixed to the tarsal plate, static double eyelids will result. The double eyelid lines will be evident, even when the eyes are closed. If large amounts of tissue are detached or if buried sutures are added, deep double eyelids will be created, and if buried sutures are not added, superfic al double eyelids will result (Fig. 24-14).

352

Part IV 

Cosmetic Surgery of the Eyelid

Surgical technique Nonincis io n Metho ds

As anesthetic in buried double eyelid operation, 1% lidocaine with 1:100,000 epinephrine is infiltrated under predetermined points of the subcutaneous tissue and the conjunctival side. Usually 0.5 ml of lidocaine with epinephrine is enough in each of the conjunctival and skin sides. The syringes should be 1 ml volume and have 23-gauge or thinner injection needles. To avoid damaging the blood vessels, subcutaneous tissue should be infiltrated at several points to the shallowest depths possible. In the conjunctiva, thin running blood vessels should be avoided when the lidocaine is injected. Because heavy bleeding will cause trouble in performing the buried method of double eyelid formation, care should be taken to prevent the patient from bleeding. Surgery should be avoided for women during their menstrual period, because they can bleed easily.

Suture Insertion Above the Tarsal Plate One method of placing a nonincision nonburied suture is the ligation method, which involves the passage of the suture through tissue above the upper tarsal plate (see Fig. 24-2, B). This kind of Asian upper blepharoplasty is commonly called the suture technique. The suture is inserted on the conjunctival surface, immediately above the upper edge of the tarsal plate. Th s maneuver induces scar adhesions through local inflammation to create double eyelids. It has a low probability of the suture to scratch the cornea. The suture is removed 5 to 10 days postoperatively.

Suture Insertion Through the Tarsal Plate Another method involves the passage of a suture through the tarsal plate (see Fig. 24-2, A). The upper eyelid is turned inside out, and the needle is inserted approximately at the junction of the upper and middle third of the tarsal plate from the medial to lateral upper eyelid. The suture (2-0 silk) is passed through the tarsal plate to the planned line on the skin surface. The other end of the suture is passed through the tarsal plate 3 to 4 mm lateral to the fi st suture and then through the skin. The two suture ends are ligated. Th s technique is performed three to six times on the planned line, and the sutures are removed 5 to 10 days postoperatively. The main shortcoming of suture insertion through the tarsal plate is the possibility of scratching the cornea with the sutures if they are not suffici tly buried on the conjunctival surface. Th s can cause keratitis. Fig. 24-15 shows this method. A nonincision suture method that is widely used involves suturing glass beads to the eyelids1 (Fig. 24-16). It is advantageous to place the beads before ligation, because this evenly distributes the pressure, thus enabling the creation of a smooth, natural double fold line. In this method, the upper eyelid is turned inside out, and a size 5 round needle attached to 2-0 white silk is passed through the full thickness of the upper eyelid on the planned line. It pierces the conjunctiva at approximately two thirds the height of the tarsal plate. The other needle is passed in the same manner 4 to 5 mm laterally. Four or five sutures are placed in this manner on each upper eyelid. A 2 mm diameter glass bead is placed on each suture and then the sutures are ligated. When necessary, skin may be excised after sutures are ligated. The skin sutures and beads are removed 5 to 7 days postoperatively, depending on the patient’s progress. Temporary triple eyelids that form on the upper eyelids after surgery can be corrected by affix g tape. Th s should remain in place for several days. Immediate postoperative eyelid swelling is more severe with this method than with other methods. The swelling typically subsides considerably within 2 to 3 days after removal of the beads. Rarely, the double eyelid crease becomes shallow but does not disappear.

Chapter 24 

353

Upper Blepharoplasty

A

B

C

D

E

F

Fig. 24-15  Double eyelid surgery in which the suture penetrates the upper part of the tarsal plate. A, Preoperative de-

sign. B, A 2-0 silk suture is passed through the conjunctiva to the skin. C and D, The needle is passed through the skin. The same technique is performed with the other end of the suture, approximately 3 to 4 mm laterally. E, After all sutures are placed, they are ligated. F, The suture tags are shortened.

D A

B

C

Bead

E

F

G

H

Fig. 24-16  Nonincision double eyelid operation using beads. A, Preoperative skin markings. B, Preoperative con-

junctival markings. C, Sutures have been placed through the tarsus and before beads are applied. D, Cross-sectional view. E, White silk sutures are placed through the tarsus, and beads are added. F, The beaded sutures are ligated. G, The skin is excised after ligation. H, The skin is sutured.

K23345_Pu_c24 Upper Bleph_r6_cl_0345-0376.indd 353

4/9/2015 1:25:48 PM

354

Part IV 

Cosmetic Surgery of the Eyelid

Nonincision Buried Methods Many nonincision buried suture methods are available. The shape of the double eyelids depends on the position of the suture (Fig. 24-17). One Buried Suture The placement of one buried suture in the center of the eyelid is an easy method. It is suitable for patients with double eyelid lines that are inconsistently present, those in whom double eyelids appear when tape is affixed, those with very thin eyelids, and those whose eyelids lack fat. The skin is pierced partial thickness with a No. 11 blade at two points. These are located 6 to 8 mm above the eyelid margin and approximately 1 cm apart. On the conjunctival side, a No. 11blade is used to pierce two points into which buried sutures will be inserted. These are made approximately 1 mm above the tarsal plate and at the same interval as the incisions on the skin. A double-armed 6-0 or 7-0 nylon suture is used. The needles are passed through the eyelid from the two points on the conjunctival side to the points on the skin surface. The needle in the incision line on the side of the nose is then passed through subcutaneous tissue to the incision site on the lateral side. The suture is ligated on the skin side over the lateral incision line. Tension needs to be appropriate. One stitch each is sutured on the two small incision sites on the eyelid (Fig. 24-18). Beak and Kim2 performed this method on 762 patients and obtained good results. The surgery had to be repeated in approximately 5% of the patients.

A

B

Fig. 24-17  Buried suture locations. A, Cross-sectional

view of the upper eyelid. (a, Levator muscle; b, Whitnall’s ligament; c, levator aponeurosis; d, Müller’s muscle; e, inner septum; f, tarsus; g, conjunctiva; h, outer septum; i, orbital fat.) B, Shape of the buried suture. (1, The suture can be placed in the levator aponeurosis to produce a double eyelid with a signifi ant width; 2, the suture can be placed through the tarsal plate of the same level; 3, the suture can be placed through the tarsal plate of the lower level to create a double eyelid with a short width; a, a part of the suture is exposed over the conjunctiva; b, the entire suture is buried in tissue.)

a a

b c

h e

i

d

1 2 3

f

b

g

A

B

C

D

Fig. 24-18  Single buried suture technique. A, The skin is marked. B, The needle is passed through to the tarsus or above it. C, The suture is ligated over the lateral incision. D, Immediate postoperative result.

Chapter 24 

355

Upper Blepharoplasty

Two Buried Sutures Double eyelids can be produced using two buried sutures. Four shallow small skin incisions are made to the level of the dermal layer along the planned line on the upper eyelid skin. Th s method is appropriate for patients with a small amount of fat in the eyelids. It is often performed when good results are simulated preoperatively by pressing on the eyelids with only a pin end. In cases where double eyelid lines appear when only pressed by pin ends or in cases where patients want double eyelid lines that are not apparent, only one buried suture with one skin incision may be made. However, if the skin is hard and contains a large amount of fat or if the skin is thick, more than three sutures are recommended. Mutou and Mutou3 used the following procedure (Fig. 24-19). On both the medial limbus side and the lateral limbus side of this skin, the markings consist of two point holes about 5 mm apart. The markings on the conjunctival side are the same as those on the skin side. A double-armed 6-0 nylon suture is used. The eyelid conjunctiva is sutured shallowly, sutures spreading at an interval of 5 mm in the transverse direction at a point around 3 mm above the superior margin to the inverted upper tarsal plate. The needle is passed from a point 1 to 2 mm lateral to the sutured point to the planned line on the skin surface. The needle at the other end is passed through the eyelid to the skin surface in the same method. The needle at one end of the suture is passed through subcutaneous tissue to the other point where a small incision has been made. The two suture ends are ligated with appropriate tension and placed into the incision line (Fig. 24-20).

A

B

Fig. 24-19  Double buried suture

technique described by Mutou and Mutou. A, Insertion of a buried suture on the tarsal plate side. B, Ligation of the suture on the skin.

A

D

B

C

E

Fig. 24-20  Double buried suture technique. A, Th skin is incised. B, Conjunctival design. C, The needle is passed through to the tarsus or above it. D, After the needle penetrates the skin, the sutures are ligated on the skin side. E, The immediate postoperative result.

356

Part IV 

Cosmetic Surgery of the Eyelid

A

B

C

D

E

F

Fig. 24-21  Buried technique by three-point fix tion. A, Skin markings. B, The needle is passed through the tarsus or

above it, depending on what type of double fold is being created. C, The needle penetrates the skin. D, Ligation of the fi st buried suture. E, Ligation of the last buried suture. F, The immediate postoperative result.

Th ee Buried Sutures Another method involves three buried sutures. Small incisions are made at six points in three areas on the skin along the planned double eyelid line. A double-armed needle threaded with 7-0 nylon suture is passed through the tarsus itself or the conjunctiva immediately above the inverted tarsal plate to transversely pass through 3 to 4 mm of the tarsal plate or the conjunctiva immediately below the tarsal plate. The needle is passed through the skin incision at the other end. The suture ends are ligated and placed in the incision line (Fig. 24-21). If small incisions are made on three points of the skin on the planned double eyelid, double-armed 6-0 or 7-0 silk, nylon, or catgut suture is inserted at the eyelid conjunctiva immediately above the inverted tarsal plate. The suture is passed through intermediate tissue as if it is being ligated, and the two ends of the suture are ligated at the skin incision site, so the suture will be completely buried. However, because the suture will pass through one skin incision, the suturing width of the suture will be narrow; thus the suture will sink down to a deeper area and the double eyelid effect will be reduced. Multiple Buried Sutures Multiple buried sutures can be placed to produce double eyelids (Fig. 24-22). Usually, four or five points are established, although seven points are sutured in patients with a large amount of upper eyelid fat and hard skin. Increasing the number of sutures allows fi e adjustments of double eyelid line curves and reduces the number of cases in which double eyelid lines do not remain permanent. Although the position of the double eyelid line is measured in the examination room, it is measured again before surgery using a caliper. The suture lines are marked using gentian violet at four or five points on the planned line. The plan is revised when necessary while the patient sits on the operating table. Before the operation begins, 1% lidocaine with epinephrine is infiltrated under the predetermined points in the subcutaneous tissue and the conjunctival side. Usually 0.5 ml of lidocaine with epinephrine is enough in each of the conjunctival and skin sides. The syringes should be 1 ml volume and have 23-gauge or thinner injection needles.

Chapter 24 

A

D

B

357

Upper Blepharoplasty

C

Fig. 24-22  Design for a nonincision double eyelid surgery involving

multiple buried sutures. A, Double eyelid design and marks for the suture are made both inside and outside the eyelid. B, A double-armed needle threaded with a 7-0 nylon suture is inserted directly over the conjunctival side of the tarsal plate. The suture can either penetrate or not penetrate the conjunctiva. C, Sutures extend from the skin markings. D, The suture should be placed superfic ally and then tied.

A

B

Fig. 24-23  Continuous buried suture technique. A, The fi st suture is placed. B, The second suture is placed. The solid line represents the tarsal plate; the dotted line represents the dermal suture line.

During these revisions the patient is placed in a upright position by operating room personnel to ensure symmetry of the eyes. The upper eyelid is turned inside out. I use a 6-0 or 7-0 nylon or synthetic absorbable double-armed suture with 18 mm long 3∕8 circle needle. A needle is inserted through the upper eyelid conjunctive at the center of the lid fissure, approximately 3 mm above the superior margin of the tarsal plate. It is passed to the planned line on the skin surface. The other needle is inserted through the upper eyelid conjunctiva at a point approximately 4 mm away from the first point and passed through the skin in the same method. The suture on the conjunctival surface may not be inserted below the conjunctiva. Because sutures exposed to the conjunctiva are rapidly buried below the conjunctiva, suturing by having sutures below the conjunctiva is not indispensable. The distance between the points of needle entry should be 3 mm in the area of the lateral canthus and 2 mm in the intermediate area. At these two points on the skin, one end of the suture should be placed in the subcutaneous tissue, or the skin area between the two skin incision sites should be abraded so that the suture can be easily buried (see Fig. 24-22). Continuous Buried Suture In the continuous buried suture technique, 7-0 nylon sutures are used to suture the subcutaneous tissue and the tarsal plate alternately in an S shape, and the two ends of the suture are ligated. Th s method is widely used, because the longer-lasting results of double eyelids can be created using this method (Fig. 24-23). The main drawback of this method is that double eyelid lines can become less noticeable or disappear. The use of 7-0 white nylon suture can help to prevent this problem. The use of 7-0 nylon (transparent or blue), Prolene, or extremely thin Dexon is recommended for the buried sutures. Blue, thin nylon sutures are easy to fi d if they need to be removed.

358

Part IV 

Cosmetic Surgery of the Eyelid

Incis io n Metho ds

Permanent Buried Suture Method Double eyelids can be produced using a permanent buried suture method. An incision 5 to 7 mm wide is marked on the center of the lid fissure. An excision line 7 to 8 mm wide (maximum) is marked above the planned line. The skin between these two lines is excised. The excision line along the orbicularis oculi muscle is opened using the tip of a scissors. A transverse skin incision is made, penetrating the tarsal membrane to expose the orbital fat, which is not excised. The dermis of the inferior margin of the wound is ligated with the levator palpebrae muscle at three points with 6-0 or 7-0 nylon sutures. The skin is closed with 7-0 nylon sutures. Sutures are removed 3 to 5 days postoperatively. Th s procedure is attributed to Fernandez and Learbert.4 These authors mainly used a method in which they extracted orbital fat from the lateral section and placed buried sutures at the most superior margin of the tarsal plate. Using one suture, they sutured part of the tarsal plate and the levator palpebrae muscle aponeurosis together and then together with the dermis4 (Fig. 24-24). A modifi d Fernandez method is available.4 To make distinct double eyelids using the Fernandez II method, the height of the skin between the skin incision line and the lid margin is 7 to 8 mm. The distance of the excision line above the incision line is 8 to 10 mm (maximum). The orbicularis oculi muscle is excised 3 to 5 mm from the inferior margin of the incision. The tarsal membrane is excised in the same range. An appropriate amount of orbital fat is removed. Subcutaneous fat and intermediate connective tissue are not excised. The subcutaneous tissue and dermis are sutured on the inferior margin of the incision and the levator muscle. The skin is successively sutured4 (Fig. 24-25). The skin excision and orbital fat excision vary according to each patient’s requirements. Th s technique is shown in Fig. 24-26. A

B

Fig. 24-24  The Fernandez method. A, Excision of

Exposed orbital fat

surplus skin. Orbital fat is exposed, but not excised. B, The lower margin of the incision is ligated with the levator palpebrae muscle aponeurosis. (From Fernandez LR. Double eyelid operation in the Oriental in Hawaii. Plast Reconstr Surg 25:257-264, 1960.)

A

B

C

Fig. 24-25  Fernandez method. A, Excision of orbicularis oculi muscle. B, Excision of orbital fat. C, Suture.

Chapter 24 

359

Upper Blepharoplasty

A

B

C

D

E

F

G

H

I

J

K

L

Fig. 24-26  Incision blepharoplasty. A, The skin is incised and the orbicularis oculi muscle is exposed. B, The orbital

septum is exposed through a small incision over conjunctiva. C, A part of the orbital fat is exposed. D, Incision through the orbital septum for fat removal. E, The orbital fat is exposed. F, The levator aponeurosis is exposed. G, Orbital fat is removed. H, Bleeding is controlled with electrocautery. I, The orbicularis oculi muscle in front of the tarsal plate is excised. J, The upper portion of the tarsal plate is grasped with a forceps. K, The upper portion of the tarsal plate is sutured to the dermis. L, Immediate postoperative result.

K23345_Pu_c24 Upper Bleph_r6_cl_0345-0376.indd 359

4/9/2015 1:25:53 PM

360

Part IV 

Cosmetic Surgery of the Eyelid

Fig. 24-27  Adhesion is induced by tissue dissection and pas-

sage of the suture from the skin to the tarsal plate to the skin. Skin excision, septum exposure and removal of orbital fat as well as dermis over tarsal plate and fat under orbicularis oculi, and ligation suture were performed.

Tissue Dissection to Induce Adhesion Double eyelids can be produced by fixing the skin to the tarsal plate (or aponeurosis) or by fixing the muscle to the skin using tissue dissection. The extent of skin removal is determined based on its goal. I performed skin excision, septum exposure, and removal of orbital fat, dermis over the tarsal plate, and fat under the orbicularis oculi muscle, followed by ligation suturing. Compared with the placement of buried nonabsorbable sutures, the advantage of this method is that all sutures are removed 3 to 6 days postoperatively, preventing granuloma formation or corneal irritation. I prefer to remove a moderate amount of tissue. The pretarsal tissue is sutured to the superior margins of the two wounds in the order of skin to tarsal plate to skin 5 to 8 mm from the lid margin. I typically remove sutures 5 to 7 days postoperatively (Fig. 24-27). Extent of skin removal is determined by its goal.

Induction of Tissue Adhesion Using Ligation Sutures The use of ligation sutures to induce tissue adhesion is a relatively old method and not widely used. Th s method involves placing ligation sutures above the upper skin incision margin to induce adhesion (see Fig. 24-16).

Par ti al-I ncis io n Metho d

In patients with signifi antly sagging upper eyelid skin or excessive fat tissue, a partial-incision method comprising a buried method and an incision method produces optimal results. Partial-incision methods have the advantages of both techniques and are applicable in eyelids of any orbital fat layer thickness.

Small Single Incision on the Center of the Eyelid One partial-incision method involves designing a small single incision on the upper eyelid (Fig. 24-28). The patient is asked to open the eyes, and thin wires are placed on the upper eyelids to determine the location of double eyelid folds. While the patient is under general anesthesia, a 5 to 7 mm single partial incision is made on the center of the eyelid at the level selected preoperatively. The skin is carefully detached up to the tarsal membrane using iris scissors with sharp ends. An incision is made on the tarsal membrane, and the fat is removed using hemostatic forceps and electrocautery. The orbicularis oculi muscle is not removed from this area. The skin is detached upward to the upper boundary of the tarsal plate. With a vertical mattress suture pattern, 7-0 black nylon sutures are placed through the dermis and tarsal plate to produce double eyelid lines, and the incision is closed.

Small Single Incision and Placement of One Buried Suture The double eyelid lines on the medial side of the eyelid can be made more distinct (Fig. 24-29). Th s technique involves a single central incision through which buried medial and lateral sutures are placed or a

Chapter 24 

361

Upper Blepharoplasty

C A

D

B Incision

Fig. 24-28  Double eyelid surgery with a single central incision with fat removal. A, Design of double eyelid surgery with central minor incision. B, After fat removal. C, Sectional view. D, Sectional view of double eyelid surgery by suturing the dermis to the tarsal plate.

A

B

C

D

E

F

G

Fig. 24-29  Double eyelid surgery with a single lateral incision and buried suture on the medial side. A, Incision. B, Protruded fat. C, Removed fat. D and E, Medial buried suture. F, Fixing the tarsal plate and dermis. G, View after suturing.

K23345_Pu_c24 Upper Bleph_r6_cl_0345-0376.indd 361

4/9/2015 1:25:54 PM

362

Part IV 

A

Cosmetic Surgery of the Eyelid

B

C

D

E

F

G

H

Fig. 24-30  Double eyelid surgery with a lateral minor incision and buried sutures on two lateral sides. A, The eyelid

is marked, and a lateral incision is made. B, Fat protrudes through the incision. C and D, Fat is removed. E, Two lateral buried sutures are placed. F, The dermis of the lateral incision and tarsal plate are fixed with a buried suture. G and H, Immediate postoperative result.

single lateral incision through which two buried medial sutures are placed (Fig. 24-30). The length of the central incision is approximately 5 mm, and the depth is determined by the orbital septum. A 7-0 double arm nylon suture is placed through conjunctiva, Müller’s muscle, aponeurosis, orbital septum, orbicularis oculi muscle, and skin. Closure is performed with a 7-0 black nylon suture.

Small Single Lateral Incision and Successive Buried Medial Sutures The purpose of this procedure is to make a smoother, longer-lasting double fold. Fat or muscle is removed through a lateral incision. The surgeon must ensure that double eyelid lines are maintained with continuous buried sutures (Fig. 24-31).

Chapter 24 

363

Upper Blepharoplasty

A

B

C

D

E

F

Fig. 24-31  Double eyelid surgery with a lateral single incision and two buried sutures on the medial side. A, A lateral

incision is made. B and C, Protruded fat is excised. D and E, Two buried sutures are placed medially, and the dermis is fi ed to the upper portion of the tarsal plate. F, The incision is sutured.

Postoperative Care Immediately after surgery, a small amount of oxytetracycline hydrochloride is given as a topical antibiotic ointment on the suture site. Although it is not absolutely necessary to give antibiotics and antiinflammatory agents because postsurgical infection is rare, we do prescribe them for 3 to 5 days after surgery, along with eyedrops and analgesics. Patients are given sterile gauze pads for cleansing their eyes. The course of postoperative swelling is reviewed, and patients are given instructions about face washing, bathing, and wearing makeup. Those who have surgery on both eyes should wear sunglasses, and those who have one eye corrected can wear a gauze pad over the upper eyelid. Alternatively, a hole is cut in a gauze pad to fashion an eye patch that is worn over the eye. Patients who have only one eye corrected typically prefer to use sunglasses after surgery. These procedures are performed on an outpatient basis, and the patients return for follow-up visits on postoperative days 1 and 5 (when their sutures are removed), and at 1 month, 3 months, and 6 months after surgery.

K23345_Pu_c24 Upper Bleph_r6_cl_0345-0376.indd 363

4/9/2015 1:25:56 PM

364

Part IV 

Cosmetic Surgery of the Eyelid

Results In my practice, approximately 60% of cosmetic blepharoplasty patients undergo an incision technique, and in 40% I use a nonincision technique. The incision techniques include skin excision only, skin excision and nonburied suture fix tion, skin excision and buried suture fix tion, and blepharoplasty with simultaneous ptosis correction. The complication rate is approximately 6.6% for the incision group and 5% for the nonincision group. Most patients are happy with the cosmetic result, although the overall outcome, success rate, and patient satisfaction rate are a little higher in the nonincision group in my practice.

Fig. 24-32 This patient had double eyelid surgery through the nonincision, nonburied suture method, in which the suture penetrated the upper part of the tarsal plate.

Fig. 24-33 Th s patient underwent a single buried suture procedure.

K23345_Pu_c24 Upper Bleph_r6_cl_0345-0376.indd 364

4/9/2015 1:25:57 PM

Chapter 24 

Upper Blepharoplasty

365

Fig. 24-34 Th s patient had a nonincision double eyelid operation with beads.

Fig. 24-35 Th s patient underwent a nonincision procedure with two buried sutures. The buried sutures are located just above the medial limbus and lateral limbus line of the eye.

K23345_Pu_c24 Upper Bleph_r7_bs_0345-0376.indd 365

4/10/2015 1:16:16 PM

366

Part IV 

Cosmetic Surgery of the Eyelid

Fig. 24-36 Th s patient had nonincision double eyelid surgery with a buried suture technique involving three-point fix tion.

Fig. 24-37 Th s patient had an upper blepharoplasty with the modifi d Fernandez method.4

Fig. 24-38 Th s patient had an incisional upper blepharoplasty that involved skin excision only. The skin is excised, then the septum is opened and fat removed. Skin closure is performed without fix tion.

Chapter 24 

Upper Blepharoplasty

367

Fig. 24-39 Th s patient had an upper blepharoplasty with tissue removal and adhesion. No buried sutures were placed.

Fig. 24-40 Th s patient had an upper blepharoplasty combined with senile ptosis correction.

K23345_Pu_c24 Upper Bleph_r6_cl_0345-0376.indd 367

4/9/2015 1:25:59 PM

368

Part IV 

Cosmetic Surgery of the Eyelid

Fig. 24-41 Th s patient had an upper blepharoplasty by tissue removal and fix tion with buried suture. The double eyelid folds are created by suturing the upper end of the tarsal plate or the levator palpebrae aponeurosis after skin excision.

Management of Complications Complications after upper blepharoplasty occur less frequently for experienced surgeons and usually develop after incision techniques. Two types of complication are observed: temporary and persistent. Temporary complications develop immediately after surgery and usually heal without problems. An exception is hematoma, which can be prevented with meticulous hemostasis. Persistent complications include ectropion, asymmetry, enophthalmos, ptosis, lagophthalmos, and scars. Some of these problems require secondary upper blepharoplasty or revision procedures.

Hemat oma and Hemor r ha ge

Ecchymosis and anterior hematomas do not require treatment if only petechiae are present. However, hematomas with distinct boundaries may require treatment after suture removal. Retrobulbar hemorrhage can result in blindness in rare cases. A major cause of this complication is damage to blood vessels. Th s does not occur when the tarsal membrane remains intact and only the skin is excised; it results when the fat is excised and blood vessels bleed deep into the orbit. In some cases the eyeball becomes extremely hard. Findings in patients with retrobulbar hemorrhage include increased eyelid petechiae, remarkable exophthalmos, and resultant pain. In addition, ophthalmoplegia can develop from reduced visual acuity or pupillary reflex. Observations can include Marcus Gunn pupils, hard orbital surroundings, and elevated intraocular pressure with retrobulbar hematoma. Management involves imme-

K23345_Pu_c24 Upper Bleph_r6_cl_0345-0376.indd 368

4/9/2015 1:26:00 PM

Chapter 24 

Upper Blepharoplasty

369

diate removal of the sutures to open the incisions. Ice packs are placed and diuretics or antihypertensive medications are given. If the intraocular pressure continues to increase, a lateral canthotomy is performed. An emergent ophthalmology consultation is often needed.

Cor neal Expos ur e or Dr yness

The cornea and the conjunctiva can be directly injured from the surgical procedure or from drying during surgery. They can be damaged if a bandage is worn for too long after surgery or if the bandage is worn with the eye open. The cornea can undergo dessication if tears evaporate because of incomplete closure of the eyelid. Eye ointment should be given. After discussion with an ophthalmologist, damage to the corneal epithelium is evaluated using a fluorescein stain and slit-lamp biomicroscopy. Postoperatively, placement of a cold compress and elevation of the patient’s head can help to reduce corneal exposure and dryness.

Chemos is

Chemosis can develop immediately after surgery or after time has passed. It is attributable to (1) corneal drying, (2) incomplete eyelid closure, (3) an allergic reaction to oral or injected drugs, and (4) subconjunctival edema. Treatment involves frequent cleaning of the cornea and conjunctiva with eyedrops or ointment. A steroid is applied locally, or intraocular pressure is periodically tested. In severe cases, exposure of the tarsal membrane and the conjunctiva are prevented by temporarily suturing the upper and lower eyelids or by other operations.

Dr y-Eye Synd r ome and Epipho ra

Dry eyes are caused by incomplete eyelid closure, temporary eyelid lags, lagophthalmos, and evaporation phenomena. Most cases resolve without treatment within several weeks to several months. If the problem persists as an anaphase complication, it is diagnosed as dry-eye syndrome. Upper blepharoplasty can aggravate dry-eye syndrome. Thus various tests, including those mentioned previously, should be conducted preoperatively. Persistent postoperative dry-eye syndrome can develop into keratitis or keratohelcosis, which is treated in close cooperation with an ophthalmologist. Epiphora that develops immediately after surgery is most often caused by edema at the surgical site. Th s prevents discharge of tears and is relieved in most cases as the edema decreases.

Infl ammatio n and Infectio n

Cysts can develop as a foreign body reaction to sutures that are not well absorbed. Management involves suture removal. Small, yellowish-white inclusion cysts can develop if skin drainage tubes become blocked. The contents of the tube are removed using needles. If the inclusion cysts are large, holes are drilled in the tube with a needle through which a high-frequency wave is passed, and the contents are extracted. Infection is rare after upper blepharoplasty. If it occurs, palliative treatment is performed with antiinflammatory and antibiotic agents or open drainage. Antibiotics should be used in combination with a warm compress. Because severe infection is rare in the eyelid, many surgeons do not give oral antibiotics prophylactically.

K23345_Pu_c24 Upper Bleph_r6_cl_0345-0376.indd 369

4/9/2015 1:26:00 PM

370

Part IV 

Cosmetic Surgery of the Eyelid

Fig. 24-42  Th s patient developed an inflammatory cyst around the buried suture.

Fig. 24-43  Th s patient developed an infection postoperatively. Treatment consisted of combination therapy including oral antibiotics, drainage, and a topical antibiotics ointment.

An abscess or cyst forms around buried sutures relatively frequently. It will not cause problems if the sutures are removed and the pus is expressed with slight compression on the site (Figs. 24-42 and 24-43).

Blep har opt os is

Temporary mild to moderate blepharoptosis from edema develops in most patients who have eyelid surgery. If it persists longer than several days, the levator palpebrae muscle may have been damaged or the levator aponeurosis cut during surgery. Patients who have blepharoptosis preoperatively require careful assessment. If it does not improve by approximately 6 months postoperatively, secondary surgery should be performed in the usual ptosis surgery method (Figs. 24-44 and 24-45).

Hyper tr ophic Scars

The skin of the upper and lower eyelids is generally very thin, and hypertrophic scars rarely are a problem. They typically resolve without further treatment after approximately 6 months.

Chapter 24 

Upper Blepharoplasty

Fig. 24-44  Th s patient had unilateral ptosis after upper eyelidplasty that was corrected with revision surgery.

Fig. 24-45  Th s patient had bilateral ptosis after upper eyelidplasty and required revision surgery.

Hypertrophic scars can develop in the medial canthus and at incision sites near the medial canthus. If possible, sutures should be removed 3 or 4 days postoperatively, and the medial canthus region should be fi ed with tape. If thickening progresses, a small amount of a steroidal agent should be injected and the patient observed. Although severe hypertrophic scars can be treated by local injection of steroid two or three times at 10-day intervals, complications can occur. Therefore ophthalmologic examinations, including intraocular pressure measurements, are necessary in some cases. Other persistent or late complications include asymmetry, undercorrection or overcorrection, eyelid depression, and loss of the double eyelid folds. Other problems related to newly created double eyelids are primarily discussed in Chapter 25.

Pearls for Success • A careful preoperative evaluation is essential for a successful outcome. • The operative method should be appropriate for the patient. • Preservation of fat, skin, and the orbicularis oculi muscle helps to reduce the need for sunken eyelid correction. • To minimize the degree of ptosis, pretarsal skin is affixed to the supratarsal tissue (the levator aponeurosis). • The lateral eyebrow and lacrimal gland can be internally suspended in conjunction with upper blepharoplasty.

371

372

Part IV 

Cosmetic Surgery of the Eyelid

Expert Commentary Susumu Takayanagi Upper blepharoplasty is the most popular aesthetic operation in Asian countries, and many types of proce­ dures are available. Some patients wish to have double eyelids, and some want to change the height of their double eyelid folds. Others desire correction of ptosis, sunken eyes, and/or sagging eyelids to create a youthful appearance. Several techniques are available to produce youthful eyelids, including filler or fat graft injection, skin-muscle resection, subbrow resection, en bloc fat grafting, and levator shortening.

Preoperative Assessment Preoperatively, the quality of the patient’s skin is assessed. Some Asians have a tendency toward hypertrophic scarring, keloid formation, and/or pigmentation. In patients with white, red, or oily skin, the eyelid scar will not be visible. In patients who have either atopic dermatitis or asthma, most hypertrophic scars and pigmentation will become visible. Patients who have dark, dry skin require great care. Scars elsewhere on the body should be evaluated, because eyelid scars may have the same qualities. Skin thickness and the condition of the fat in the eyelid are assessed carefully. The function of the levator muscle is estimated by measuring the muscle movement and the eyelid’s vertical height. The eyelid shape is evaluated, including its relation to the eyebrow position. Patients are informed of existing asymmetry. Some patients do not realize that their eyes were asymmetrical until after surgery.

Double Eyelid Surgical Procedures Incis io n Techniq ue

Incision techniques are very reliable and produce permanent results. To determine a patient’s desired double eyelid width, a paper clip is used to press on the eyelid to create a temporary double eyelid. Th s is done while the patient’s eyes are closed and the patient is facing a mirror. The patient is asked to open the eyes and assess the shape and width of the proposed double eyelids (Fig. 24-46, A). After an incision is made, a 2 to 3 mm width of the orbicularis oculi muscle is excised (Fig. 24-46, B). Next, the orbital septum is opened at the caudal part, the fat tissue is retracted, and the levator aponeurosis is identifi d. The upper and lower edges of the incision are sutured to the levator aponeurosis (Fig. 24-46, C). If redundant skin is present between the new double eyelid crease and the eyelashes, a small amount of skin can be excised just below the new double eyelid fold.

Bur ied Sutur e Techniq ue

In a buried suture technique, four tiny holes are made for needle insertion on each side of the eyelid along the marked double eyelid line (Fig. 24-47, A). On the conjunctival surface, the same distance is marked between the new double eyelid line and the upper eyelid margin (Fig. 24-47, B). A 1 to 2 mm shallow incision is made on the reverse side of the tarsus for the insertion of the needle; 7-0 clear nylon is inserted from the reverse side of the tarsus to one of the superfic al skin holes (Fig. 24-47, C and D).

Chapter 24 

A

373

Upper Blepharoplasty

B

C

Fig. 24-46  A, Various double eyelid depths can be simulated by gently pressing a device on the eyelid while the patient

opens the eyes. B, Using an incision technique, a 2 to 3 mm width of the orbicularis oculi muscle is removed. C, The suture is placed through the skin of one edge of the incision, the levator aponeurosis, and the skin of the other edge.

A

B

C

D

Fig 24-47  A, Four holes are made for needle insertion. B, On the reverse side of the eyelid, the width of the double

eyelid is marked and a small incision is made. C, A 7-0 nylon suture is inserted on the conjunctival side, and the needle is pulled through one of the holes in the skin. D, The other end of the suture is inserted to the surface. The suture ends are tied with appropriate tension by putting the needle into the tissue.

The suture should not be exposed on the reverse side of the tarsus or the surface of the eyelid. The buried suture technique may be adequate for patients who require a short recovery time so they can return quickly to daily activities. Disadvantages are possible impermanence of the double eyelid and asymmetry, which can be corrected with an incision technique. Patients should be informed of these potential problems preoperatively.

Red ucing the Wid th of the Double Eyelid

Some patients want the width of their double eyelids reduced after surgery. If the original surgery involved a buried suture technique, an incision technique is made. When the original operation involved an incision technique, then the new incision is placed at the desired level of the double eyelid and just superior to the

K23345_Pu_c24 Upper Bleph_r6_cl_0345-0376.indd 373

4/9/2015 1:26:05 PM

374

Part IV 

Cosmetic Surgery of the Eyelid

scar of the original procedure. The skin between the two incisions is removed, including the surgical scar. In both cases, the septum of the orbital fat beneath the orbicularis oculi muscle is identifi d and opened, and fat tissue is pulled down to the level of the new double eyelid line. The suture is then placed through the skin, the levator aponeurosis, the lower edge of the orbital fat, and the skin. If insuffici t fat tissue extends downward to the desired new double eyelid line, a small volume of free en bloc fat graft is placed without sutures beneath the stretched-thin orbital fat to prevent a sunkeneye effect (Fig. 24-48).

A

B

Fig. 24-48  A, An incision technique was used in this 29-year-old woman to create double eyelids. She was not satisfi d with the result, because the double eyelids were too wide. B, She is shown 3 months after a revision procedure.

Skin-M uscle Res ectio n and Subbr ow Res ectio n

Two techniques are available for patients with redundancy of the upper eyelid: skin-muscle resection around the double eyelid line and subbrow resection. When more than 5 to 6 mm of skin is resected in the upper eyelid, a subbrow resection should be selected (Fig. 24-49). If a wide area of skin is removed, including or around the double eyelid, the skin just above the double eyelid will be very bulky and unnatural.4 When less than 5 to 6 mm of skin is resected, then redundant eyelid skin can be resected to include the original double eyelid line.

A

B

Fig. 24-49  A, Th s 56-year-old woman desired correction of her ptotic upper eyelids. Because the skin redundancy

was severe, subbrow skin resection was planned. B, A 9 mm width of subbrow skin was resected. The patient is shown 6 months postoperatively.

Chapter 24 

Upper Blepharoplasty

Fat Grafting

When the upper eyelids have a slightly concave deformity, fat injection can be a solution. Usually, the fat tissue is harvested from the abdominal wall through the umbilicus and is then purifi d. An 18-gauge needle is used to make two or three holes through which fat is injected with a 21-gauge dull needle. Th ough these needle holes, the 21-gauge needle is used to undermine the area with a crisscross method beneath the orbicularis oculi muscle. Fat is injected in as many places as possible in the smallest volume possible. A total amount of less than 1 cc of fat should be injected in one session. The volume of injected fat can be estimated according to the volume of injected local anesthesia. When the deformity appears smooth and youthful as anesthesia is injected, the total volume of anesthesia is measured, and the same volume plus an additional 20% can be injected. Immediately after injection, each needle hole is sutured with 7-0 nylon (Fig. 24-50). If necessary, sessions can be repeated 2 to 3 months after the fat injection until the patient is satisfi d with the result.

A

B

C

Fig. 24-50  A, Th s 39-year-old woman requested correction of the concave deformity of her right eyelid. B, The injection area was marked. A total of 0.8 cc of fat was injected. C, Her result is good 4 months postoperatively.

Levat or Sho r tening

Ptosis of the upper eyelid is a sign of aging. Most middle-aged or elderly patients also have a sunken-eye deformity. Th s can be corrected by levator shortening. Preoperative assessment includes the function of the levator muscle, the redundancy of the eyelid skin, the width of the double eyelid if present, and the position of the eyebrow. When the levator muscle function is less than 9 mm, I prefer to resect the muscle. When the levator muscle function is more than 10 mm, a tucking technique without resection of the muscle is preferable. In most patients, levator muscle function is more than 10 mm, and the levator aponeurosis is advanced without

375

376

Part IV 

Cosmetic Surgery of the Eyelid

resection of the muscle. Because the amount of fat tissue that advances forward with levator shortening is sometimes unpredictable, patients should be informed that simultaneous en bloc fat grafting may be required or that fat injection or en bloc fat grafting can be performed at a later surgery (Fig. 24-51).

A

B

Fig. 24-51  A, Th s 53-year-old patient had blepharoptosis. A tucking technique was performed, and 2 mm of skin was resected together with the underlying orbicularis oculi muscle. B, The patient is shown 4 months postoperatively.

Levator shortening is relatively difficult. After a temporary suture is placed in the levator aponeurosis and tarsus, it may be helpful to place the patient in a sitting position and tell him or her to look upward and close the eyes. Th s maneuver can be useful for obtaining a good result.

Refer ences 1. Kobayashi K, Shirakabe T. Blepharoplasty in Orientals: nonincision technique. Probl Plast Reconstr Surg 1:496, 1991. 2. Beak SM, Kim SS. Oriental blepharoplasty: single-stitch, nonincision technique. Plast Reconstr Surg 83:236-242, 1989. 3. Mutou T, Mutou H. Intradermal double eyelid operation and its follow-up results. Br J Plast Surg 25:285-291, 1972. 4. Fernandez LR. Double eyelid operation in the Oriental in Hawaii. Plast Reconstr Surg 25:257-264, 1960.

25 Secondary Upper Blepharoplasty

A

Chau-Jin Weng

mong aesthetic plastic surgeons and laypersons in Asian countries, the term upper blepharoplasty typically includes the creation of supratarsal folds in individuals who have small or nonexistent supratarsal folds. Thus the surgical technique used in Asian patients is somewhat different from that used for upper blepharoplasty in most white patients. In those of European ancestry, upper blepharoplasty is most often performed to excise loose tissue in aging eyelids and is performed together with lipectomy if necessary. Supratarsal fix tion is rarely necessary for whites. Although plastic surgeons in Asian countries primarily perform upper blepharoplasty on aging patients, younger patients also request this procedure, mainly for the creation of supratarsal folds, and some aging patients request this as well. In addition, most younger patients require supratarsal fix tion.1-4 Techniques for upper blepharoplasty for Asians may be divided into surgical and nonsurgical methods. In the nonsurgical method, also called the suture (or stitches) method, three to five sutures are applied through a small punch wound. These sutures create traction with the levator aponeurosis on the subcutaneous tissue of the eyelid, forming the traction fold at the supratarsal area of the eyelid, like lifting Venetian shades, when the patient’s eyes are open. There are many different ways to perform suture fix tion.5-8 The surgical methods used to perform upper blepharoplasty are delicate procedures requiring the excision of skin and the removal of excess fatty tissue. Lipectomy of the retroorbicularis oculi fat and the indispensable supratarsal fix tion also may need to be performed. The surgeon can usually apply the supratarsal fix tions more precisely and fi mly under direct vision with an open approach.2,4-9 Both the nonsurgical suture method and the surgical suture method have many variations. Their advantages and disadvantages are discussed in Chapter 24. The tissue layers of the upper eyelid are very thin, soft, and fragile. Some tissue layers have particular dynamic functions, whereas other layers play a static role. Upper blepharoplasty involves dissection of tissue layers down to the posterior wall of the orbital septum. Because “the eyes are the windows to the soul,” it is very important for surgeons to achieve artistic eye shapes with well-matched, tailored supratarsal folds for each patient. Patients present with very specifi goals, and the plastic surgeon should make his or her best effort to achieve the patient’s goals, given the constraints of the patient’s facial anatomy.

377

378

Part IV 

Cosmetic Surgery of the Eyelid

Preoperative Assessment Evaluation of a patient with an unfavorable result from a previous surgery is the same as that for evaluating a primary surgery candidate. The most important thing is to listen to his or her concerns about the upper eyelids and to understand the problem from an anatomic as well as an aesthetic point of view. Usually the patient can describe exactly where the problems are and discuss issues about the lids that the surgeon cannot see. However, some patients may be most concerned about relatively minor problems rather than the obvious area of concern. The aesthetic surgeon must focus on two aspects of the patient’s periorbital condition. The fi st is the anatomic relationship of the periorbital region, which must be observed to determine the cause of the patient’s problem. The surgeon has to analyze the harmonious condition of the eyes and periorbital tissues. Some degree of asymmetry might be caused by nonharmonious periorbital tissue; for example, the position of both eyebrows will frequently cause asymmetry of both supratarsal folds. Second, if the patient really has a problem caused by a previous surgery, the surgeon must request the patient’s preoperative photographs from the previous surgery to help determine whether there were any hidden problems that were not revealed before that surgery. A surgeon can speculate on possible problems, but errors that lead to the need for secondary surgery frequently come from the fi st surgeon’s failure to perform the necessary systematic observation and assessment of the patient’s ophthalmologic condition before surgery. It is essential for the surgeon performing a revision surgery to communicate with the surgeon who performed the previous operation to determine any problems that resulted from that surgery. If the current issue resulted from a revision surgery, the surgeon needs to review the patient’s presurgical photographs and the operative record to discover any anatomic problem or a step in the surgery that might have been missed. To trace the preoperative history of the patient’s ophthalmologic condition, the surgeon must review the patient’s general physical condition and photographs at different ages. Th s analysis will provide very important information to apply to the revision procedure. By understanding the cause of each unfavorable result, the surgeon can perform the revision not only to achieve good results but also to prevent any further complications.

Common Complications and Unfavorable Results of Primary Blepharoplasty Box 25-1 lists the most common complications or unfavorable results of upper blepharoplasty according to their frequency.

Box 25-1  Common Complications or Unfavorable Results of Upper Blepharoplasty Surgery 1. Loosening of the supratarsal folds 2. Asymmetry of the supratarsal folds 3. Narrowed supratarsal folds 4. Wide supratarsal folds 5. Blepharoptosis that becomes evident after upper blepharoplasty 6. Multiplicative deformities

Chapter 25 

Secondary Upper Blepharoplasty

As with most surgical procedures, complications or unfavorable results sometimes occur in upper blepharoplasty. The causes of most of these problems can usually be determined and are avoidable if the surgeon understands the anatomic characteristics of Asian eyes, masters the surgical techniques for each procedure, and stays alert for hidden pathologic conditions. Thus it is of utmost importance for the surgeon to conduct an in-depth observation, examination, and communication to understand the patient’s demands and to achieve a surgical goal that will satisfy both the patient and surgeon. Complications large and small can occur with upper blepharoplasty. Unforeseen problems can arise as a result of miscommunication between the patient and surgeon and from failure to understand the patient’s concept of beauty, such as a minor difference in the shape and width of the supratarsal folds or even a tiny scar.

Anal ysis of Common Complica tio ns and Unf avorable Res ul t s Loosening of the Supratarsal Folds

Loosening of the supratarsal folds is the most frequently seen unfavorable result of upper blepharoplasty. Th s problem can be caused by several factors, including the stitches method being the surgical technique most likely to loosen the supratarsal fold. The most frequent cause is the use of wrong suture material for supratarsal fix tion. Some surgeons prefer to use absorbable suture thread, such as catgut, to perform the fix tion between the levator aponeurosis and the subcutaneous tissue. These suture materials will be absorbed shortly before the scar adhesion matures and fi mly adheres, and that will fail to cause traction of the aponeurosis to the subcutaneous layer. Thus the newly created supratarsal fold will fade gradually. Another frequent cause of a fading supratarsal fold is using the wrong plan for tissue fix tion. The proper supratarsal fix tion is between the levator aponeurosis and the subcutaneous layer, where the fix tion can establish a rather solid connection or adhesion. When the supratarsal fix tion is improperly placed in the wrong tissue layer—whether the levator aponeurosis to the subcutaneous fatty layer, or between the subcutaneous layer and the preaponeurotic layer or the preaponeurotic areolar tissue—the supratarsal fold will eventually be loosened (Fig. 25-1). A

B

C

D

Fig. 25-1  Th s woman underwent a revision upper blepharoplasty to correct loosening of the supratarsal folds in both of her upper eyelids.

379

380

Part IV 

Cosmetic Surgery of the Eyelid

Some surgeons contend that the supratarsal fix tion will yield a good result when it can be performed between the subcutaneous layer and the inferior flap of the anterior septum. However, the stability of this combined fix tion is very questionable. The success of creating a supratarsal fold through this method is mainly dependent on the strength of the connection between the subcutaneous layer and the levatoaponeurotic tissue. The orbital septal layers, especially the anterior layer, is very thin and fragile, particularly the lower leaf near the lower cul-de-sac, which is often located at the lowest level of the preseptal region. The fix tion between the subcutaneous layer and the lower leaf of the anterior septum can only exert very weak traction; in addition, because the lower leaf of the anterior septum is located near the upper part of the preseptal area, this fix tion cannot provide adequate preseptal skin traction to create a lasting fold.5-14 It is generally thought that a strong and static supratarsal fix tion must be established under defin te fix tion between the subcutaneous layer and the levator aponeurosis or tarsal plate.

Asymmetry of the Supratarsal Folds There are four potential causes of asymmetry of the supratarsal folds: 1. Failure to use preoperative markings. We have found that in patients with asymmetrical supratarsal folds after primary blepharoplasty, the surgeon performed the procedure without making preoperative markings. Depending solely on the naked eye to judge the proper width of the supratarsal folds is unreliable. It is best to use a rule or caliper to measure the width of the proposed incision line. It is also difficult to fi d the exact level for the incision, especially without the guidance of proper markings, when the tissue is swollen after injection of a topical anesthetic agent. In addition, asymmetry will occur if the surgeon marks both upper eyelids but fails to place the skin of both lids under the same tension. 2. Improper anchoring. Improper anchoring of the supratarsal fix tion on both sides might cause unequal stretching of the supratarsal skin. Th s will also cause some discrepancy in the shape of the supratarsal folds. 3. Lack of attention to brow location. Another situation that will cause asymmetry of both upper lid folds is the surgeon’s failure to assess the position of both of the patient’s brows preoperatively. As a result, the lid fold on the lower brow side will eventually be covered by the drooping lid skin, which will be exaggerated by the downward pressure of the lowering brow. 4. Missed ptosis diagnosis. One of the several factors that will definitely cause asymmetry of the width of the lid folds after upper blepharoplasty is unveiled blepharoptosis, with different degrees of weakness in one or both upper eyelids that has gone undetected by the primary surgeon. Because many Asians do not have supratarsal folds, the margin and lashes of the upper lid are generally covered by the drooping upper lid skin. Thus mild ptosis may be missed that can eventually lead to fold asymmetry. The surgeon must carefully assess for this before surgery. 9,11-13 Regardless of the cause, asymmetry of the supratarsal folds can be corrected by redefini g the premise under which the initial upper blepharoplasty was performed. Th s is accomplished by performing a revision to increase the width of the narrow fold, redraping the preseptal skin flaps under the same tension of supratarsal fix tion, or reducing the wider lid fold to match the contralateral side (Fig. 25-2). Sometimes it is necessary to revise both upper eyelids by increasing the width of the narrowed side and simultaneously reducing the width on the wider side to achieve optimal symmetrical supratarsal folds (Fig. 25-3). A different technique will be required to correct blepharoptosis (see the “Correcting Postoperative Blepharoptosis” section later in this chapter).

Chapter 25 

Secondary Upper Blepharoplasty

A

B

C

D

381

Fig. 25-2  To correct this woman’s asymmetrical supratarsal folds, it was only necessary to revise the side of one upper

eyelid.

A

B

C

D

Fig. 25-3  To revise this woman’s asymmetrical supratarsal folds, it was necessary to revise both eyelids. Reducing the

width of the supratarsal fold on one side and simultaneously increasing the width of the supratarsal fold on the other side achieved better results.

K23345_Pu_c25 26_Sec Upper Bleph_r5_cl_377-394.indd 381

4/3/2015 8:36:04 AM

382

Part IV 

Cosmetic Surgery of the Eyelid

A

B

C

D

Fig. 25-4  Patient 1: A, Th s woman had narrowed supratarsal folds after having upper blepharoplasty. B, The results after revision show more pronounced supratarsal folds. Patient 2: C, Th s woman also had narrowed supratarsal folds after having upper blepharoplasty. D, The results after revision show more distinct supratarsal folds.

Narrowed Supratarsal Folds The rather sophisticated problem of narrow supratarsal folds can be troublesome for both aesthetic plastic surgeons and oculoplastic surgeons. What is the optimal width of a supratarsal fold? There is no standard answer. Most plastic surgeons who perform upper blepharoplasty for Asian patients agree that the optimal width of a supratarsal fold is 5 to 8 mm at the central point of the upper eyelid.2,3,8,9,12,14 The selection of the width of the supratarsal fold is determined by several factors, including the patient’s preference and the patient’s general periorbital condition, including the size of the orbit and the condition of the soft tissue of the upper eyelid and the epicanthus. Supratarsal folds narrower than 5 mm will soon become unnoticeable, because the upper lid skin will droop and cover the lid margins9,12 (Fig. 25-4). Patients frequently use their frontalis muscle to lift oth brows, thus reducing the pressure of the drooping brow on both upper eyelids and releasing the interference of the drooping upper lid on the vision of both eyes. The visual interference is released after upper blepharoplasty, when the patient no longer needs to use the frontalis muscle to lift he brow. The brow will often return to a lower relaxed state when the postoperative edema subsides and the scar softens. The relaxed, drooping brow will exert downward pressure on the upper lid skin to cover the supratarsal fold, and the visible part of the supratarsal fold will be narrower than expected (Fig. 25-5).

Wide Supratarsal Folds A lid fold width greater than 8 mm is generally not acceptable. The limitation of the lid fold width in Asians is generally narrower than that of individuals of European descent. On average, the supratarsal folds, skulls, and bony orbital structure of Asians are shorter than those of whites. Some Asian patients unrealistically request upper lid folds that mimic those of Westerners, leading some surgeons to relent and disregard the patient’s anatomic realities by performing a procedure that can only yield unsatisfactory results. Although many Asians have a very wide natural lid fold that is similar to that of Westerners, these patients usually request particular skeletal and soft tissue features that will yield a result that is even more like that of whites.9-12

Chapter 25 

Secondary Upper Blepharoplasty

A

B

C

D

Fig. 25-5  To reduce the interference of the drooping lid skin, patients who have no supratarsal folds tend to use their

frontalis muscles to lift the brow. After blepharoplasty, the brows will descend to a relaxed state. Patient 1: A, Th s woman needed secondary blepharoplasty to correct her brow lift B, After revision, her brows have relaxed and descended. Patient 2: C, Th s woman also needed secondary blepharoplasty to correct her brow lift D, The results for this woman also show that her brows have relaxed and descended.

A

B

C

D

Fig. 25-6  After her initial surgery, this woman had wide supratarsal folds, beyond the acceptable width of 8 mm. A and C, She is shown before surgery. B, After revision, she has a fairly normal appearance. D, In this postoperative photo with her eyes closed, some of the old scars can be seen above the new scars.

Wide lid folds that do not match the patient’s skeletal structure cause disharmony in the patient’s appearance. In addition to the unattractive appearance of the upper eyelid, an unusually wide lid fold might also cause mechanical ptosis, because the highly located supratarsal fix tion suture might prevent upward excursion of the lid, and it can only close to half of the normal range of excursion (Fig. 25-6). The best strategy to revise wide supratarsal folds is to reduce the lid fold to an optimal width and to release the old fix tion (see Fig. 25-6). Sometimes the old scar cannot be removed completely; in such a case, the

383

384

Part IV 

A

Cosmetic Surgery of the Eyelid

B

Fig. 25-7  After initial blepharoplasty, this woman presented for correction of congenital ptosis. scar is left nd a new one placed at an acceptable level. Frequently, however, the old scar might cause a problem, such as folding above the new fold, because the dermal layer and subcutaneous tissue are thin and atrophic after the previous surgery. Th s problem can be treated at a later stage by excising the old scar if it is not too far away from the new one, or it can be corrected by inserting a fat graft under the old, thin scar.

Blepharoptosis That Becomes Evident After Upper Blepharoplasty It is not rare for ptosis to be revealed in one or both upper eyelids after an upper blepharoplasty. The most common reason for this is the surgeon’s failure to note the patient’s ophthalmologic condition during the preoperative evaluation. As previously mentioned, in a patient without obvious lid folds, the upper lid margins are generally covered by hanging lid skin. Mild ptosis will not be readily apparent if the surgeon does not closely examine the eyelid condition and its range of excursion. The existing ptosis will be revealed only after the upper blepharoplasty is performed. Blepharoptosis can have a congenital origin (Fig. 25-7); it may be of long standing or be part of a degenerative process, such as in the early stages of myasthenia gravis. As previously mentioned, both postoperative ptosis and an extremely wide lid fold will cause mechanical ptosis (Fig. 25-8). Another possible cause of upper eyelid ptosis is traumatic injury to the levator aponeurosis during dissection. Patients prone to this problem have very little orbital septal fat or a narrow amount of space between the anterior and posterior septal walls. During incision of the orbital septum, it is possible to accidentally cut or lacerate the levator aponeurosis at the deeper plane (Fig. 25-9). A scar adhesion or adherent fat graft can also cause mechanical ptosis. Congenital or degenerative ptosis can be corrected through several surgical modalities. Myasthenia gravis requires additional study; medical treatment is initiated fi st, and there is no surgical indication for the patient until the patient is medically stabilized.

Multiplicative Deformities Occasionally a surgeon encounters some incredible complications after upper blepharoplasty. Many of these result from initial procedures that were performed by physicians who were not well trained or were not board certifi d. Patients sometimes present with extreme deformities of the periorbital region and lid tissue deficie cy. It is not uncommon for patients to present with destruction of the medial canthus after an attempted medial canthoplasty, in which a fat graft is inserted into the supratarsal or orbital septal layer, resulting in severe adhesions and some deformities. Patients frequently present with a wide supratarsal fold and a supratarsal depression together with blepharoptosis. Complications often consist of two or more deformities requiring revision, and these types of complications are very frustrating for surgeons. Some problems can be revised to achieve an acceptable result, but others are irreparable.

Chapter 25 

Secondary Upper Blepharoplasty

A

B

C

D

385

Fig. 25-8  After an initial upper blepharoplasty, this woman had mechanical ptosis resulting from wide supratarsal folds. A and C, She is shown before surgery. B, She is shown after revision of the supratarsal folds, which consisted of lowering the width of the folds and correcting ptosis. D, The new incision line can be seen with her eyes closed.

A

B

C

D

Fig. 25-9  Th s woman had traumatic ptosis after initial upper blepharoplasty, some of which was related to the location

of her scars. Her incision was readdressed equally on both upper eyelids at the proper height, and the adhesion on both upper eyelids was released. The ptotic problem on her right upper eyelid was corrected by releasing the scar adhesion and correcting the damaged levator aponeurosis.

K23345_Pu_c25 26_Sec Upper Bleph_r5_cl_377-394.indd 385

4/3/2015 8:36:09 AM

386

Part IV 

Cosmetic Surgery of the Eyelid

Surgical Technique The surgeon’s fi st task in evaluating complicated secondary cases preoperatively is to review the history of the patient’s earlier surgeries. The patient’s medical history and surgical notes must be obtained from the previous surgeon to help determine why revision surgery is necessary. It might be possible to trace the patient’s history of eyelid problems and determine what type of surgery is required just by reviewing a series of photographs obtained from all surgeons who performed the patient’s surgeries; therefore, before performing surgery, the surgeon should attempt to obtain the original surgical photographs if they are available. If the patient had a questionable condition before the primary procedure, such as congenital ptosis, senile or degenerative ptosis, or possible attenuated myasthenia gravis, an additional consultation with an ophthalmologist or a neurologist is very important. Before revision surgery, the surgeon should talk to the patient about the surgical plans for secondary upper blepharoplasty and the potential that multiple stages will be necessary to revise the patient’s deformity. Patients always expect a complete and ideal result after surgery. However, the results are not always as predicted; thus the possible outcome needs to be clearly discussed with the patient, and a comprehensive consent form must be signed before the procedure.

Cor r ecting Lo os ening Supra t arsal Folds

Some surgeons and laypersons believe that revising loosening supratarsal folds through the suture fix tion method is much easier than revising the complications caused by surgery, but this is not always true. All cases of loosening supratarsal folds, whether corrected by the suture method or by an open surgical procedure, require layer-by-layer dissection of the eyelid tissue, release of the old scars, and removal of the suture knots (see Fig. 25-1). Although the supratarsal folds might have more scars and adhesions from the previous surgery, they can be corrected by the suture fix tion method when they have very tough scar adhesions. It can be much more difficult to fi d the orbital septum, because the adhesion or scar might obscure the planes between each layer. The orbital-septal cavity can be easily approached from the lateral direction. The space between the anterior and posterior septa can hardly be identifi d, especially in people who have very little fatty tissue remaining in the orbital-septal cavity, whether most of the orbital fat has been removed through genetic atrophy or previous surgery. Therefore the surgeon can inject topical anesthetic solution into the septal area to balloon the septal tissues; this has a hydraulic effect, assisting dissection through the separate septal layers. Then, in the orbital cavity, the surgeon can easily apply supratarsal fi ation fi mly in precise layers. If in any instance the supratarsal depression needs to have a fat graft, t is advisable to lay the grafted fat on the preseptal space, which in general can be easily dissected (Fig. 25-10).

A

B

Fig. 25-10  Th s woman underwent fat grafting to correct a supratarsal depression and wide lid folds.

Chapter 25 

Secondary Upper Blepharoplasty

Cor r ecting Asymmetr ical Supra t arsal Folds

When planning the new supratarsal folds for secondary fold asymmetry cases, the patient must be consulted as to whether the width on the wide fold should be reduced to match the narrow side or the width of the narrow fold should be increased to match the wider side (see Fig. 25-2). Sometimes, however, it is necessary to increase the width of the narrow side and simultaneously lower the wider side to achieve the ideal width and shape of the supratarsal fold (see Fig. 25-3). Th s decision is ultimately made by the surgeon, who must consider the patient’s preferences and specific anatomic characteristics.

Cor r ecting Nar r ow Supra t arsal Folds

The problem of narrow supratarsal folds cannot always be attributed to a previous surgical procedure, and the manner of correction is often totally dependent on patient preference. To revise a narrow supratarsal fold is usually simple. The new fold is to be located within the optimal range of 5 to 8 mm wide. The old scar can be disregarded, because the gentle traction of the pretarsal skin by the supratarsal fix tion will smooth the old scar (see Fig. 25-4).

Cor r ecting Wid e Supra t arsal Folds

Asian patients, and the Asian public in general, tend to dislike the appearance of wide supratarsal folds. Because the generally accepted width of a supratarsal fold is 5 to 8 mm, the height of the incision line must be within that range. An incision line greater than 8 mm will be inappropriate for the upper eyelid, and it might affect the upward excursion of the upper eyelid. The revision of the lid fold width must be placed at an appropriate level within the range of 5 to 8 mm, as determined by the patient’s orbital size and browlid distance (see Fig. 25-6). At any point, if the difference between both upper lids is too wide, the surgeon must reduce the width of the lid fold on the wider side and simultaneously increase the width on the narrow side to make them symmetrical.

Scars

Some old scars cannot be excised completely, and the residual scar often causes a problem (see Fig. 25-4), such as a depression or folding when the patient’s eyes are open. At that point, there may be two folds, the new fold plus the old one remaining from the old scar. To prevent or revise this problem, the surgeon may consider releasing the scar or performing fat grafting during revision surgery—or at a later stage if the problem is revealed after the postoperative edema subsides. Sometimes the old scar can be excised, if it is not located at an extremely high position and if the eyelid tissue is adequate. Frequently, however, the old supratarsal fold is located at the higher position, and the old scar is somewhat far away from the new supratarsal fold; therefore the old scar and the tissue between the old scar and the new incision line cannot be excised. The surgeon has to leave the old scar and make a new supratarsal fold. The old scar will remain for a while: it will appear by turning in and under the folding of the lid skin if the width of the old scar is at the appropriate height. Thus the old scar will be hidden under the new fold. When the scar of the old supratarsal fold is located at the extremely high position, it is far away from the new fold and therefore visible all the time (see Fig. 25-5). Th s old scar also causes trouble by inducing indentation and folding. Revision of the wide supratarsal fold will be more complicated, because these problems require dissection of the scar and adhesions among the layers of eyelid skin, soft tissue, orbital septum, and levator aponeurosis, which might involve the correction of ptosis.

387

388

Part IV 

Cosmetic Surgery of the Eyelid

Cor r ecting Pos t opera tive Blep har opt os is

Before performing any upper eyelid surgery, the surgeon must review the patient’s preoperative condition to determine whether there is any ptosis. Th s will help to confi m whether surgery is necessary and whether the patient needs additional correction of hidden ptosis. If blepharoptosis existed before any surgery was performed, the surgeon must determine whether it is congenital or a later-onset problem. For most patients, a diagnosis of congenital ptosis can be easily derived from the patient’s past medical history. If the patient noticed the blepharoptosis after having surgery but it could not be determined whether it was congenital or later onset, the surgeon has to weigh a differential diagnosis that includes congenital ptosis, degenerative ptosis, myasthenia gravis, and an iatrogenic condition. Congenital or degenerative ptosis can be treated as its own pathologic entity. The most complicated cases of postoperative ptosis are iatrogenic. Each of these various complications is divergent in form. The iatrogenic cause of ptosis could be trauma to the orbital septum that led to scarring and adhesion, trauma to the levator aponeurosis, or a complete transection or partial laceration of the levator aponeurosis. The treatment for each of these entities must be well planned after a thorough examination to determine the exact cause. Correction of congenital ptosis follows the principle of the correction of congenital blepharoptosis (see Fig. 25-7). The treatment of postoperative ptosis can be categorized as follows: 1. The strategies for the treatment of myasthenia gravis must be planned depending on the stage of the disease if surgery is not immediately indicated. First, the myasthenia gravis must be treated medically, and then surgery can be considered for residual ptosis after the condition has been treated and is stable. The technique to correct ptosis associated with myasthenia gravis is similar to that for congenital ptosis. 2. Ptosis originating from a degenerative or senile atrophic change and mechanical ptosis from an extremely wide supratarsal fold can been treated by reassigning the optimal level to the supratarsal fold and reinserting the levator aponeurosis to the appropriate level at the tarsal plate (see Fig. 25-8). 3. If the ptosis was caused by trauma to the levator system, it must be repaired accordingly. The problems of generalized tissue scarring and adhesion between the layers of aponeurosis and the orbital septa are more difficult, and the surgeon must be patient to correct them in accordance with the intraoperative conditions. Many different techniques can be used to correct these kinds of deformities (see Fig. 25-9).

Cor r ecting Complica ted Pos t opera tive Defo rmities

A supratarsal depression is a postoperative deformity that is not noticed immediately after upper eyelid surgery; instead, it gradually appears months or years later. A supratarsal depression can be caused by fatty degeneration, or by genetic factors. These types of depressions are generally simple to correct. The related tissue layers are intact, and the gliding function of the orbital septum is good. The depression can be corrected with fat grafting, filling the depression with either bolus fat or a fine particle fat graft. In addition, these problems are now much easier to correct with fat injection grafts (see Fig. 25-10). Surgery might be needed to reduce the supratarsal fold, and simultaneously the surgeon could inject a fat graft in front of the anterior orbital septum to achieve a sound result (see Fig. 25-11).

Chapter 25 

Secondary Upper Blepharoplasty

A depression caused by scar adhesion after surgery of the upper eyelid or retraction of the eyelid after secondary surgery is difficult to correct (see Fig. 25-12). These problems occur after repeat surgery, with trauma resulting from improper manipulation of the tissues and from adhesion of the orbital septal layers. These depressions are sometimes difficult to revise and continue to be a concern for the patient, even after several stages of revision (see Fig. 25-13). A scar on the upper eyelid does not always need to be excised. When revising a high supratarsal fold to a normal lower supratarsal area, the surgeon must leave the old scar alone; otherwise, a large amount of eyelid tissue must be excised between the higher old scar and the new lower incision, which might cause signifi ant tissue deficie cy and result in lagophthalmos. The best way in which to correct a supratarsal depression is with fat grafting. The fat graft should be placed in front of the anterior septal layer. Fat grafting into the orbital septal cavity may lead to multiple problems, such as scarring and adhesion.

Results

A

B

C

Fig. 25-11 This woman had multiple deformities, with wide supratarsal folds and depressions. Secondary surgery was needed to reduce the width of the supratarsal folds and to perform fat grafting. She is shown before revision surgery (Fig. 25-11,A), immediately after revision surgery (Fig. 25-11,B), and 10 months postoperatively (Fig. 25-11,C).

389

390

Part IV 

Cosmetic Surgery of the Eyelid

A

B

C

D

Fig. 25-12 These two women presented with deformities after upper blepharoplasty, such as a wide supratarsal fold, a supratarsal depression, and blepharoptosis. Patient 1: Th s woman is shown before revision surgery (Fig. 25-12, A). She had good results after a revision procedure, in which the width of her right supratarsal fold was reduced, blepharoptosis was corrected, and fat grafting to the depressed supratarsal area was performed (Fig. 25-12, B). Patient 2: Before revision surgery, this woman’s right upper lid showed a deformity caused by shortening of the levator aponeurosis and exaggerated upward traction of the upper lid (Fig. 25-12, C). She had good results after the revision procedure, which included releasing the scar, leveling down the adhesion fix tion of the levator aponeurosis, and redraping the supratarsal fold (Fig. 25-12, D).

Chapter 25 

Secondary Upper Blepharoplasty

A

B

C

D

E

F

Fig. 25-13 This woman had surgery to correct her right upper eyelid deformity, which resulted from previous trauma, through revision upper blepharoplasty and fat grafting, which resulted in additional deformities. She had scar adhesion and difficulty opening her right upper eyelid, and a compression sensation made her appear panicked. Preoperatively, she had strain and tightness in her eyelids (Fig. 25-13, A and B). The revision surgery released the scar adhesion (Fig. 25-13,C). Grafted fibrotic fatty tissues were removed during the surgery (Fig. 25-13, D). The fi al result of the revision surgery shows signifi ant improvement (Fig. 25-13,E and F).

391

392

Part IV 

Cosmetic Surgery of the Eyelid

Discussion The orbital skeletal structure of Asians and the condition of their periorbital soft issue, skin thickness, fatty tissue, and related orbital septal structure are quite different from those of whites. In addition, the ethnic characteristics among various Asian nationalities may also be quite distinct. Therefore, to avoid creating problems during a primary upper blepharoplasty that will require secondary surgery, aesthetic plastic surgeons must master the diverse anatomic characteristics of Asian eyes. Surgeons must also learn the different procedures and related surgical techniques that can meet the demands of Asian patients. In addition to developing the required knowledge to perform such procedures on Asians, the surgeon needs to have the basic ophthalmologic knowledge to perform a sound, thorough examination and the ability to diagnose some of the problems with Asian eyelids and visual functions. Only then can the surgeon effectively determine the appropriate surgical procedures for each Asian patient. The advantages and disadvantages of each surgical technique must be clearly understood. There is no standard procedure that will fit all patients, but there are minimum requirements and maximum limitations for the surgeon to follow in each case. The periorbital condition of each patient is unique; therefore the procedure must be customized to satisfy the particular requirements for each patient. Upper blepharoplasty for Asians is generally supposed to create symmetrical supratarsal folds to enhance the patient’s appearance. It is unlike the procedure for whites, for whom surgeons usually have existing guidelines; for whites, the surgeon will often be able to follow the example provided by the preexisting supratarsal fold, which does not require surgical revision. When creating the supratarsal fold for the Asian eyelid, the surgeon must understand the basic mechanism of the supratarsal fold and its relationship to the surrounding tissues. A significant degree of skill and artistry is required to create aesthetically pleasing supratarsal folds that are not an imitation of a Western eye, but retain the essence of the individual’s ethnic characteristics and provide a harmonious balance that is consistent with the patient’s facial features.

Pearls for Success • Prevention of surgical sequelae is better than correction by secondary surgery. • Awareness of the condition of the patient’s general ophthalmologic functions that may affect the results of upper eyelid surgery is much more important than a focus on the actual results of the blepharoplasty. • Thorough observation and examination are required to determine the nature of the problem, its location, and its source. • To explore a scarred and adhesive upper eyelid, the surgeon will fi d it much easier to start the assessment from the lateral side of the upper eyelid, which often has more intact tissue layers and space. • The tissues of the upper eyelid are delicate and fragile; therefore these tissues are easily scarred and prone to adhesions, which are often difficult to dissect and separate during surgery. Hydraulic dissection with a local anesthetic solution is often helpful. • A scar on the upper eyelid may not always need to be excised, especially when the surgeon is revising a high supratarsal fold to a normal lower supratarsal area. • Correction of a supratarsal depression is best performed with fat grafting; the fat graft should be placed in front of the anterior septal layer.

K23345_Pu_c25 26_Sec Upper Bleph_r5_cl_377-394.indd 392

4/3/2015 8:36:13 AM

Chapter 25 

Secondary Upper Blepharoplasty

393

Refer ences 1. Zide BM. Anatomy of the eyelids. Clin Plast Surg 8:623-634, 1981. 2. Chen WP. Asian blepharoplasty. Update on anatomy and techniques. Ophthal Plast Reconstr Surg 3:135-140, 1987. 3. Liu D, Hsu WM. Oriental eyelids. Anatomic difference and surgical consideration. Ophthal Plast Reconstr Surg 2:59-64, 1986. 4. Rees TD, Aston SJ, Thorne CHM. Blepharoplasty and facialplasty. In McCarthy JG, ed. Plastic Surgery. Philadelphia: WB Saunders, 1990. 5. Uchida J. A surgical procedure for blepharoptosis vera and for pseudo-blepharoptosis orientalis. Br J Plast Surg 15:271-276, 1962. 6. Mutou Y, Mutou H. Intradermal double eyelid operation and its follow-up results. Br J Plast Surg 25:285-291, 1972. 7. Boo-Chai K. Plastic reconstruction of the superior palpebral fold. Plast Reconstr Surg 31:74-78, 1963. 8. Hiraga Y. The double eyelid operation in the Asian patient. In González-Ulloa M, Meyer R, Smith W, et al, eds. Aesthetic Plastic Surgery. St Louis: Mosby, 1988. 9. Weng CJ. Oriental upper blepharoplasty. Semin Plast Surg 23:5-15,2009. 10. Homma K, Mutou Y, Mutou H, et al. Intradermal stitch blepharoplasty for Orientals: does it disappear? Aesthetic Plast Surg 24:289-291, 2000. 11. Hin LC. Oriental blepharoplasty—a critical review of technique and potential hazards. Ann Plast Surg 7:362-374, 1981. 12. Weng CJ, Noordhoff MS. Complications of Oriental blepharoplasty. Plast Reconstr Surg 83:622-628, 1989. 13. Chen SH, Mardini S, Chen HC, Chen LM, Cheng MH, Chen YR, Wei FC, Weng CJ. Strategies for a successful corrective Asian blepharoplasty after previously failed revisions. Plast Reconstr Surg 114:1270-1277; discussion 1278-1279, 2004. 14. Chen WP. Asian blepharoplasty. In McCord CD, Codner MA, eds. Eyelid and Periorbital Surgery. St Louis: Quality Medical Publishing, 2008.

K23345_Pu_c25 26_Sec Upper Bleph_r5_cl_377-394.indd 393

4/3/2015 8:36:13 AM

K23345_Pu_c25 26_Sec Upper Bleph_r5_cl_377-394.indd 394

4/3/2015 8:36:13 AM

26 Medial Epicanthoplasty

T

Haiming Zhang

he   characteristics of the Asian upper eyelid generally include the absence of a supratarsal fold, excessive fat (especially preseptal and/or septal), laxity of the pretarsal skin, and a medial epicanthal fold (sometimes called the Mongolian fold).1-10 A double upper eyelid blepharoplasty eliminates the drooping skin of the upper lids, thereby revealing the beautiful arc of the palpebral margin and enhancing the palpebral fissure, making it larger and more attractive. Th s procedure has become common in Asian countries. Some patients have had medial epicanthal complications after double blepharoplasty. As mentioned previously, most Asians have the medial epicanthal fold, a skin crease: it is present in more than 50% of Chinese people2 and about 50% to 90% of Koreans and Japanese.1 The medial epicanthus, which appears as a skin-webbed band that stretches the upper pretarsal skin downward, can be divided into four sections: the epicanthus supraciliaris, tarsalis, palpebralis, and inversus.3,4 Unfortunately, all too often after a double blepharoplasty, the medial epicanthus becomes like a tight skin curtain that makes the palpebral fold shorter, narrower, or unappealing in the later postoperative period, or the fold is actually eliminated,3-5 in which case the patients are not satisfi d. This unintended consequence is of concern to plastic surgeons in Asian and Western countries.3-14 To find a solution, we researched many articles in plastic surgery, and identifi d several dozen medial epicanthoplasty methods from which to choose. To eliminate the disadvantages of the epicanthus for the double eyelid fold and to decrease scarring to a minimum, the best methods for correcting the medial epicanthus with upper double blepharoplasty are modifi ations of Z-plasty,3-8 Y-V advancement,9,10 or other simple methods.11-14 These methods are selected according to the medial epicanthal deformities and the surgeon’s experience.

Anatomic Features of the Medial Epicanthus On the basis of observations of anatomic dissections, investigators4-13 have suggested that an underdeveloped nasal root and an excess of horizontal medial canthal skin relative to a vertical skin shortage, insertion of superfic al fibers of the medial canthal ligament, and the orbicularis oculi muscle running through the

395

396

Part IV 

Cosmetic Surgery of the Eyelid

fold are the primary causes of the Asian epicanthal fold. The difference in skin thickness between thin eyelid skin and thick nasal skin also contributes to the fold. In addition, researchers have determined that the orbicularis oculi muscle fibers running through the epicanthal fold belong mainly to the preseptal portion. On the basis of their anatomic dissections in surgery, Zhang3 and Song et al14 considered that the medial epicanthus resulted from malposition of the orbicularis oculi muscle fibers (see Figs. 26-1, D, and 26-2, D). Initially, when elevated, the outer skin of the medial epicanthus is very thin, and there is no visible subcutaneous fat tissue. The immediately exposed tissues are the partial orbicularis oculi muscle fibers and the superfic al head of the medial canthal ligament. The direction of the superfic al muscle fibers at the free margin of the epicanthus—which attach to the dermis of the medial epicanthus from the preseptal, orbital, or pretarsal portion—determines the type of medial epicanthus. If the superfi ial head of the medial canthal ligament is located more laterally, then the medial epicanthus is absent. Finally, when the undersurface skin of the epicanthus is displaced medially with a small forceps, the pretarsal horizontal skin tension of the upper eyelid is increased. Th s means that the horizontal skin in the medial upper eyelid is short. Which structural abnormality is the main cause of the medial epicanthus? The malpositioned orbicularis oculi muscle fibers, which insert to the medial canthal ligament, can produce a deformity that stretches the superfic al head of the ligament and moves the ligament laterally, thereby forcing the medial canthal skin to move laterally. Th s causes horizontal skin excess and vertical skin shortage. But in the medial upper eyelid, a horizontal skin shortage that appears as a curtain band will undoubtedly decrease the operative effects and make the double eyelid fold disappear. The secondary causes of the medial epicanthal fold, suggested by Zhang et al,3 include lateral elongation of the superfic al head of the medial canthal ligament, pretarsal skin shortage in the medial upper eyelid, saddle nose deformity, and an excess of horizontal medial canthal skin relative to the vertical skin shortage. Although thick skin of the medial canthus is encountered occasionally, it is not extending from the nasal skin and is a result of individual difference; moderate scar proliferation may occur in these cases, which will take longer to resolve than in thin skin.

Classification of Medial Epicanthal Deformity The medial epicanthus, identifi d in the eyelids of patients of Asian descent, could be considered as a physiologic characteristic and be divided into the following three categories: 1. Upper eyelid type: Th s is a deformity of the beginning of the orbicularis oculi muscle of the upper eyelid around the medial canthus. The epicanthus originates from the upper eyelid, extends inferomedially, and ends at the medial part of lower eyelid. The appearance of the medial canthus is sharp and directed medially and inferiorly. 2. Lower eyelid type: Th s is a deformity of the beginning of the orbicularis oculi muscle of the lower eyelid around the medial canthus. The epicanthus begins from the lower eyelid, extends superomedially, and ends at the medial part of upper eyelid. The appearance of the medial canthus is sharp and directed medially and superiorly. 3. Mixed upper and lower eyelid type: Th s is a deformity of the beginning of the orbicularis oculi muscle of the upper and lower eyelids around the medial canthus. The epicanthus begins from the upper and lower eyelids, extends upward and downward medially, and converges at the canthal area. The medial epicanthus is round.

Chapter 26 

Medial Epicanthoplasty

Severity of the Medial Epicanthal Deformity One main disadvantage of the medial epicanthus is that it covers the lacrimal caruncle and the medial part of the eyelid fissure, which makes the eyelid fissure shorter and the intercanthal distance longer. The severity of medial epicanthal deformity can be classifi d according to different degrees of coverage, as follows: • Mild: Less than one third of the lacrimal caruncle is covered by the medial epicanthus. • Moderate: About half of the lacrimal caruncle is covered by the medial epicanthus. • Severe: More than two thirds of the lacrimal caruncle is covered by the medial epicanthus.

Indications and Contraindications The Z-epicanthoplasty is indicated for all types and degrees of medial epicanthal deformities. Th s procedure is especially effective in young people from 15 to 25 years old because they have more elastic skin (see Figs. 26-2 and 26-3). I think that there are no absolute contraindications to Z-epicanthoplasty, but rather relative contraindications. Reduced elasticity of the skin may result in some wrinkles at the medial canthus after surgery, and more prominent scarring may occur in patients with thicker skin (with more fat) at the medial canthus.

Surgical Technique When patients with medial epicanthal folds ask surgeons to “westernize” their eyes, they hope that any visible scars will disappear from their medial canthal areas. Consequently, an acceptable epicanthoplasty that satisfies both cosmetic surgeons and their patients must have the following3-6: • The main cause of the deformity is removed (that is, the tensions added to the medial canthal area must be removed). • The webbed skin curtain is removed by making up the pretarsal skin shortage in the medial upper eyelid. • Prominent scarring in the medial canthal area is prevented. • The procedure must have an easy design, easy operation, and precise performing with a concomitant double eyelidplasty, and it must yield an excellent and reproducible result. In this chapter, two different single Z-plastic techniques are introduced in detail.

Zhang’s Techniq ue 3

Several anatomic markers are involved in this procedure (Fig. 26-1, A). The proximal end of the epicanthus at the upper eyelid is designated as points d and d9, whereas the distal end of the epicanthus (at the lower eyelid) is designated points b and b9. Point a is located at the epicanthal skin, lateral to the anterior dacryocyst crista and at the same level or slightly inferior to point d, where flap B can be extended by using a small-toothed forceps. Line a-b is an arc at the lateral side of the skin juncture between the medial canthus and nose, which extends downward in the medial epicanthal area for several millimeters and then turns laterally to point b. Th s line is not extended to the nasal skin. Line d-b lies on the free border of the epicanthus between points d and b. Line a-b9-d forms a triangular flap A, which includes the majority of the outer superfluous skin in the epicanthus. Point c is on the line from point d9 to the medial canthal corner and is generally close to the medial canthal corner. Th s length will be determined by the type of eyelidplasty that the patient selects: outfolded (longer) or infolded (shorter). Line c-d9-b forms a triangular flap B, which lies at the inner side of the epicanthus (see Fig. 26-1, A).

397

398

Part IV 

Cosmetic Surgery of the Eyelid

The anesthetics used for this procedure are a mixture of 0.5% lidocaine and 1:200,000 epinephrine, which are injected under the orbicularis oculi muscle and under the skin at the medial canthus (Fig. 26-1, B). Line a-b9-d is incised (Fig. 26-1, C) and the triangular flap A is raised with a No. 11blade from the surface of the medial canthal ligament and muscle fibers, and is rotated upward (Fig. 26-1, D). The lateral portion of the superficial head of the ligament and wrong-positioned partial muscle fibers are exposed. Along the

A

B

C

d d9

d, d9 a

B A c

a

b9 b

b, b9 N

N

D

N

E

F

b9 A a

d d9

d d9

a

c b

c b

N

N

G

H

N

I

A

d d9 c B

a

b

d9

c

A

d

B

B b

N

N

J

N

K

d a

A a B c

A c

b

b N

d

N

Fig. 26-1  Zhang’s procedure. A, Anatomic landmarks involved in the procedure. B, Injection of anesthetics at the site

of surgery. C, Initial incision. D, Elevation of the triangular flap; the skin is turned over and upward. E, Trimmed ends of the muscle fibers. F, Incision to create triangular flap B. G, Medial movement of triangular flap B. H, Suture point for point d. I, Subcutaneous suture of lines d-b and a-b. J, Cutaneous suture of lines d-b and a-b. K, Final view of the completed procedure. (N, Nose.)

Chapter 26 

Medial Epicanthoplasty

upper rim of the medial canthal ligament, the incorrectly positioned orbicularis oculi muscle fibers to the superfic al head of the medial canthal ligament are transected. The ends of the redundant muscle fibers, which protrude into the area being operated, are trimmed off according to the position of the upper skin incision (Fig. 26-1, E). From point d9 to point c (Fig. 26-1, F), the skin is incised and the triangular flap B is elevated. Point c is located anterior and superior to the palpebral rim, or when flap B is turned over and the medial epicanthus is corrected to the desired degree. If the patient likes the infolded eyelid, the length of line d9-c should be about one third shorter than that of the outfolded eyelid. Care should be taken not to damage the lacrimal tube of the upper eyelid. The muscle fibers connecting to flap B are removed to decrease the tension they added to this flap and to allow the flap B to freely turn to the gap after rotation of flap A. Any bleeding spots are cauterized. Th s is done so that the triangular flap B can be transported medially to the gap as flap A is turned over (Fig. 26-1, G). Point d9 is fi st sutured to point a with 7-0 nylon (Fig. 26-1, H). If the size of flap B is larger than the gap a-b-d, it must be trimmed to the size of the gap to diminish the skin wrinkles postoperatively. Lines d9-b and a-b are sutured subcutaneously (Fig. 26-1, I) and cutaneously (Fig. 26-1, J) with 7-0 nylon. Because of the transposition of flap B, gap d-c-d9 at the medial upper eyelid is covered by lateral rotation of flap A. The redundant skin of flap A is trimmed to the size of the gap to diminish the skin wrinkles postoperatively. The top (point b9) of flap A is sutured to point c; two sides of flap A are sutured to the corresponding sides of the gap (Fig. 26-1, K). If flap A is trimmed to the extent that it is too small to suitably fit the gap, the contour of the upper double eyelid fold will be incomplete and unacceptable!

Modified Par k’s Techniq ue 4-6

The markers for this procedure differ slightly from those in the previous technique (Fig. 26-2, A). Points b and b9 are set at the beginning of the medial epicanthus (at the upper lid). Points a and a9 are at the distant end of the medial epicanthus at the lower eyelid. Point d is located at the epicanthal skin, lateral to the anterior dacryocyst crista and at the same level or just inferior to point b, which can be found using a small-toothed forceps to extend flap B to its farthest reach. Line d-b is a straight line. Line a-b9 lies on the free border of the medial epicanthus between points a and b9. Line a-b9-d forms a triangular flap A, which includes the majority of outer superfluous skin in the medial epicanthus. Point c is on the line from point d to the medial canthal corner, and is generally close to the medial canthal corner. Line c-a9-b forms a triangular flap B, which lies at the inner side of medial epicanthus (see Fig. 26-2, A). Compared with Park’s method, the design of this modifi d method, which includes only two triangular skin flaps, is simpler and easier to perform. In contrast to the previous design, the sizes of the two skin flaps are trimmed accurately during the procedure to fit the actual skin gaps. These modifications make the skin more elastic and flex ble. A mixture of 0.5% lidocaine and 1:200,000 epinephrine is injected under the orbicularis oculi muscle and under the skin at the medial canthus (Fig. 26-2, B). Lines a-b9 and d-b are incised (Fig. 26-2, C) and the triangular flap A is elevated with a No. 11 surgical blade, from the surface of the medial canthal ligament and muscle fibers, and is turned downward. The lateral part of the superfic al head of the ligament and incorrectly positioned partial muscle fibers are exposed (Fig. 26-2, D).

399

400

Part IV 

A

Cosmetic Surgery of the Eyelid

B

b9

C

b

b d

d

N

D

N

E

F

b

b d b9 N

c a, a9

a, a9 N

b9

d

m c

b9

a, a9 N

a9

b d a9 c b9

c a

a N

Fig. 26-2  Modifi d Park’s procedure. A, Anatomic landmarks involved in the procedure. B, Injection of anesthetics

at the site of surgery. C, Initial incision. D, Elevation of the triangular flap; skin is turned over and downward. E, Ends of the muscle fibers are trimmed, with attention paid to avoid damage of the lacrimal tube of the lower eyelid. F, Final view of the completed procedure. (N, Nose.)

From point a to point c (Fig. 26-2, C), the skin and attached muscle fibers are incised together, and the triangular flap B is elevated (Fig. 26-2, E). Point c is located just anterior and inferior to the palpebral rim. Care should be taken not to damage the lacrimal tube of the lower eyelid. At the same time, the muscle fibers attached to flap B and the malpositioned muscle fibers from point a to point d should be transected to rotate flap B with no tension, so that the triangular flap B can be transported medially to the gap as flap A is turned over. Point a9 is fi st sutured to point d with 7-0 nylon. To diminish skin wrinkles postoperatively, if the size of flap B is larger than gap d-b-c, the flap must be trimmed to fit the gap. Lines a9-b and d-b are sutured together subcutaneously and cutaneously with 7-0 nylon. Those subcutaneous sutures are important for minimizing scar formation. Gap a-c-d at the medial lower eyelid is covered by lateral rotation of flap A because of the transposition of flap B. In addition, the redundant skin of flap A is trimmed to the size of the gap to diminish skin wrinkles postoperatively. The top (point b9) of flap A is sutured to point c; two skin sides of flap A are sutured to the corresponding sides of the gap (Fig. 26-2, F).

Postoperative Care The medial canthal areas are covered by dressing that is removed the next day of the operation. Oral antibiotics are administered routinely in the fi st 3 days after surgery. All sutures are removed on postoperative day 7.

Chapter 26 

Medial Epicanthoplasty

Results Diminis h the For ces That Caus e the Defo rmit y A Z-plasty on the medial epicanthus is undertaken to solve the problem of a skin curtain, from which two flaps are formed to compensate for the vertical shortness (Figs. 26-3 and 26-4) To remove the primary deformity-causing force of the medial epicanthus, exposed orbicularis oculi muscle fibers are transected along the upper rim of the medial canthal ligament (see Figs. 26-1, E, and 26-2, E). The outcomes evident on long-term follow-up support the long-lasting effects from these two procedures (Figs. 26-3, B and 26‑4, B).

  A

B

Fig. 26-3 Th s 19-year-old woman presented with a mild medial epicanthal deformity of the upper eyelid and strabismus. The medial epicanthus exacerbated the strabismus. The bilateral medial epicanthi were corrected using Zhang’s method. The photo in Fig. 26-3, B, taken 7 months after the operation, shows that the medial epicanthi were eliminated and that the lacrimal caruncles and the medial parts of sclera were completely exposed. The strabismus was improved. The incision imprints around the medial canthi were invisible. The original infold double eyelids became outfold double eyelids.

  A

B

Fig. 26-4 This 29-year-old woman had severe medial epicanthi of a mixed upper and lower eyelid type. The contours of the medial canthi were circular. The lacrimal caruncles were covered completely by the medial epicanthi. The bilateral medial epicanthi were corrected using the modifi d Park’s method. The photo in Fig. 26-4, B, taken 5 months after the operation, shows the medial epicanthi almost eliminated and the lacrimal caruncles and the medial parts of the sclera completely exposed. No incision scars were visible around the medial canthi.

401

402

Part IV 

Cosmetic Surgery of the Eyelid

Contr oll able Res ul t s

The sizes of the two flaps determine whether we create an infolded or outfolded double eyelid. The smaller the flaps are, the more likely the medial epicanthus is corrected.

Per fo rmed Solel y or Conc omitantl y

Our experience suggested that the Z-epicanthoplasty can be performed alone (see Figs. 26-3 and 26-4) or concomitantly with a double eyelidplasty. When the Z-epicanthoplasty is performed alone, attention must be paid to precise trimming of flaps A and B to avoid redundant skin tissue that would make the contour of the medial canthus unnatural.

Less Pr ominent Scar r ing

Our long-term follow-up showed that the surgical scar changes gradually, from proliferating to fading away. The period of scar transformation is based on individual differences and is related to skin thickness. Generally beginning 4 weeks postoperatively, the surgical scar will begin to gradually vanish. There is no long-term prominent scar in this series. Eventually, an invisible gray-white surgical mark remains at the medial canthus.

Excellent

Res ul t s

In my long-term follow-up, outcomes were satisfactory for the majority of patients with respect to the contours of eyelid fissures: larger palpebral fissures, shorter intercanthal distance, exposed eyelashes, and a beautiful and natural arc of the double eyelid folds. Medial epicanthoplasty has many advantages: it has a straightforward design, it is simple yet precise when performed with concomitant double eyelidplasty, and it yields an excellent and reproducible result. The primary part of the surgical scar is hidden in the double eyelid fold; the remainder is at the margin between the medial canthus and the nose (see Fig. 26-3, B), or at the rim of medial epicanthus (see Fig. 26-4, B) and is not easily seen. The medial epicanthus is corrected completely or partially according to the patient’s needs. The covered lacrimal lake is exposed. The eyelid fissure becomes larger and more westernized and attractive.

Management of Complications Skin Depr ess io n

Some patients who had the outfolded double eyelid procedure complained about a skin depression on flap B adjacent to the surgical scar; this can be prevented by not removing the transected muscle fibers attached to flap B.

Chapter 26 

Medial Epicanthoplasty

403

Asymmetr y

Asymmetry is a common complication in epicanthoplasty. Partial correction (the position of point c is asymmetrical) and asymmetrical bilateral management of muscle fibers are the causes.

Incis io n Impr int s

All the incisions around the medial canthi eventually become gray lines, which are invisible, but they are still visible in the early postoperative period. Careful and effective subcutaneous suturing ensures that the proliferation of scars is minimized.

Skin Wr inkles

Skin wrinkles appear in the elderly in whom palpebral skin has decreased elasticity, and become more visible than before the surgery when patients can strongly close their eyes.

Revision Surgery After a medial Z-epicanthoplasty, two problems may require revision: (1) a mild depression deformity at the medial canthus and (2) the factitious appearance of a medial part of the double eyelid fold. The fi st problem is caused by removal of too much muscle tissue under flap A, without suturing the muscle tissues under flap A after transferring, or a wider incision scar may cause the mild depression deformity at the medial canthus. Therefore, after forming flap A, I only transect the deformed muscle fibers but do not remove them. Retaining these muscle fibers at the site can maintain a normal volume at the medial canthi. When suturing the incisions after the flaps are transferred, I also suture the muscle fibers under flap A carefully. This tension-releasing suturing maneuver ensures smooth and effective healing of the skin incisions. Another patient concern is an unnatural appearance at the medial part of double eyelid fold, including the fold dropping mildly or a longer double eyelid fold. During the Z-epicanthoplasty procedure, we have noted redundant skin at the medial upper eyelids. To prevent this redundant skin when drawing the incision lines, it is better to set point d about 5 mm lateral to the beginning of the medial epicanthus. After flap B is transferred, triangular protruding skin along line d-c should be trimmed (removing the dog-ear). If the medial Z-epicanthoplasty and the double eyelidplasty are performed concomitantly, the upper incision line of the double eyelidplasty must be connected smoothly with point d. A longer double eyelid fold is caused by overtrimming the medial muscle fibers under flap B, resulting in adherence of the local incision skin to the deep tissues and lengthening of the double eyelid, possibly with extension into the medial canthal areas. To prevent this outcome, the muscle fibers that disturb the transfer of flap B should be managed carefully. The occurrence of wider incision scars can cause the skin incision to appear depressed. Resecting the wider scars and resuturing the subcutaneous tissues and skin incisions carefully with 7-0 nylon may be effective in these cases.

K23345_Pu_c26 27_Medial Epican_r4_cl_395-404.indd 403

4/3/2015 8:38:02 AM

404

Part IV 

Cosmetic Surgery of the Eyelid

Pearls for Success • The medial Z-epicanthoplasty is used to correct medial epicanthal deformities. • There are two main goals: ȤȤ Make the eyelid fissure larger, more open, and attractive. ȤȤ Minimize operative imprints. • Skin incisions should be precisely designed. • The anatomic features that form the epicanthus are removed. • Operative injuries to the muscles, such as incision scars, must be carefully avoided or minimized. • The muscles must be precisely and carefully sutured under the flaps and skin incisions.

Refer ences 1. Flowers RS. Upper blepharoplasty by eyelid invagination. Anchor blepharoplasty. Clin Plast Surg 20:193-207, 1993. 2. Xue TS. Investigation of the modality in 1731 students. Chin J Plast Surg 15:318-319, 1999. 3. Zhang H, Zhuang H. A new Z-epicanthoplasty and a concomitant double eyelidplasty in Chinese eyelids. Plast Reconstr Surg 118:900-907, 2006. 4. Park JI. Z-epicanthoplasty in Asian eyelids. Plast Reconstr Surg 98:602-609, 1996. 5. Park JI. Modifi d Z-epicanthoplasty in the Asian eyelid. Arch Facial Plast Surg 2:43-47, 2000. 6. Park JI, Park MS. Park Z-epicanthoplasty. Facial Plast Surg Clin North Am 15:343-352, 2007. 7. Yoo WM, Park SH, Kwag DR. Root z-epicanthoplasty in Asian eyelids. Plast Reconstr Surg 109:2067-2071; discussion 2072-2073, 2002. 8. Lu JJ, Yang K, Jin XL, et al. Epicanthoplasty with double eyelidplasty incorporating modifi d Z-plasty for Chinese patients. J Plast Reconstr Aesthet Surg 64:462-466, 2011. 9. Kao YS, Lin CH, Fang RH. Epicanthoplasty with modifi d Y-V advancement procedure. Plast Reconstr Surg 102:1835-1841, 1998. 10. Lee YJ. Periciliary Y-V epicanthoplasty. Ann Plast Surg 56:274-278, 2006. 11. Chen W, Li S. Medial epicanthoplasty using the palpebral margin incision method. J Plast Reconstr Aesthet Surg 62:1621-1626, 2009. 12. Yen MT, Jordan DR, Anderson RL. No-scar Asian epicanthoplasty: a subcutaneous approach. Ophthal Plast Reconstr Surg 18:40-44, 2002. 13. Lee Y, Lee E, Park WJ. Anchor epicanthoplasty combined with out-fold type double eyelidplasty for Asians: do we have to make an additional scar to correct the Asian epicanthal fold? Plast Reconstr Surg 105:1872-1880, 2000. 14. Song JX, Sun MQ, Cheng JP, et al. Anatomy of oriental epicanthus and its correction. Chin J Med Aesthet Cosmet 7:251, 2001.

K23345_Pu_c26 27_Medial Epican_r4_cl_395-404.indd 404

4/3/2015 8:38:02 AM

27 Correction of Blepharoptosis

T

Chung-Sheng Lai, Ya-Wei Lai

he   upper lid margin normally covers the sclerocorneal limbus by 1 to 2 mm in primary gaze when the patient is in a relaxed and comfortable position. Upper lid ptosis, which means that the upper lid margin is lower than the normal position, is commonly related to dysfunction of the levator muscle and aponeurosis. Most patients with ptosis have congenital ptosis caused by an underdeveloped levator muscle, agenesis of the levator muscle, or acquired ptosis caused by involutional attenuation or dehiscence of the levator aponeurosis to the tarsal plate. Ptosis may also result from trauma or from neurogenic or myogenic dysfunction. The stiff issue makes the patient with congenital ptosis appear to have lid lagging or “hanging up”when gazing downward, which is a chief diagnostic sign of congenital ptosis. Compensatory contraction of the ipsilateral frontalis muscle in a patient with ptosis typically shows elevation of the involved eyebrow and prominent forehead wrinkles. The distance between the eyebrow and eyelashes in a ptotic lid is commonly longer than that in the normal lid. Before choosing an appropriate surgical treatment, proper anatomic and functional evaluation of upper lid ptosis is essential. There are four grades of levator function: poor, fair, good, and normal. There are three degrees of ptotic severity: mild, moderate, and severe. Therefore there are 12 different conditions of eyelid ptosis. A team approach that includes a plastic surgeon, neurologist, and ophthalmologist is needed to evaluate and treat patients with complicated ptosis. For an experienced surgeon, it is not difficult to get a good result from upper lid ptosis surgery; however, it is very challenging to get perfect and symmetrical results in most patients. The potential results of surgery should be carefully communicated to the patient beforehand as part of informed consent to ensure that the patient’s expectations are realistic and that the surgeon and patient agree on achievable goals; this is essential to prevent patient dissatisfaction with the outcome.1-3

Classification and Evaluation of Ptosis Levat or Functio n Mea sur ement

Levator function is the most important and useful indicator for the classifi ation and treatment of upper lid ptosis. The levator function, which is measured in millimeters, is defi ed as the amount of excursion of the upper lid from extreme downgaze to extreme upgaze. The upper lid retractors, which include the levator muscle, Müller’s muscle, and the frontalis muscle, are responsible for opening the upper lid. When the examiner measures the function of the levator muscle, the thumb or fi ger should be used to block the

405

406

Part IV 

A

Cosmetic Surgery of the Eyelid

B

Fig. 27-1  Levator function is measured by evaluating the upper lid excursion in millimeters from A, extreme downgaze to B, extreme upgaze. The action of the frontalis muscle is intentionally blocked by the examiner’s fi ger.

Box 27-1  Special Terms Related to Blepharoptosis • Palpebral fissure (eyelid slit): The distance between the upper lid margin and the lower lid margin in the midpapillary axis; approximately 9 to 10 mm • Upper lid crease height: The distance between the upper lid margin and the skin crease formed by pulling the levator aponeurosis; usually 6 to 8 mm • Margin reflex distance (MRD1): The distance between the central corneal light reflex to the upper lid margin; normally 4 to 5 mm • Margin reflex distance (MRD2): The distance between the central corneal light reflex to the lower lid margin; normally 5 to 6 mm • Upper lid retractors: Muscles for opening the upper lid, including the levator, Müller’s, and frontalis muscles • Levator function: The distance of excursion from downgaze to upgaze of the upper lid ȤȤ Normal (more than 12 mm) ȤȤ Good (10 to 12 mm) ȤȤ Fair (6 to 9 mm) ȤȤ Poor (less than 5 mm) • Ptosis severity: The degree to which the upper lid droops and covers the limbus compared with that of the normal lid ȤȤ Mild (2 mm) ȤȤ Moderate (3 mm) ȤȤ Severe (more than 4 mm) • Synkinesia: The abnormal, involuntary eyelid movement associated with special facial movement, usually after facial palsy or trauma • Hering’s law: The masking phenomenon of the less ptotic eyelid, which looks either normal or less ptotic, resulting from the same neurostimulation of the more severe ptosis of the contralateral eyelid • Oculopharyngeal dystrophy: A familial muscle dystrophy in which progressive bilateral ptosis is associated with facial weakness and difficulty swallowing; usually occurs in patients of FrenchCanadian descent • Myotonic dystrophy: An inherited disorder accompanied by progressive weakness or myotonia of the facial and peripheral skeletal muscles; associated with abnormalities in other organ systems, and ptosis is slowly progressive • Chronic progressive external ophthalmoplegia (CPEO): A progressive myopathy affecting the external eye muscles bilaterally; ptosis with nearly total lack of eye movements defin tely occurs with CPEO

K23345_Pu_c27 28_Correx Bleph_r5_cl_405-424.indd 406

4/3/2015 8:40:10 AM

Chapter 27 

Correction of Blepharoptosis

action of the frontalis muscle (Fig. 27-1). The levator function is classifi d into four conditions: (1) normal: more than 12 mm, (2) good: 10 to 12 mm, (3) fair: 6 to 9 mm, and (4) poor: less than 5 mm. Some special terms related to blepharoptosis are defi ed in Box 27-1.

Pt os is Sever it y Eval uatio n

Traditionally, the severity of ptosis is based on the drooping degree of the upper lid more than the normal eyelid by 1 to 2 mm. As noted earlier, ptosis severity is classifi d into three types: mild, 2 mm; moderate, 3 mm; and severe, more than 4 mm. Alternatively, the position of the upper lid margin can also be quantified by MRD1 and upper lid slit (fissure). With the patient and the examiner at the same eye level, the patient is asked to look straight ahead at a distant target while he or she is in a relaxed and comfortable position. The penlight is shined and focused on his or her eyes, and the MRD1 is measured.2 Both MRD1 and the palpebral fissure (eyelid slit) can indirectly show the degree of the levator function and ptosis severity. The comparison among the different measurements, including the drooping upper lid margin, MRD1, and palpebral fissure (eyelid slit), is shown in Table 27-1. The normal data should be based on the contralateral normal eyelid position in unilateral blepharoptosis. The upper lid position is usually lifted 1 mm below the limbus to be measured as normal data in bilateral blepharoptosis.

Etio l o gic Cl a ss ifica tio n

Upper lid ptosis is traditionally divided into either the congenital or acquired category, depending on when ptosis fi st occurred. Congenital ptosis is commonly associated with poor or fair levator function; acquired ptosis tends to be associated with normal or near-normal levator function. Based on anatomic lesions, a classic etiologic classifi ation system identifies our groups of ptosis.4 As detailed in Box 27-2, we have added another category: the mixed ptosis group.

Table 27-1  Measurement Methods for Assessing Severity of Upper Lid Ptosis Ptosis Severity

Lid Margin Below Limbus (normal: 1-2 mm)

Palpebral Fissure (Eyelid Slit) (normal: 9 mm)

MRD1 (normal: 4 mm)

Mild: 2 mm

3-4

7

2

Moderate: 3 mm

4-5

6

1

Severe: 4 mm

$5

#5

#0

Box 27-2  Categories of Ptosis • Aponeurotic ptosis: Related to the attenuation or dehiscence of the levator aponeurosis; usually caused by senile involution, trauma, allergy, or contact lens wear • Myogenic ptosis: Related to a lesion of the levator muscle; usually results from congenital underdevelopment, agenesis, trauma, myasthenia gravis, CPEO, myotonic dystrophy, or oculopharyngeal dystrophy • Neurogenic ptosis: Related to a lesion of the nerve; may be caused by nerve tumor, trauma, or synkinesis, Horner’s syndrome, cranial nerve III palsy, or facial synkinesis • Mechanical ptosis: Related to increased weight of the upper lid; usually results from an upper lid tumor, a foreign body, or swelling • Mixed ptosis: Related to more than two pathogenic lesions; may result from any combination of the previously mentioned factors

407

408

Part IV 

Cosmetic Surgery of the Eyelid

Blepharoptosis may concomitantly be caused by two or more factors. The most common example of blepharoptosis is the combination of aponeurotic and myogenic pathogenesis in an acquired involutional ptosis. Traditionally aponeurotic ptosis has referred to disinsertion, dehiscence, rarefaction, or attenuation between the levator aponeurosis and its originally inserted tarsal plate, with the levator muscle being normal. Typically, aponeurotic ptosis is associated with good levator function, high upper lid crease, and upper lid drop on downgaze. Levator aponeurosis plication or advancement is the procedure of choice, because the levator function is normal. However, in my own series, in most patients with involutional ptosis, disinsertion of the levator aponeurosis to the tarsal plate was not common (see Results section), occurring in only three patients of my 50 consecutive cases (6%) with involutional ptosis. Most of these patients not only presented with rarefaction of the levator aponeurosis, but also had degeneration of the levator muscle. Normal levator function is not always present in all involutional ptosis; it may indicate that the involutional ptosis is caused by both aponeurotic and myogenic pathogenesis, the treatment for involutional ptosis should be based on the levator function on a case-by-case basis.1,5 Pseudoptosis means that many conditions may mimic ptosis but are not the true ptosis; thus the underlying true cause or causes of ptosis should be carefully evaluated. Many conditions can resemble blepharoptosis, including severe upper lid skin achalasia, blepharospasm, enophthalmos, or Hering’s phenomenon caused by the contralateral upper lid retraction resulting from Grave’s disease or of congenital origin.

History-Taking and Physical Examination Because the treatment plan should be based on the confi med diagnosis, detailed history-taking and a comprehensive physical examination are essential to determine the correct type of ptosis and its severity. History-taking with ptotic patients should include the questions listed in Box 27-3. The evaluation form for the physical examination of upper lid ptosis is shown in Fig. 27-2. Because ptosis with decreased vision may be associated with cranial neuropathies, including tumor or inflammation, careful CNS evaluation should be performed. Dry eye syndrome usually becomes worse after ptosis correction. Ptosis surgery tends to be technically more difficult after the fi st operation. Progressive drooping of the upper lid during newspaper reading or TV watching indicates the possibility of myasthenia gravis; therefore systemic evaluation should be performed. Abnormal synkinetic movement of the upper eyelid may have a congenital or acquired origin, primarily resulting from aberrant nerve regeneration after facial nerve palsy. A person with Marcus Gunn jawwinking syndrome has elevation of the ptotic upper lid during chewing or mouth opening; an abnormal connection between cranial nerve III (oculomotor nerve) and cranial nerve V (trigeminal nerve) has been

Box 27-3  Questions for Patients with Ptosis • Is the condition congenital or acquired? • Does the condition run in the family, or is there a history of trauma? • Is the condition unilateral or bilateral? • What is the patient’s treatment history? • Does the patient have a history of dry eye? • Does the patient have synkinetic ptosis with chewing, or when opening or closing the mouth? • Does the patient have any blurred vision, diplopia, or enophthalmos? • Does the ptosis get worse when reading a book or watching television? • Does the patient have limited eyeball movement? • Does the patient have other systemic diseases or neurologic disorders?

Chapter 27 

Correction of Blepharoptosis

409

PATIENT INFORMATION Name____________________________________________________________________ Date_________________________ Age___________________________ Chart No.___________________________ Phone______________________________ Address���������������������������������������������������������������������������������������������� PTOSIS EVALUATION Normal Data Under limbus 1-2 mm MRD1 4-5 mm Cornea size 10-11 mm Eyelid slit 9-10 mm Right Eye Left Eye Preop Postop Preop Postop Palpebral fissure height (eyelid slit) ________________ _______________ _______________ ________________ MRD ________________ _______________ _______________ ________________ Severity (select one) Mild (2-3 mm) ________________ _______________ _______________ ________________ Moderate (3-4 mm) ________________ _______________ _______________ ________________ Severe (.4 mm) ________________ _______________ _______________ ________________ Levator function* (select one) Normal (.12 mm) ________________ _______________ _______________ ________________ Good (10-12 mm) ________________ _______________ _______________ ________________ Fair (6-9 mm) ________________ _______________ _______________ ________________ Poor (,5 mm) ________________ _______________ _______________ ________________ Onset Congenital (Y/N) ________________ _______________ _______________ ________________ Acquired (Y/N) Age: _____ ________________ _______________ _______________ ________________ Location Bilateral ________________ _______________ _______________ ________________ Right ________________ _______________ _______________ ________________ Left ________________ _______________ _______________ ________________ Cause Neurogenic ________________ _______________ _______________ ________________ Myogenic ________________ _______________ _______________ ________________ Aponeurotic ________________ _______________ _______________ ________________ Mechanical ________________ _______________ _______________ ________________ Mixed ________________ _______________ _______________ ________________ Pseudoptosis ________________ _______________ _______________ ________________ Special remarks:________________________________________________________________________________________ UNDERLYING SYSTEMIC DISEASE h DM h H/T h Myasthenia gravis h Myotonic dystrophy h CPEO h Other:________________________________ Family history:________________________________________________________________________________________ Ocular/neurologic exams Cover test/Hering’s law__________________ Synkinesia_________________ EOM limitation_________________________ Visual acuity______________ Pupil size/Light reflex_______________ Baseline tear production_______________________ Schirmer’s test: h Normal (.15 mm) h Borderline (5-10 mm) h Hyposecretion (,5 mm) Other:_______________________________________________________________________________________________ PREVIOUS TREATMENT Procedure:________________________________________________________________ Date_________________________ Operations h Mullerectomy _____/_____ mm (R/L) h Levator aponeurosis plication _____/_____ mm (R/L) h Levator shortening _____/_____ mm (R/L) h Levator/Müller’s muscle shortening _____/_____ mm (R/L) h Frontalis sling with ________________ [material] h FOO muscle flap shortening _____/_____ mm (R/L) Other:_______________________________________________________________________________________________ *Nesi. 1998. CPEO, Chronic progressive external ophthalmoplegia; DM, diabetes mellitus; EOM, equal ocular movement; FOO, frontalis orbicularis oculi; H/T, hypertension; MRD, margin reflex distance.

Fig. 27-2  Evaluation form for upper lid ptosis.

K23345_Pu_c27 28_Correx Bleph_r5_cl_405-424.indd 409

4/3/2015 8:40:10 AM

410

Part IV 

Cosmetic Surgery of the Eyelid

reported with this syndrome. A person with Marin-Amat syndrome has acquired upper lid drooping during chewing or mouth opening, resulting from an abnormal connection between the cranial nerve VII (facial) and cranial nerve V. Paradoxical movement resulting from a congenital origin is named reverse Marcus Gunn syndrome. Marcus Gunn syndrome has been reported to be successfully treated with a frontalis sling and orbicularis oculi muscle flap shortening combined with recession of the levator muscle.6 Marin-Amat syndrome can be corrected by performing selective myectomy of the preseptal orbicularis oculi muscle.7 The goal of physical examination is to measure the levator function and its related factors. Typical signs of congenital ptosis are an absent or weak upper lid crease, lid lagging on downgaze, and reduced levator function. Typical signs of involutional ptosis are a high upper lid crease, lid drooping without lid lagging on downgaze, and good to normal levator function (Fig. 27-3). Asymmetrical ptosis is common. Based on the principles of Hering’s law (simultaneous innervation), the less ptotic eyelid receives the same innervations and stimulations as the more severe ptotic eyelid, resulting in a normal position or less ptosis than the contralateral eyelid. When the more ptotic eyelid is corrected surgically, the extra amount of nerve stimulation to the opposite unoperated side will disappear, resulting in ptosis8; therefore this compensatory masking phenomenon should be carefully examined preoperatively. Total covering of the ptotic eyelid for approximately 5 to 10 minutes (covering test), and then observation and measurement of the uncovered opposite side, should carefully be performed in every ptotic patient (Fig. 27-4). Manual elevation of the ptotic upper lid by the surgeon (lifting test) to the normal position (1 to 2 mm below the limbus), and then observation of the opposite upper lid position, is another method to test for Hering’s phenomenon. A

B

C

Fig. 27-3  A, Bilateral congenital ptosis in a 24-year-old man shows absent upper lid crease. B, Lid lagging, a cardinal sign of congenital ptosis, is present in this 7-year-old girl. C, Bilateral involutional ptosis in this 65-year-old woman shows a high upper lid crease and deep forehead wrinkles.

A

B

Fig. 27-4  A, Typically, the ptotic left upper eyelid shows the elevated eyebrow, the high upper lid crease, and decreased MRD1, whereas the right eye looks normal. B, A covering test of the left eye resulted in ptosis of the right upper lid caused by Hering’s law. (MRD, Margin reflex distance.)

Chapter 27 

411

Correction of Blepharoptosis

Surgical Correction of Upper Lid Ptosis The levator function is the most important method to determine the type of ptosis correction. Basically, if the levator function is good to normal, the ptotic upper lid can be corrected surgically by simple plication of the levator aponeurosis. Advancement of the levator/Müller’s muscle is indicated for ptotic eyelids with fair to good levator function. In congenital ptosis with poor levator function, shortening or advancement of the weak levator muscle can only provide limited improvement to the lifting movement of the upper lid, because the levator muscle fibers have been replaced with fibrous and fat tissue. Therefore, traditionally, using a frontalis sling is the chosen procedure. The recent development of the frontalis orbicularis oculi muscle flap shortening technique is also a good alternative for blepharoptosis correction. Ptosis surgery needs to be carefully evaluated on a case-by-case basis, and the chosen procedure should depend on both general principles and the techniques with which the surgeon is personally familiar.

Levat or Aponeur os is Plica tio n

Levator aponeurosis plication is the operation that is indicated for the ptotic eyelid with good to normal levator function. It is usually performed with use of a local anesthetic; however, general anesthesia is required for children.9 The operative techniques of levator aponeurosis plication include the steps shown in Fig. 27-5. The steps in the levator aponeurosis plication procedure are as follows: 1. Aseptically prepare the patient. 2. Mark the upper lid crease, which is usually 6 to 8 mm from the upper eyelid margin. 3. Mark the redundant upper lid skin by performing the pinch test. 4. Inject local anesthetic with epinephrine (1:200,000). 5. Make an incision through the upper lid crease. 6. Dissect the orbicularis oculi muscle in the supratarsal border. 7. Open the septum and remove the excessive fat bags. 8. Identify the levator aponeurosis and perform upward dissection for approximately 10 to 12 mm. 9. Plicate the levator aponeurosis and attach it to the tarsal plate with 5-0 or 6-0 nylon skin fixation sutures. The plication length of the levator aponeurosis is based on lifting the ptotic upper lid margin to approximately 1 mm below the corneoscleral limbus. 10. Form the upper lid crease with three stitches on the skin aponeurosis with 6-0 nylon. 11. Close the wound using 6-0 or 7-0 nylon sutures.

A Orbicularis oculi muscle

B

C

Whitnall’s ligament Levator aponeurosis

Tarsus

Fig. 27-5  Levator aponeurosis plication. A, Submuscular dissection beneath the orbicularis oculi muscle proceeded

up to Whitnall’s ligament. The levator aponeurosis is clearly shown. B, The levator aponeurosis was advanced and fi ed to the tarsal plate with three 5-0 or 6-0 nylon horizontal mattress sutures; the length of plication is commonly around 10 to 12 mm. C, The lifting level of the upper lid margin should be carefully adjusted during the operation on a case-by-case basis.

412

Part IV 

Cosmetic Surgery of the Eyelid

Levator aponeurosis plication is an easy and simple technique; however, it is only limited to ptotic eyelids with a levator function greater than 10 mm; otherwise, undercorrection is the most common complication (see Results section for examples). The approximate length of plication is usually 10 to 12 mm, and the ideal length of plication should be carefully adjusted case by case during the operation. In some patients with congenital blepharoptosis, the sutures may even be passed beyond Whitnall’s ligament.

Levat or/M üller’s Muscle Advancement Opera tio n

Levator/Müller’s muscle advancement is the procedure indicated for a ptotic eyelid with fair levator function, because levator aponeurosis advancement alone usually cannot achieve a satisfactory result for this condition, with undercorrection being the most common complication. Therefore the primary operative procedure to correct the ptotic eyelid with fair levator function is dissecting the levator and Müller’s muscles, then pulling the muscle flap downward and affix g it to the tarsal plate to lift the ptotic eyelid to the desired level (Fig. 27-6). If the levator function is between 5 and 10 mm, the levator/Müller’s muscle shortening technique is recommended. The approximate length of flap resection is usually between 12 and 16 mm in Asians, based on the lifting upper lid margin located 1 mm below the limbus. Double eyelidplasty, combined with ptosis surgery, is almost always requested by Asian ptosis patients; therefore a small strip of the levator aponeurosis that is distal to the tarsus-anchoring sutures remains to facilitate the formation of the upper lid crease (see Results section for examples). Horizontal mattress sutures are recommended to anchor the levator aponeurosis to the anterior border of the upper tarsus by taking a partial thickness of the tarsus, because the simple suture may cut through the friable tarsal cartilage. The central suture is usually located immediately medial to the pupil to form a relatively natural eyelid contour. Anatomically, the medial horn of the levator aponeurosis is relatively weaker than the lateral horn; therefore it can be advanced 1 to 2 mm more than the central part.10 The suture must be passed through the tarsus no closer than half the distance from the eyelid margin to the upper tarsal border to avoid entropion and tarsal buckling. After the ideal position of the ptotic upper lid margin is achieved, the upper lid crease formation is performed with the height similar to that of the contralateral normal upper lid, or 6 to 8 mm in bilateral ptotic eyelids. The epinephrine in the local anesthetic may stimulate the Müller’s muscle and result in a higher eyelid position intraoperatively than what was expected postoperatively. The difference can be corrected by setting the eyelid position 1 mm higher than the desired postoperative position. Based on the levator function A

Whitnall’s ligament

B

C

Orbicularis oculi muscle Tarsus

Levator aponeurosis

Levator/Müller’s

Conjunctiva

Fig. 27-6  Levator-Müller’s muscle advancement. A, Levator aponeurosis, Whitnall’s ligament, and the tarsal plate are

clearly shown after the dissection beneath the orbicularis oculi muscle. B, The levator/Müller’s muscle flap dissection started in the supratarsal border and then proceeded upward, where vertical cuts in the medial and lateral sides of the flap were performed. The underlying conjunctiva was meticulously kept intact. C, The levator/Müller’s muscle was advanced, shortened, and tightly anchored to the tarsal plate to allow the ptotic upper lid to be lifted to the desired level.

Chapter 27 

413

Correction of Blepharoptosis

and our clinical experience, when a patient is under general anesthesia, the following principles are used to adjust the upper lid margin intraoperatively: • Positioned 1 mm below the limbus, if the levator function is good to normal (.10 mm) • Barely resting on the limbus, if the levator function is fair (6 to 9 mm) • Positioned 1 mm above the limbus, if the levator function is poor (,5 mm) However, the level of the ptotic upper lid margin should be adjusted case by case during the operation, because there are many factors affecting the fi al results.11,12

Fr ont alis Sling Opera tio n

In children, the frontalis sling operation is usually performed with a general anesthetic, but a local anesthetic can be used in adults. The most common indication for the frontalis sling operation is congenital ptosis with poor levator function (,5 mm), but it also can be used for any type of ptosis with poor levator function. A corneal protective shield is applied over each eye during the operation, and a local anesthetic with epinephrine (1:200,000) is injected into the proposed incision sites. A 10 mm skin incision is made over the central portion of the eyebrow, just above the hairline. The incision is carried down to the level of the frontalis muscle, and the subcutaneous fatty tissue is undermined to allow space for the attachment of suspensory material. The upper lid crease is marked and incised, and the redundant skin and excessive fat bags are removed. The tarsal plate is dissected, exposing the upper two thirds of its surface. A trocar needle with the suspensory material is passed from the suprabrow skin incision to the medial end of the skin crease incision, staying between the orbicularis oculi muscle and the underlying levator muscle. The suspensory material is then anchored to the tarsal plate with a 6-0 nylon suture in three points located medially, centrally, and laterally to the related position of the iris in primary gaze. Under the guide of a trocar needle, the lateral end of the sling material is pulled out from the supraeyebrow incision, again staying between the orbicularis oculi muscle and the underlying levator muscle.13,14 The length and tension of the suspensory material are adjusted until the upper lid is elevated adequately. If the desired contours are obtained, the suspension material can be looped or sutured on the underlying frontalis muscle (Fig. 27-7). A

B

Frontalis muscle

C

Orbicularis oculi muscle Tarsus

Levator aponeurosis

Fig. 27-7  Frontalis sling. A, Supraeyebrow incision (10 mm) and upper lid crease incision are performed to show the

frontalis muscle and the tarsal plate, respectively. B, The suspensory material is passed from the supraeyebrow incision to the eyelid incision wound, staying beneath the orbicularis oculi muscle. The suspensory material is fixed to the medial, central, and lateral points of the tarsal plate based on the location of the iris, and then passed from the eyelid incision to the supraeyebrow incision, staying again beneath the orbicularis oculi muscle. C, The suspensory material is looped together with sutures and anchored to the underlying frontalis muscle after adjustment of the upper lid margin in the ideal position.

414

Part IV 

Cosmetic Surgery of the Eyelid

Fr ont alis Or bicul ar is Oculi Muscle Fl ap Sho r tening Opera tio n Anatomic Study

In the traditional understanding of anatomy, the frontalis muscle and orbicularis oculi muscle were considered two separate muscle groups without interdigitation. However, an anatomic study of a fresh cadaver revealed that the vertically oriented fibers of the frontalis muscle extend into the horizontally oriented orbicularis oculi muscle and are interlaced together in the preorbital portion of the orbicularis oculi muscle15,16 (Fig. 27-8). Th s important anatomic fi ding makes the frontalis orbicularis oculi muscle flap shortening technique useful for correcting blepharoptosis based on the tight interdigitation of the frontalis muscle and the orbicularis oculi muscle.15,16 A

Frontalis muscle

Orbicularis oculi muscle

Frontalis muscle

B

Frontalis muscle

C

Orbicularis oculi muscle

Orbicularis oculi muscle

Fig. 27-8  A, Cross-section at the eyebrow region from a fresh cadaver was sent for hematoxylin-eosin and Masson’s trichrome stain. B and C, The vertically oriented fibers of the frontalis muscle were found to extend into the horizontally oriented orbicularis oculi muscle and interlace together in transverse and longitudinal sections. (From Lai CS, Chang KP, Lai CH, et al. A dynamic technique for the treatment of severe or recurrent blepharoptosis: frontalis-orbicularis oculi muscle flap shortening. Ophthalmologica 223:376-382, 2009.)

Chapter 27 

415

Correction of Blepharoptosis

Surgical Technique The upper lid crease is marked with methylene blue and is based on the height of the contralateral normal upper lid crease in a patient with unilateral ptosis. The height of the upper lid crease is marked at approximately 6 to 8 mm in a patient with bilateral blepharoptosis. The excess redundant eyelid skin is drawn and excised. The supraorbital notch should be carefully palpated and marked to prevent nerve injury during flap dissection. General anesthesia is required for small children, but local anesthesia is preferred for adults. With subcutaneous infiltration of lidocaine containing 1:200,000 epinephrine solution, the surgeon can easily dissect the subcutaneous plane between the skin and the underlying orbicularis oculi muscle through the upper lid crease incision. The dissection proceeds upward to reach the superior margin of the eyebrow. The posterior dissection is performed beneath the orbicularis oculi muscle, and the orbital septum is opened to remove some of the protruding fat. Next the dissection proceeds upward to above the superior orbital rim, leaving the levator aponeurosis intact. The orbicularis oculi muscle is advanced downward as a single flap after two perpendicular cuts are made at the lateral and medial sides of the orbicularis oculi muscle, forming the superiorly based rectangular frontalis orbicularis oculi muscle flap. Then the frontalis muscle can be easily moved with downward traction of the frontalis orbicularis oculi muscle flap, and any tethered fibers limiting the motion of the frontalis orbicularis oculi muscle flap should be released completely. The distal portion of the flap is trimmed to have an arch contour similar to the anatomic shape of the tarsus. Three to five mattress sutures with 5-0 or 6-0 nylon should be tied snugly between the flap and tarsal plate at the proper advanced point of the flap. Upper lid crease formation is performed as the standard Asian double eyelidplasty, and the skin is closed with running, nonabsorbable 7-0 sutures (Fig. 27-9). In unilateral cases, the ptotic upper lid margin is corrected and lifted 1 mm higher than that of the normal side. For bilateral cases, it is usually recommended that the upper lid should be corrected 1 mm below the upper border of the limbus of the globe at the primary position. After adjustment of the fix tion level, the redundant part of the frontalis orbicularis oculi muscle flap below the fix tion margin is excised. A Supraorbital nerve

Frontalis muscle

B

C

Frontalis orbicularis oculi muscle Orbital Preseptal Pretarsal

Portions of orbicularis oculi muscle

Levator aponeurosis

Fig. 27-9  Frontalis orbicularis oculi muscle flap shortening. A, Biplane dissections between the subcutaneous and sub-

muscular layers up to the subeyebrow area and superior orbital rim, respectively, are performed, keeping the supraorbital nerve intact. B, The frontalis orbicularis oculi muscle flap is pulled downward after two perpendicular cuts of the orbicularis oculi muscle are made, any tethered fiber is released, and the flap is shortened based on the desired lifting level of the ptotic lid. C, The frontalis orbicularis oculi muscle flap is anchored snugly to the tarsal plate with three to five horizontal mattress sutures.

416

Part IV 

Cosmetic Surgery of the Eyelid

The length of the frontalis orbicularis oculi muscle flap to be resected is measured when it is under traction with full stretching (Fig. 27-10). The flap length determines the type of case as follows (see Results section for examples). Artific al tears and eye ointment are applied postoperatively for corneal protection, and eye protection should be encouraged in the early postoperative period. In addition, transparent wrap or eye patches are applied to the involved eyes during sleep to prevent keratopathy caused by lagophthalmos. A patient with complete eye closure can usually recover between 3 and 6 months after ptosis correction. The frontalis orbicularis oculi muscle flap for ptosis correction is effective for the following reasons17: • No suspensory materials are needed. • To lift the ptotic eyelid, the compensatory hypertrophic frontalis muscle is transmitted powerfully to the tarsus through the frontalis orbicularis oculi muscle flap. • The frontalis orbicularis oculi muscle flap for ptosis correction is one technique that works well to correct all kinds of ptosis, because it resects the appropriate length of the flap, which can vary. • The pliable and healthy frontalis orbicularis oculi muscle flap that lifts he upper lid more closely mimics the natural look. The frontalis orbicularis oculi muscle flap shortening technique is highly recommended for the correction of severe blepharoptosis with poor levator function. In my own clinical cases, I use the frontalis orbicularis oculi muscle flap shortening technique to replace the classic frontalis sling, because related complications can be avoided with autologous and synthetic suspensory material being unnecessary.

A

B

Fig. 27-10  Frontalis orbicularis oculi muscle flap shortening technique. A, Subcutaneous dissection up to the subeye-

brow area and submuscular dissection up to the arcus marginalis are completed. The rectangular frontalis orbicularis oculi muscle flap is formed after two perpendicular cuts of the orbicularis oculi muscle are made. B, The frontalis orbicularis oculi muscle flap is pulled downward and fi ed to the tarsus to lift he ptotic lid to an ideal position, and the redundant orbicularis oculi muscle is resected.

Chapter 27 

Correction of Blepharoptosis

Results

A

B

C

D

E

F

Fig. 27-11 An 11-year-old girl presented with congenital bilateral ptosis with good levator function (Fig. 27-11,A, C, and E). Her bilateral levator aponeurosis plication surgery was successful; the shortened length was 11 mm in both upper lids. Follow-up at 7 months after surgery shows satisfactory results (Fig. 27-11, B, D, and F).

417

418

Part IV 

Cosmetic Surgery of the Eyelid

A

B

C

D

E

F

Fig. 27-12 Bilateral involutional ptosis was noted in a 71-year-old woman (Fig. 27-12, A, C, and E). She underwent 12 mm levator aponeurosis plication surgery in both upper lids, and upper blepharoplasty with removal of retroorbicularis oculi fat. Results were satisfactory 22 months after surgery (Fig. 27-12, B, D, and F).

Chapter 27 

Correction of Blepharoptosis

A

B

C

D

E

F

Fig. 27-13 A 54-year-old man presented to the clinic with bilateral severe ptosis with fair levator function (Fig. 2713, A, C, and E). Levator/Müller’s muscle advancement and an upper blepharoplasty were performed, and the length was shortened to 15 mm on both sides. The results were satisfactory 13 months after the surgery (Fig. 27-13, B, D, and F).

419

420

Part IV 

Cosmetic Surgery of the Eyelid

  A

B

C

D

E

F

Fig. 27-14 A 25-year-old woman had an unknown procedure to correct congenital ptosis in her childhood. She presented to our clinic with moderate ptosis with poor levator function in her left upper lid, and no upper lid crease was noted on either side (Fig. 27-14, A, C, and E). Frontalis orbicularis oculi muscle flap shortening of approximately 27 mm in length and double eyelidplasty were performed (Fig. 27-14, B, D, and F). Good results are shown 4 months after surgery.

Discussion Eval uatio n of Pos t opera tive Res ul t s

Although it is not easy to get a perfect result with blepharoptosis surgery, satisfactory improvement is not difficult to achieve. The postoperative results are classifi d into good, fair, and poor grades. A good result is defi ed as follows: • Less than 1 mm of asymmetry in the height of the upper lid margin in unilateral cases, or less than 1 mm of asymmetry in MRD1

Chapter 27 

Correction of Blepharoptosis

• No more than 2 mm below the upper border of the limbus of the primary position in bilateral cases • Normal eye opening and closing with the interpalpebral gap less than 1 mm on complete eyelid closure, and a symmetrical eyebrow A poor result occurs in cases of asymmetry of more than 2 mm, either in the height of the upper lid margin or MRD1. A fair result occurs when the amount of asymmetry is 1 to 2 mm, either in the height of the upper lid margin or MRD1.

Pos t opera tive Complica tio ns

The most common complications of ptosis surgery are undercorrection and abnormalities of the eyelid contour. Immediate postoperative overcorrection is not uncommon; however, true overcorrection after long-term follow-up is extremely rare. Other postoperative complications include asymmetry, chemosis, dry eyes, keratoconjunctivitis, ocular irritation from the suture, wound infection, hematoma, recurrent ptosis, and lagophthalmos. Postoperative ptosis of the contralateral upper lid as a result of Hering’s phenomenon is not uncommon after correction of unilateral blepharoptosis; we estimate that this occurs in approximately 15% of our patients. Blindness from hemorrhage is extremely rare.

Management of Complications To reduce the amount of time to achieve the fi al result with an easier revision procedure, patients with unsatisfactory blepharoptosis surgery are encouraged to have an early adjustment within the fi st 2 postoperative weeks. To achieve the proper level of upper lid lifting and an attractive contour, the levator aponeurosis may need to be advanced or recessed and then resutured snugly to the tarsus.18,19 If undercorrection is obvious (more than 2 mm), early readjustment is suggested, because dissection is comparatively easier through the previous incision site. Minimal undercorrection (1 to 2 mm) may result from the increased weight of the involved upper lid caused by signifi ant postoperative swelling. To improve the chance of recovery and to allow the operative scar to mature, late revision after 4 to 6 months is suggested. Most cases of mild overcorrection of blepharoptosis can be improved through a loosening effect, which is achieved with early postoperative stretching exercises; it usually takes 1 to 2 months to reach the desired position of the upper lid. Cases of more severe overcorrection can be improved by removing the central suture, followed by stretching exercises and massage.20 Hematoma needs to be emergently evacuated and decompressed, with careful hemostasis. Chemosis is treated with eyedrops containing a steroid and antibiotics (tobramycin and dexamethasone [Tobradex]) and eyeball exercises, and it usually disappears within 1 to 2 months. Obvious postoperative lagophthalmos may be caused by improper suture or scar adhesions between the septum and the levator or tarsus; correction requires reopening the wound and readjusting the suture or lysis of the scar bands. The overall postoperative surgical revision rate for blepharoptosis is approximately 10% to 20%.

Prevention of Complications In blepharoptosis surgery, choosing the right suture to fix he lifting muscle of the eyelid and to allow proper length and position of the tarsus is the best way to prevent abnormal eyelid contour. The levator aponeurosis, levator/Müller’s muscle, or frontalis orbicularis oculi muscle flap is snugly fi ed to the central tarsus with a 5-0 or 6-0 silk suture. Depending on the consistency of the tarsus, 6-0 nylon is recommended in a young patient with a relatively elastic tarsus, and 5-0 nylon is suggested in an older patient with a relatively fibrous tarsus. Th ee mattress sutures with 3 mm broad-based partial-thickness bites are placed 1 to 2 mm below the superior tarsal border (upper third of the tarsus) in the nasal, central, and temporal tarsus. It is imperative that the suture bites be placed in the correct position to avoid ectropion or abnormal

421

422

Part IV 

Cosmetic Surgery of the Eyelid

eyelid contour. The surgeon should routinely ask the patient, “Is there any foreign body sensation in your eyes?” The eyelid can also be everted to determine whether any suture is penetrating the tarsus; this will prevent the risk of irritable keratoconjunctivitis developing from the sutures. The height of the ptotic eyelid is usually overcorrected 1 to 2 mm higher than the intended fi al position. During the operation, the patient is frequently placed in a sitting position to check the appropriate height of the eyelid and its contour. If the eyelid height is undercorrected, the surgeon should remove the stitch and readjust the position of fix tion to its proper location. We usually place the involved eyelid 1 mm below the limbus in patients with good to normal levator function, barely resting on the limbus in patients with fair levator function, and 1 mm above the limbus in patients with poor levator function. Each surgeon may have his or her own rule of thumb in blepharoptotic correction; however, careful preoperative evaluation and appropriate adjustments during surgery are mandatory to prevent unsatisfactory results. Meticulous hemostasis is essential to prevent postoperative hemorrhage and hematoma. Patients should stop taking aspirin-containing products, vitamin E, NSAIDs, and herbal medicines at least 2 weeks before surgery. Lifting heavy objects, intense exercise, and bending over should be avoided postoperatively. If sneezing or intense coughing cannot be avoided, patients are instructed to close their eyes and gently compress their eyelids with gauze for several minutes during sneezing or coughing to reduce the risk of abrupt bleeding.

Pearls for Success • Detailed history-taking, physical examination, and evaluation of the underlying causes of blepharoptosis and possible systemic disease are essential for surgical success. • The surgeon who is going to perform blepharoptosis surgery should perform thorough ocular and neurologic examinations and have a good understanding of the relative anatomy of ptosis. • Proper preoperative examinations of the palpebral fissure (eyelid slit), MRD1, ptosis severity, and levator function are necessary to correct blepharoptosis surgically. • Before surgery, the surgeon should discuss the possible complications and postoperative revision rate with the patient and obtain informed consent. • Patient education is necessary for a realistic surgical result and proper postoperative care and compliance. • To determine how to treat ptosis, the surgeon should consider not only the best technique for the patient, but also the one with which he or she is most familiar. • Partial-thickness bites of the upper third of the tarsus should be used to ensure proper fix tion of the lifting muscle. • The ptotic lid margin should always be overcorrected by approximately 1 mm. • During the operation to correct blepharoptosis, the surgeon should not hesitate to readjust the lid height if necessary.

K23345_Pu_c27 28_Correx Bleph_r5_cl_405-424.indd 422

4/3/2015 8:40:19 AM

Chapter 27 

Correction of Blepharoptosis

423

Refer ences 1. McCord CD Jr, Codner MA. Ptosis: evaluation and treatment. In McCord CD Jr, Codner MA, eds. Eyelid and Periorbital Surgery. St Louis: Quality Medical Publishing, 2008. 2. Nerad JA. Evaluation and treatment of the patient with ptosis. In Nerad JA. Techniques in Ophthalmic Plastic Surgery: A Personal Tutorial. St Louis: Elsevier, 2009. 3. Putnam JR, Nunery WR, Tanenbaum M, et al. Blepharoptosis. In McCord CD, Tanenbaum M, Nunery WR, eds. Oculoplastic Surgery, ed 3. New York: Raven Press, 1995. 4. Frueh BR. The mechanistic classifi ation of ptosis. Ophthalmology 87:1019-1021, 1980. 5. Collin JR, Beard C, Wood I. Experimental and clinical data on the insertion of the levator palpebrae superioris muscle. Am J Ophthalmol 85:792-801, 1978. 6. Tsai CC, Lin TM, Lai CS, et al. Use of the orbicularis oculi muscle flap for severe Marcus Gunn ptosis. Ann Plast Surg 48:431-434, 2002. 7. Lai CS, Lu SR, Yang SF, et al. Surgical treatment of the synkinetic eyelid closure in Marin-Amat syndrome. Ann Plast Surg 67:498-501, 2011. 8. Schechter RJ. Ptosis with contralateral lid retraction due to excessive innervation of the levator palpebrae superioris. Ann Ophthalmol 10:1324-1328, 1978. 9. Jordan DR, Anderson RL. The aponeurotic approach to congenital ptosis. Ophthalmic Surg 21:237-244, 1990. 10. Berke RN. Results of resection of the levator muscle through a skin incision in congenital ptosis. Arch Ophthalmol 61:177-201, 1959. 11. Chen WPD. Ptosis (Blepharoptosis). In Chen WPD, Khan JA, eds. Color Atlas of Cosmetic Oculofacial Surgery, ed 2. Philadelphia: Elsevier, 2010. 12. Linberg JV, Vasquez RJ, Chao GM. Aponeurotic ptosis repair under local anesthesia. Prediction of results from operative lid height. Ophthalmology 95:1046-1052, 1988. 13. Crawford JS. Repair of ptosis using frontalis muscle and fascia lata: a 20-year review. Ophthalmic Surg 8:31-40, 1977. 14. Wagner RS, Mauriello JA Jr, Nelson LB, et al. Treatment of congenital ptosis with frontalis suspension: a comparison of suspensory materials. Ophthalmology 91:245-248, 1984. 15. Lai CS, Lai CH, Huang SH, et al. A new trend for the treatment of blepharoptosis: frontalis-orbicularis oculi muscle flap shortening technique. J Plast Reconstr Aesthet Surg 63:233-239, 2010. 16. Park DH, Choi SS. Correction of recurrent blepharoptosis using an orbicularis oculi muscle flap and a frontalis musculofascial flap. Ann Plast Surg 49:604-611,2002. 17. Lai CS, Chang KP, Lai CH, et al. A dynamic technique for the treatment of severe or recurrent blepharoptosis: frontalis-orbicularis oculi muscle flap shortening. Ophthalmologica 223:376-382, 2009. 18. Dortzbach RK, Kronish JW. Early revision in the offic for adults after unsatisfactory blepharoptosis correction. Am J Ophthalmol 115:68-75, 1993. 19. Shore JW, Bergin DJ, Garrett SN. Results of blepharoptosis surgery with early postoperative adjustment. Ophthalmology 97:1502-1511,1990. 20. McCord CD Jr, Nahai F. Ptosis surgery in the blepharoplasty patient. In Nahai F, ed. The Art of Aesthetic Surgery: Principles & Techniques, ed 2. St Louis: Quality Medical Publishing, 2010.

K23345_Pu_c27 28_Correx Bleph_r5_cl_405-424.indd 423

4/3/2015 8:40:19 AM

K23345_Pu_c27 28_Correx Bleph_r5_cl_405-424.indd 424

4/3/2015 8:40:19 AM

28 Correction of Tear Trough Deformity

T

Chin-Ho Wong

he tear trough deformity is one of the most common complaints of patients presenting for facial rejuvenation. The tear trough is a cutaneous groove located between the lid-cheek and nasolabial segments of the midcheek and extends from just below the medial canthus to the medial pupil line. Loeb 1 referred to this deformity as a groove between the lower eyelid and cheek medially and called it the nasojugal groove. The term tear trough was coined by Flowers.2 It is the most commonly used term for this deformity today and thus is used in this chapter. The tear trough deformity is such an important aesthetic concern that it is perhaps one of the most discussed landmarks in facial aesthetic surgery. Its exact anatomic origin was essentially unknown until recently. To effectively and logically treat or correct the tear trough deformity, an understanding of the anatomic origin of this deformity is a prerequisite.

Anatomy A careful observation of the changes in the medial suborbital region with aging yields valuable diagnostic clues regarding the anatomic origin of the tear trough deformity (Fig. 28-1). First, the tear trough is not exclusively a feature of the aging face; it may be present in newborns, children, and young adults. Its presence in youth suggests that it is not a result of degradation with aging (as was commonly assumed) but is caused by adherence or anatomic fix tion of the periorbital tissues. Second, the tear trough is not a static structure but changes dynamically with aging. In older patients the tear trough deformity is always present, from every angle. However, the dynamic changes in the medial suborbital region are best appreciated in younger patients. In young patients, the tear trough is not seen in repose, but with contraction of the orbicularis oculi muscle during squinting, frowning, or even crying, a deep groove develops in the exact location of the tear trough. Close observation reveals that an area of relative fix tion exists at the tear trough, and the muscle above and below this area bunches the tissues cephalad and caudal to the trough,

425

426

Part IV 

Cosmetic Surgery of the Eyelid

Fig. 28-1  The tear trough is a cutaneous groove that extends inferolaterally from the medial canthus to approximately the midpupillary line.

Palpebromalar groove

Tear trough

Fig. 28-2  With more advanced aging, the tear trough becomes continuous with the palpebromalar groove laterally. The presence of prominent lower lid bags accentuates this deformity. Th s appearance is descriptively called the prominent lid-cheek junction.

which accentuates the tear trough. With more advanced aging, the tear trough becomes continuous with the palpebromalar groove (Fig. 28-2). It is well known that the anatomic cause of the palpebromalar groove is fix tion of a widely known facial-retaining ligament, the orbicularis retaining ligament (also known as the orbitomalar ligament). Accordingly, the continuity of the tear trough and the palpebromalar groove with aging is further evidence that the tear trough (like the palpebromalar groove) is the result of fixation of an undocumented ligament. In a youthful face, the midcheek is full and rounded and is positioned high on the midcheek skeleton. The infratarsal crease is the only groove on the midcheek and is located below the pretarsal bulge (formed by the pretarsal orbicularis oculi muscle). Visually, this is the lid-cheek junction that is high and youthful. As we age, the tear trough is the next midcheek groove that appears, which is followed some years later by the palpebromalar groove. With progressive aging, the tear trough deepens (now assuming the term tear trough deformity), and it becomes continuous with the palpebromalar groove, which is now also deeper

Chapter 28 

427

Correction of Tear Trough Deformity

Box 28-1  Clinical Observations • The tear trough is a feature present in all age groups. • The tear trough is a point of fix tion with a high degree of mobility both above and below it. • The tear trough deformity becomes continuous with the palpebromalar groove with aging. • The palpebromalar groove has its anatomic origin in the orbicularis retaining ligament. • Accordingly, the tear trough deformity may have its anatomic origin in an undocumented ligament.

Orbital rim Orbicularis oculi muscle Palpebral portion Orbital portion

Lateral orbital thickening Orbital retaining ligament

Tear trough ligament

Zygomaticofacial nerve Prezygomatic space Zygomaticus minor muscle Levator labii superioris muscle

Zygomaticus major muscle

Fig. 28-3  The tear trough ligament is the anatomic basis for the tear trough deformity.

and more distinct. Th s continuous tear trough–palpebromalar groove takes over as the visual separation between the lid and cheek. Th s is the so-called lengthening of the lid-cheek junction that is seen with aging and is one of the main features of the aging midcheek. The clinical implications are listed in Box 28-1. In a cadaveric study of 48 hemifaces, Wong and Mendelson3 and Wong et al4 clearly demonstrated that the tear trough ligament is the primary etiologic factor responsible for the tear trough deformity (Fig. 283). In histologic studies they also demonstrated that the tear trough ligament is identical to the zygomatic ligaments, the most widely recognized facial retaining ligament, which conclusively proves the ligamentous nature of this structure. A true osteocutaneous ligament, called the tear trough ligament, arises from the maxilla and inserts into the skin along the exact location of the tear trough. The tear trough ligament continues laterally as the bilayered orbicularis retaining ligament5,6 (Fig. 28-4). This anatomy explains the clinical observation that with more advanced aging, the tear trough becomes continuous with the palpebromalar groove laterally. The cutaneous groove, which is formed by the tethering provided by the tear trough–orbicularis retaining ligamentous system, is the anatomic basis for the prominent lid-cheek junction that develops with aging (Box 28-2).

428

Part IV 

Cosmetic Surgery of the Eyelid

5 mm 6 mm 7 mm

8 mm

Fig. 28-4  The tear trough–orbicularis retaining ligament complex. The tear trough ligament continues laterally as the

bilamellar orbicularis retaining ligament from the medial pupil line. In turn the orbicularis retaining ligament continues as the lateral orbital thickening at the level of the lateral canthus. The origins of the palpebral and orbital parts of the orbicularis oculi, and the tear trough ligament located between them span a mean distance of 8 mm. The orbicularis retaining ligament is located several millimeters below the orbital rim. The upper and lower lamellae of the orbicularis retaining ligament are separated by a variable distance.

Box 28-2  Prominence of the Tear Trough Deformity With Age • The primary reason for the presence of a trough or groove is the tethering effect caused by the tear trough ligament. • There are contrasting tissue characteristics above and below the ligament. • Dark eye circles are present above the ligament. Th s is contributed in part by the thin skin and absence of subcutaneous fat here. • Below the tear trough ligament, the dermis is signifi antly thicker and there is abundant subcutaneous fat. • With age, the tear trough deformity becomes more noticeable because of the protrusion of the eye bags, descent of the soft issues or the nasolabial segment of the midcheek, and retrusion of the maxilla.

Preoperative Assessment I developed a grading system based on the severity of the tear trough deformity and the associated aging changes of the midcheek (Fig. 28-5). Th s grading system is useful in deciding whether to use a surgical or a nonsurgical approach for patients with a tear trough deformity. For patients with a grade 1 tear trough deformity, nonsurgical techniques will yield a good result, and surgery can generally be deferred until the tear trough deformity is more pronounced. For patients with grade 2 and above, surgical correction is generally indicated. For patients with a grade 2 tear trough deformity who do not want or are not ready for surgery, nonsurgical techniques can yield a satisfactory result with softening of the tear trough deformity. In contrast, patients with grades 3 and 4 generally require surgery.

Chapter 28 

429

Correction of Tear Trough Deformity

A

Grade 0

C

B

Grade 1

Grade 2

E

D

Grade 3

Grade 4

Fig. 28-5  A grading system for the tear trough deformity. A, Grade 0: Th s is a youthful lower eyelid. The lid-cheek

junction is high, with no evident tethering seen from the tear trough ligament. A pretarsal bulge (from a hypertrophic orbicularis oculi) may (right image) or may not (left mage) be present. B, Grade 1: The tear trough is seen in repose as a shallow groove extending from just below the medial canthus to (but not extending beyond) the medial pupil line. Eye bags are absent and a pretarsal bulge may (right image) or may not (left image) be present. C, Grade 2: Clinical fi dings are similar to those for a grade 1 tear trough, but with the presence of eye bags, D, Grade 3: The tear trough becomes continuous with the palpebromalar groove with a visually distinct (and low) lid-cheek junction (or separation). Eye bags are seen, and midcheek retrusion and ptosis are seen below this. E, Grade 4: A sharply demarcated and continuous lid-cheek junction is seen. Prominent eye bags are present above and midcheek descent and retrusion are present below the lid-cheek junction.

K23345_Pu_c28_Crx of Tear_r5_dc_425-442.indd 429

4/3/2015 8:54:31 AM

430

Part IV 

Cosmetic Surgery of the Eyelid

NONSURGICAL TREATMENTS Nonsurgical treatments with the use of fillers and botulinum toxin A have a role in the treatment of the tear trough deformity in appropriately selected patients (for example, grades 1 and 2). Candidates for nonsurgical treatments have an early tear trough deformity and are not ready to consider surgical correction. Conceptually, fillers function to replace deficie t or lost volume below the tear trough ligament. Botulinum toxin A relaxes the orbicularis oculi above and below the tear trough ligament and deemphasizes the tear trough. Used in combination, fillers and botulinum toxin A will soften the tear trough deformity. Th s degree of softening is usually suffici t and can yield very satisfactory results for patients with grades 1 and 2. Because the tear trough ligament cannot be released or divided with nonsurgical techniques, the correction that can be achieved in more advanced tear trough deformities (grades 3 and 4) is generally insuffici t, and a surgical approach is needed. Fillers and Botox should be applied carefully in the tear trough because of the potential for complications. Especially for beginners, I recommend that only products made from hyaluronic acids be used around the orbits. Th s is because, in the event of any problems, hyaluronidase may be used to reverse the effects of the filler materials. The use of fillers to correct the tear trough is an advanced technique that requires considerable experience with the use of injectables, because (1) the anatomy of the area is complex and very compact, with the potential to damage vessels and nerves, and (2) incorrect or excessive placement of a filler may exacerbate the tear trough deformity. Fillers may be placed deep or at a superfic al level. If placed at a deep level, the filler should be injected caudal to the tear trough ligament on the anterior maxilla. Here fillers correct the maxillary retrusion (which may be congenital in some patients or be caused by anterior maxillary resorption resulting from aging in older patients) and the deflation that occurs with aging. Deep filler placement augments the skeletal deficiency and replaces the volume that is lost with aging. Th s correction restores the soft issue support inferior to the tear trough ligament and prevents the soft tissues from dragging on the tear trough ligament. Thus the tethering effect is reduced and in some patients is eliminated, which results in a smoother lidcheek junction. Because the placement is deep and for the purpose of skeletal augmentation, the volume of filler material needed is relatively large.

Injection Techniques Fillers and Botulinu m Toxin A

As noted, depending on the specific needs of each patient, the filler may be placed at a deep or superfic al level, or most commonly both. Fillers will yield satisfactory results in appropriately selected patients and require minimal downtime. Either blunt cannulas or needles may be used for the injections, depending on the surgeon’s preference. Regarding the type of product, a softer (or more fluid) product should be used to correct the tear trough deformity, because the tissues are very thin and the filler may be palpable with stiffer fillers. Deep injection of the filler corrects the maxillary retrusion that is commonly seen in Asian patients. The filler should be placed below the tear trough ligament to restore support to the soft issues in the medial suborbital area. As previously noted, the lack of skeletal support in this area accentuates the tear trough deformity. Depending on the degree of maxillary retrusion, I normally use 0.3 to 0.6 cc per

K23345_Pu_c28_Crx of Tear_r5_dc_425-442.indd 430

4/3/2015 8:54:31 AM

Chapter 28 

Correction of Tear Trough Deformity

side over the anterior maxilla. Fillers should not be placed above the tear trough ligament, because this will worsen the tear trough deformity and have an effect similar to that of eye bags on the tear trough deformity. In contrast, superfic al placement corrects the superfic al wrinkling that is seen in some patients. Because the skin is very thin and delicate at the tear trough, the amount of filler material needed (or that can be injected) is very little—no more than 0.1 to 0.2 cc per side. Even distribution of small aliquots of the filler is necessary with a fanning method of injections. Separate injection sites may be needed to ensure even distribution of the filler, followed by immediate gentle massaging to smooth out the placement. Botulinum toxin A complements the use of fillers in the correction of the tear trough deformity by relaxing the orbicularis oculi located above and below the tear trough ligament. I prefer to use the MicroBotox technique in the tear trough (about 4 units in 0.2 ml of saline solution per side) injected at the very superfic al level, raising blebs above and below the tear trough ligament to produce more even relaxation of the muscles.

Fat Grafting

Fat harvesting, processing, and injection are performed with the Coleman technique.7,8 Fat grafting of the periorbital area must be performed meticulously to avoid potential complications such as lumpiness and irregularities visible in the thin periorbital tissues. Harvesting is performed with a Tulip 2.4 mm Sorensen Harvester. The fat is then centrifuged at 3000 rpm for 3 minutes and reinjected with a 0.7 mm blunt Tulip injector. Very small aliquots of fat are evenly injected in a fanning manner in multiple planes below the tear trough ligament.

Results These cases show the use of fillers and botulinum toxin A for various grades of tear trough deformities.

Fig. 28-6 Th s 32-year-old woman presented with a grade 1 tear trough deformity; 0.6 cc of hyaluronic acid filler was injected into the tear troughs on each side. She is shown before and 2 months after treatment.

431

432

Part IV 

Cosmetic Surgery of the Eyelid

Fig. 28-7 Th s 33-year-old woman presented with a grade 2 tear trough deformity. She is shown immediately after injection of 0.7 cc of hyaluronic acid filler into the tear troughs on each side.

Fig. 28-8 Th s 42-year-old woman presented with a grade 2 tear trough deformity. She is shown before and 4 months after an injection of 0.6 cc of hyaluronic acid filler into each tear trough.

K23345_Pu_c28_Crx of Tear_r5_dc_425-442.indd 432

4/3/2015 8:54:32 AM

Chapter 28 

Correction of Tear Trough Deformity

433

Fig. 28-9 Th s 62-year-old man presented with a grade 3 tear trough deformity and signifi ant skin laxity, both of which are more advanced aging changes of the midcheek. Surgical treatment was needed, but the patient declined surgery. I injected 1.4 cc of hyaluronic acid into each tear trough and in the midcheeks. Although there was signifi ant improvement, the correction is not optimal. A better result would have been attained with surgery.

Fig. 28-10 Th s 42-year-old woman presented with a grade 1 tear trough deformity. Her tear troughs were injected with 1.4 and 1.0 cc of microfat. Microstructural fat grafting is effective to correct the tear trough deformity and has the potential to offer a more lasting solution than synthetic fillers. The patient is shown 18 months after the correction.

K23345_Pu_c28_Crx of Tear_r5_dc_425-442.indd 433

4/3/2015 8:54:33 AM

434

Part IV 

Cosmetic Surgery of the Eyelid

Fig. 28-11  Bruising seen with filler injection. Signifi ant bruising may occur when the angular vein, and more rarely, the angular artery, is punctured during injections around the tear trough ligament.

Management of Complications Fillers and Botox should be used carefully in the tear trough because of the potential for complications. Especially for beginners, I recommend that only products made from hyaluronic acids should be used around the orbits, because in the event of any problems, hyaluronidase may be used to reverse the effects of the filler materials. Potential complications include signifi ant bruising (Fig. 28-11) from injury to the angular vein (more commonly) or the angular artery, prolonged swelling, visibility or irregularity (from excessive placement of the product, especially when the product is placed more superfic ally), and bluish discoloration over the medial midcheek. The bluish discoloration is the result of the Tyndall effect from placement of too much product too superfic ally. The bruising will resolve in about 3 weeks. Minor irregularities will improve with gentle massaging. Hyaluronidase can be used to dissolve the excessive fillers in patients in whom the fillers were injected too superficially, in patients with prolonged swelling, and in patients in whom the Tyndall effect is seen. It should be stressed that the use of hyaluronidase should rarely be indicated with the proper use of fillers. The hyaluronidase comes in 1500-unit ampules. Th s is dissolved in 1 ml of saline solution, and 0.05 ml is injected per area into the regions undergoing treatment. Precise injection of the hyaluronidase is important, and with correct placement, the hyaluronic acid will dissolve almost instantaneously. The patient should be informed that the action of the hyaluronidase is nonspecific, and all of the hyaluronic acid injected into the area may be dissolved, resulting in reversion to the preinjection state. Rarer complications include visual disturbances and even blindness from retrograde injection of filler into the angular artery that may communicate with the retinal artery. To avoid this, aspiration is advised before injection around the orbit. The use of large boluses of filler under high pressure should be avoided, and the filler should be injected slowly and stopped immediately when a patient complains of excessive pain during the procedure.

SURGICAL TREATMENTS I perform a transcutaneous lower eyelid blepharoplasty with a midcheek lift in ost patients with a signifi ant tear trough deformity. A skin-only flap is elevated off the orbicularis oculi. The orbicularis oculi is then cut, preserving a 5 mm strip of pretarsal orbicularis muscle. The preseptal space is entered and opened to its boundaries, formed by the origins of the palpebral part of the orbicularis oculi medially and

Chapter 28 

Correction of Tear Trough Deformity

Angular vein Zygomatic nerve

Suborbicularis oculi fat Levator labii superioris

Orbicularis origin

Fig. 28-12  Complete release of the orbicularis origin, with concomitant release of the tear trough ligament, is confi med

by the visualization of the levator labii superioris in the fl or and the suborbicularis oculi fat above. Note the close association between the angular vein and terminal branches of the zygomatic nerve with the orbicularis oculi muscle medially. Injury to these structures during the preperiosteal release of the muscle can be avoided by staying very close to the bone.

the orbicularis retaining ligament laterally. The orbicularis oculi origins must be completely released off the maxilla medially, because to effectively address the tear trough deformity, the tear trough ligament (located between the palpebral and orbital parts of the orbicularis oculi) must be completely released. The combined attachment of the palpebral and orbital parts of the orbicularis is wider than is generally appreciated (spanning a mean distance of 8 mm cephalocaudally at its widest). Th s release should be performed as close as possible to its insertion on the bone to avoid injury to the motor nerves and vessels running in close association with the muscle. These include the terminal branches of the buccal and zygomatic nerves and the angular vein more medially. Complete muscle release is indicated by the visualization of the fibers of the levator labii superioris muscle. The orientation of the fibers of the levator is different from those of the orbicularis oculi, and the levator does not tent with upward traction on the orbicularis oculi (Fig. 28-12). More laterally, the bilayered orbicularis retaining ligament is released sharply, and care should be taken in the lateral part of the body of the zygoma, because if damaged, the zygomaticofacial nerve and its vascular bundle may cause some bleeding. The dissection is taken laterally to about the level of the lateral canthus or the inferior part of the lateral orbital thickening. At this point, the superfic al fascia of the midcheek is completely mobilized and the tear trough ligament is divided (Fig. 28-13). To prevent the reattachment of the tear trough ligament to the anterior maxilla and to address the deficie t volume that is generally present in this area, several procedures can be used, depending on the patient’s specific needs and anatomy. In patients with a grade 2 or 3 deformity, medial fat pad transposition is done. The septum is opened medially, and the medial and middle fat pads are transposed over the orbital rim and sutured to the periosteum. In patients with a true excess of eye bags, conservative excision of the lateral fat pads of the eye bags is performed. In patients with a grade 4 tear trough deformity, septal reset as described by Hamra9,10 is performed to obliterate the very sharp lid-cheek junction. Again, in patients with very large eye bags, the lateral fat pads can be removed after the septal reset. A canthopexy is performed to support the lower eyelid. Before closure, the orbital septum is irrigated with diluted triamcinolone acetonide (Kenacort). A midcheek lift s then performed by suspending the orbicularis oculi muscle to the

435

436

Part IV 

Orbicularis oculi muscle (palpebral portion) Tear trough ligament

Cosmetic Surgery of the Eyelid

Orbital rim Orbital retaining ligament

Angular artery and vein

Infraorbital nerve Premaxillary space Maxillary ligament Levator labii superioris muscle

Zygomaticus minor muscle Zygomaticus major muscle

Fig. 28-13  The premaxillary space is a true facial soft issue space lined by a membrane. The levator labii superioris forms the fl or. Its superior boundary is formed by the tear trough ligament sandwiched between the origins of the palpebral and orbital parts of the orbicularis oculi.

lateral orbital rim periosteum with two 3-0 Ethibond sutures. The skin is excised very conservatively and the wounds are closed. In patients with midcheek deflation, structural fat grafting of the midcheek is performed with the Coleman technique.

Postoperative Care Bruising and swelling are expected from this procedure, particularly when the procedure is done with midcheek structural fat grafting. With meticulous technique, this can be kept to a minimum. I advise patients to be mentally prepared for the bruising and swelling, which can last up to 3 weeks.

Results Transcutaneous lower eyelid blepharoplasty with a midcheek lift s a safe and effective procedure to correct all grades of the tear trough deformity. For grades 1 and 2, this procedure gives a lasting and natural result. Although noninvasive modalities provide temporary improvement in appearance, this procedure can completely correct the tear trough deformity in patients with grades 1 and 2, so these patients should be encouraged to opt for the more permanent surgical solution. For patients with more advanced tear trough deformities (grades 3 and 4), surgery is the best option, because it can profoundly rejuvenate the midcheek and eliminate the patients’ tired look.

K23345_Pu_c28_Crx of Tear_r5_dc_425-442.indd 436

4/3/2015 8:54:34 AM

Chapter 28 

Correction of Tear Trough Deformity

437

Fig. 28-14 Th s 42-year-old woman presented with a grade 2 tear trough deformity. After a lower blepharoplasty and transposition of the medial fat pads with a midcheek lift, a efreshed effect that will be long-lasting was achieved. She is shown before and 4 years after surgery. No fillers were used in the midcheek or nasolabial folds.

K23345_Pu_c28_Crx of Tear_r5_dc_425-442.indd 437

4/3/2015 8:54:34 AM

438

Part IV 

Cosmetic Surgery of the Eyelid

Fig. 28-15 Th s 63-year-old woman presented with a grade 3 tear trough deformity. She underwent an upper blepharoplasty, a limited-incision brow lift, a l wer blepharoplasty procedure with transposition of the medial fat pads, and a midcheek lift, in addition to microstructural fat grafting of the midcheek procedures. Her rejuvenated appearance is pronounced 9 months after surgery.

K23345_Pu_c28_Crx of Tear_r5_dc_425-442.indd 438

4/10/2015 7:11:57 AM

Chapter 28 

Correction of Tear Trough Deformity

439

Fig. 28-16 Th s 45-year-old woman presented with a grade 4 tear trough deformity A lower blepharoplasty, septal reset, and midcheek lift produced a long-term correction. She is seen 9 months after surgery.

K23345_Pu_c28_Crx of Tear_r5_dc_425-442.indd 439

4/3/2015 8:54:36 AM

440

Part IV 

Cosmetic Surgery of the Eyelid

Management of Complications The lower eyelid is a very delicate structure, and as with any blepharoplasty procedure, has a small risk of complications. Patients should be monitored for early postoperative bleeding, particularly those with high blood pressure and/or who are smokers. Early recognition of postoperative bleeding is imperative. If this occurs, it may be necessary to open the sutures and remove the blood clot. Hemostasis should also be ensured. In very rare cases retrobulbar bleeding can threaten vision. Surgeons who frequently perform blepharoplasties should establish a close working relationship with an ophthalmologist, because his or her input is invaluable in these emergencies. Lower eyelid malposition or lower lid retraction and ectropion are perhaps the most worrisome complications of lower eyelid surgery and occur in about 2% of patients. Various factors predispose patients to these complications, including previous blepharoplasties. Tarsoligamentous support of the lower eyelid may have been weakened by previous surgeries. Patients with certain anatomic characteristics, including a negative-vector orbit with preexisting scleral show and lid retraction (the so-called polar bear syndrome), have poor lower eyelid support and therefore are at greater risk of postoperative problems. Intraoperatively, atraumatic and meticulous techniques are important to minimize complications. In particular, the integrity of the tarsoligamentous sling that supports the lower eyelid must be preserved. The preservation of the pretarsal orbicularis and minimal denervation of this muscle are important for this purpose. Meticulous hemostasis and perioperative blood pressure control are essential, because postoperative hematoma is a known cause of postoperative middle lamellar contracture. I think that Asian patients with a thicker orbital septum and greater scarring potential are at greater predisposition for excessive postoperative scarring compared with white patients. Th s greater scarring potential may translate into a higher incidence of lower lid problems after lower eyelid surgeries. For this reason, I perform canthopexies (with double-armed 4-0 Mersilene sutures) in most patients to provide fi m support for the lower eyelid in the early recovery period. Patients are followed closely after surgery to monitor the progress of their healing. Regarding the timeline, a middle lamellar contracture tends to start or manifest from 2 to 3 weeks after surgery and worsens up to 3 months before improvement. Accordingly, patients are seen at 1 week, 3 weeks, 1 month, and 3 months after surgery. At the slightest suggestion of a middle lamellar contracture, patients are seen weekly, and the scarring is actively managed according to our protocol. When seen at 1 week, the lower eyelid should be held snugly against the globe, and no scleral show should be present. If the lid position is less than satisfactory, lower eyelid massaging is started 2 weeks after surgery. Th s is done by gently pushing the lower eyelid superomedially against the globe and holding it in position for 1 minute for up to five times a day. The lower lid should be gently elevated to above the pupil with a cotton-tipped applicator. If there is obvious stiffness of the lower eyelid, signifi ant middle lamellar scarring has occurred. I inject a small volume of a mixture of 5-fluorouracil and triamcinolone directly into the foci of the scarring. Patients are seen at weekly intervals and their progress is monitored. The 5-fluorouracil/triamcinolone injections are repeated if the scarring persists. Generally with this regimen, the scarring will stabilize and start to reverse after 3 to 6 weeks. Most patients with minor lower eyelid retraction and ectropion will respond well to massaging and injections. Corrective surgery may be needed in some patients, but this should not be considered until at least 6 months after the primary operation.

K23345_Pu_c28_Crx of Tear_r5_dc_425-442.indd 440

4/3/2015 8:54:36 AM

Chapter 28 

Correction of Tear Trough Deformity

441

Pearls for Success • The tear trough deformity is primarily the result of fix tion of the tissues in the medial suborbital area of the midcheek provided by the tear trough ligament. • The contrasting tissue quality and quantity above and below the ligament and the dynamic changes of the tissues with aging result in an increased prominence of the tear trough deformity.s. • Because we have a clear understanding of the anatomic basis for the tear trough deformity, correction of the tear trough deformity has become more predictable and effective because procedures can be designed to target the underlying cause of the deformity. • Nonsurgical treatments of the tear trough deformity (with fillers and neurotoxins) rely on restoring support for the soft issues below the tear trough deformity, addressing the soft issue deficiency around the tear trough ligament, and relieving the muscle spasms around the tear trough. • Nonsurgical methods are benefic al only in early grades of the tear trough deformity, because the underlying cause of the deformity is not addressed. The correction is temporary, and eventually surgical options must be considered. • Patients with less severe tear trough deformities who do not want to consider surgery or who would rather defer surgery until a later time should be encouraged to consider nonsurgical approaches. • Surgical correction of the tear trough deformity offers a safe and long-term solution. • Surgical correction addresses the issue at its roots, and this gives the most optimal correction of the deformity. The results are long lasting and natural. It is effective for patients with all grades of tear trough deformities.

Refer ences 1. Loeb R. Fat pad sliding and fat grafting for leveling lid depressions. Clin Plast Surg 8:757-776, 1981. 2. Flowers RS. Tear trough implants for correction of tear trough deformity. Clin Plast Surg 20:403-415, 1993. 3. Wong CH, Mendelson B. Facial soft- issue spaces and retaining ligaments of the midcheek: defini g the premaxillary space. Plast Reconstr Surg 132:49-56, 2013. 4. Wong CH, Hsieh MK, Mendelson B. The tear trough ligament: anatomical basis for the tear trough deformity. Plast Reconstr Surg 129:1392-1402, 2012. 5. Mendelson BC, Muzaff r AR, Adams WP Jr. Surgical anatomy of the midcheek and malar mounds. Plast Reconstr Surg 110:885-896; discussion 897-911,2002. 6. Muzaff r AR, Mendelson BC, Adams WP Jr. Surgical anatomy of the ligamentous attachments of the lower lid and lateral canthus. Plast Reconstr Surg 110:873-884; discussion 897-911,2002. 7. Carraway JH, Coleman S, Kane MA, et al. Periorbital rejuvenation. Aesthet Surg J 21:337-343, 2001. 8. Coleman SR. Structural fat grafts: the ideal filler? Clin Plast Surg 28:111-11 9, 2001. 9. Hamra ST. The zygorbicular dissection in composite rhytidectomy: an ideal midface plane. Plast Reconstr Surg 102:1646-1657, 1998. 10. Hamra ST. The role of orbital fat preservation in facial aesthetic surgery. A new concept. Clin Plast Surg 23:1728, 1996.

K23345_Pu_c28_Crx of Tear_r5_dc_425-442.indd 441

4/3/2015 8:54:36 AM

442

Part IV 

Cosmetic Surgery of the Eyelid

Additio nal Read ings Barton FE Jr, Ha R, Awada M. Fat extrusion and septal reset in patients with the tear trough triad: a critical appraisal. Plast Reconstr Surg 113:2115-2121; discussion 2122-2123, 2004. Codner MA, Wolfli JN, nzarut A. Primary transcutaneous lower blepharoplasty with routine lateral canthal support: a comprehensive 10-year review. Plast Reconstr Surg 121:241-250, 2008. Hirmand H. Anatomy and nonsurgical correction of the tear trough deformity. Plast Reconstr Surg 125:699-708, 2010. Kikkawa DO, Lemke BN, Dortzbach RK. Relations of the superfic al musculoaponeurotic system to the orbit and characterization of the orbitomalar ligament. Ophthal Plast Reconstr Surg 12:77-88, 1996. Lambros V. Fat injection for the aging midface. Op Tech Plast Reconstr Surg 5:129-137, 1998. Loeb R. Naso-jugal groove leveling with fat tissue. Clin Plast Surg 20:393-400; discussion 401, 1993. McCord CD Jr, Codner MA, Hester TR. Redraping the inferior orbicularis arc. Plast Reconstr Surg 102:2471- 2479, 1998. Mendelson BC. Surgery of the superfic al musculoaponeurotic system: principles of release, vectors, and fix tion. Plast Reconstr Surg 107:1545-1552, 2001. Mendelson BC. Facelift anatomy, SMAS, retaining ligaments and facial spaces. In Aston SJ, Steinbrech DS, Walden J, eds. Aesthetic Plastic Surgery. Philadelphia: Elsevier, 2009. Mendelson BC, Jacobson SR. Surgical anatomy of the midcheek: facial layers, spaces, and the midcheek segments. Clin Plast Surg 35:395-404; discussion 393, 2008. Moss CJ, Mendelson BC, Taylor GI. Surgical anatomy of the ligamentous attachments in the temple and periorbital regions. Plast Reconstr Surg 105:1475-1490, 2000. Paul MD, Calvert JW, Evans GR. The evolution of the midface lift in ae thetic plastic surgery. Plast Reconstr Surg 117:1809-1827, 2006.

K23345_Pu_c28_Crx of Tear_r5_dc_425-442.indd 442

4/3/2015 8:54:36 AM

29 Lower Blepharoplasty

V

David Daehwan Park

isible   changes in the eyelid are often the fi st signs associated with facial aging. By addressing the components of skin/lid laxity, fat herniation, a bulging lower eyelid, and deepening wrinkles on the midface, cosmetic lower blepharoplasty attempts to reverse these changes and restore a more youthful contour to the face. In Asians, unlike Westerners, the dermal tissue of the lower eyelid is thick, there is less wrinkling on the lower eyelid, and the skin is attached more strongly to the dermal tissue. Therefore the Asian midface structure tends to descend less than that of Westerners. Lower blepharoplasty makes up a small percentage of all aesthetic surgeries in Asians. In recent years, however, lower blepharoplasty has been performed with increasing frequency in Asians compared with other aesthetic surgeries. In this chapter, I describe the anatomy of the lower eyelid, the presentation of lower eyelid aging and a classifi ation of the possible procedures to correct it, surgical techniques for lower blepharoplasty, management of complications related to surgery, and secondary operations of lower blepharoplasty.

Anatomy of the Lower Eyelid Fig. 29-1 shows a cross-sectional view of the lower eyelid. Compared with the upper eyelid, the lower eyelid has less mobility and is less active. The following list compares the differences between the lower and upper eyelid: • The lower eyelid features a thin tarsal plate. Its width is approximately half the width of the thin tarsal plate in the upper eyelid, and it is narrower. • The capsulopalpebral ligament, which originates from the inferior rectus sheath, is attached at the anteroinferior aspect of the tarsal plate of the lower eyelid. Th s ligament functions like a lid retractor, in a similar manner to the levator aponeurosis in the upper eyelid. If the function of the capsulopalpebral ligament is lost, there would be no tension on the tarsal plate in the lower eyelid, and the skin would not be able to maintain its position. Th s could cause lid retraction disorders such as entropion. The lower part of the capsulopalpebral ligament is thick and is called the Lockwood ligament because of its strength. • Unlike the orbital fat of the upper eyelid, the orbital fat of the lower eyelid is divided into three compartments—medial, center, and lateral—instead of two.

443

444

Part IV 

Cosmetic Surgery of the Eyelid

Tarsus Preseptal fat Mucosa Inferior conjunctival fornix Orbital septum Orbital fat Periosteum Arcus marginalis Postorbicularis fascia Subcutaneous fat Skin

Suspensory ligament of inferior fornix Inferior tarsal muscle Inferior rectus muscle Capsulopalpebral fascia Inferior oblique muscle Lockwood ligament Maxilla bone

Fig. 29-1  A cross-sectional view of the lower eyelid. Palpebromalar groove Lower eyelid crease Nasojugal groove Tear trough deformity Lower lid bulge Malar mound

Deepening of nasolabial fold

Fig. 29-2  Characteristics of an aging lower eyelid.

Presentation of Aging in the Lower Eyelid A summary of the structural changes of the eyelid are outlined in Fig. 29-2 and are discussed in detail later.

Palp ebral Ba g

There are primarily three causes of a palpebral bag: 1. The eyeball droops downward, because there is sagging with age of the Lockwood suspensory ligament that suspends the eyeball and maintains the eyeball position as well as the retinaculum of the lateral and medial canthi that is attached to this ligament. When the eyeball droops down, the gap between the eyeball and the inferior orbital wall decreases, and the orbital fat in it is pushed forward (Fig. 29-3). 2. The orbital septum in front of the orbital fat weakens, the orbicularis oculi muscle shrinks, and the skin of the lower eyelid is stretched. When this happens, the orbital fat can protrude to the front. 3. The soft issues around the eyes may frequently swell because of an allergy or as a result of liver, kidney, heart, or thyroid disease. Some people have congenitally signifi ant orbital fat.

Chapter 29 

445

Lower Blepharoplasty

Fig. 29-3  A patient with palpebral bags.

Tear trough deformity: depression extending inferolaterally from medial canthus Palpebromalar groove extends around lateral half of inferior orbit

Fig. 29-4  The tear trough deformity and the palpebromalar groove are important structures in the aging of the lower eyelid.

Tear trough deformity Palpebromalar groove Levator labii superioris alaeque nasi muscle

Preseptal orbicularis oculi muscle Malar fat pad

Fig. 29-5  Cadaver dissection demonstrating anatomy of the tear trough deformity and the palpebromalar groove.

Tear Tr ough Defo rmit y

There are three main issues that can cause tear trough deformity: 1. Muscle defect. Anatomically, there can be a triangular muscle defect between the orbicularis oculi muscle and the angular head of the quadratus labii superioris muscle inside the inferior orbital rim, and this defect can cause a palpebromalar groove. Th s groove can form between the septal part of the orbicularis and the attached site of the superior malar part because of differences in muscle volume, depending on the activities of the muscles. The palpebromalar groove is not deep (Figs. 29-4 and 29-5).

446

Part IV 

Cosmetic Surgery of the Eyelid

2. Descent of the cheek. A drooping cheek is caused by sagging of the relaxed orbicularis and skin at the cheek, which mainly occurs in front of the prezygomatic space. The prezygomatic space is surrounded by the orbicularis retaining ligament along the inferior orbital rim at the top, the zygomaticocutaneous ligament at the lower boundary of the zygomatic bone at the bottom, the medial end of the levator labii superioris alaeque nasi muscle on the inside, the body of the zygoma at the back, the orbicularis and fat before and after it, and skin. Because of this space, the soft tissues in front of the zygomatic bone are mobile—not fi mly attached to the zygomatic periosteum. Although the fat in front of this prezygomatic space is preperiosteal fat, the main areas of fat that sag as a result of aging are the malar fat pad, which is a subcutaneous fat layer, and the suborbicularis oculi fat below the orbicularis. The preperiosteal fat has almost no mobility. When the suborbicularis oculi fat droops down from aging, the orbicularis adheres to the arcus marginalis, where the orbital septum is attached to the bone along the inferior orbital rim, and the malar fat pad sags. The skin layer adheres to the orbicularis layer, and the soft issue layer in front of the inferior orbital rim becomes thinner, making the tear trough groove deeper. Because the orbicularis retaining ligament has a tendency to sag more than the zygomaticocutaneous ligament, the palpebral bag can droop more than 10 mm beyond the inferior orbital rim, lowering the boundary between the eyelid and cheek. Thus the distance between the eyelid and cheek in the upper lid margin can increase from 10 to 12 mm when an individual is young and to more than 20 mm in old age. The palpebral and malar bags at the upper and lower ends of the tear trough form a double-convexity contour deformity, making the tear trough deeper. 3. Suborbital malar hypoplasia or malar retrusion. The zygomatic bone is retruded at the site of the inferior orbital rim either as a result of congenital malar hypoplasia or malar retrusion from aging. Regardless of the actual cause, this retrusion deepens the tear trough.

Classification of Lower Eyelid Aging and Possible Corrective Procedures Box 29-1 describes the categories of lower eyelid aging.

Slightl y Ba ggy Eyelid

If the surgeon thinks that a slight baggy eyelid is caused by congenitally great orbital fat with few wrinkles or drooping of the eyelid, part of the orbital fat is removed by the transconjunctival approach. If the surgeon thinks that a slight baggy eyelid is caused by a weakened orbital septum and there are some wrinkles or drooping of the eyelid, he or she can tighten the orbital septum by plicating the orbital septum at the middle through the subciliary incision, or plicating the lower part of the septum and suturing it to the inferior orbital rim, or suturing the capsulopalpebral fascia to the inferior orbital rim to prevent the protrusion of the orbital fat (Figs. 29-6 and 29-7). If the eyelid droops and there is extra fat or skin within the eyelid, the redundant fat or skin must be excised.

Dar k Cir cles and Tear Tr ough Defo rmit y

The tear trough is filled through fat grafting, and pigmentation is treated by laser. If the tear trough projects at the medial cheek, suction lipectomy can achieve satisfactory results in most patients (Fig. 29-8).

Chapter 29 

447

Lower Blepharoplasty

Box 29-1  Types of Aging Lower Eyelids

Type I  Mild wrinkle, no pseudoherniation of orbital fat

Lower Lid Only Type II  Pseudoherniation of orbital fat, absence of lidcheek groove

Type III  Tear trough deformity, mild drooping lower eyelid, herniation of orbital fat, no palpebromalar groove Lid-Cheek Junction Type IV  Drooping lower eyelid with fat bulging, tear trough deformity and palpebromalar groove, border between palpebral bag and periorbital fat

Type V  Severely drooping lower eyelid and lowering of lid-cheek junction, herniation of orbital fat, prominent lid-cheek groove Midface Aging Type VI  Severe skin drooping on the lateral side of the eyelid, deepening of the nasojugal groove, presence of malar bags

K23345_Pu_c29_Lower Bleph_r6_cl_443-466.indd 447

4/3/2015 12:56:39 PM

448

Part IV 

Cosmetic Surgery of the Eyelid

Fig. 29-6  Patients with type I lower lid aging.

Fig. 29-7  Patients with type II lower lid aging.

Fig. 29-8  Patients with type III lower lid aging.

Ear l y Mid f a ce Aging

The patients most frequently encountered by plastic surgeons are those with early midface aging. A surgeon must decide which procedure to perform on a patient with early midface aging based on the condition of the patient and a few basic principles. Excision of orbital fat should be avoided as much as possible—except when it is thought that the patient has too much congenital orbital fat. The transconjunctival approach is appropriate if the eyelid skin or muscle relaxation is insuffici t and if there is no need for incising the skin or muscle. If an incision is necessary, the better choice is a subcilary incision, which is a transcutaneous approach. The transconjunctival approach can decrease postoperative edema and scar retraction and can prevent the partial denervation of the orbicularis and ectropion. However, the disadvantages of this approach are limited surgical vision, an inability to remove skin and muscle in patients with a very relaxed eyelid, and difficulty in raising a sagging cheek.

K23345_Pu_c29_Lower Bleph_r6_cl_443-466.indd 448

4/3/2015 12:56:40 PM

Chapter 29 

Lower Blepharoplasty

Fig. 29-9  Patients with type IV lower lid aging.

Fig. 29-10  Patients with type V lower lid aging.

Fig. 29-11  Patients with type VI lower lid aging.

If the palpebral bag and tear trough are conspicuous, the arcus marginalis should be opened, and the orbital fat should slide to the front of the maxillary and zygomatic bones to cover the groove (Fig. 29-9).

Sever e Mid f a ce Aging and Cheek Pt os is

In a patient with severe midface aging and cheek ptosis, Hamra’s composite rhytidectomy may be a good choice.1 Th s is a midface lift hat can be performed to raise the drooping cheek and treat the palpebral bag and tear trough by sliding the orbital fat to the front of the zygomatic bone. Th s technique will help to correct the tear trough and eradicate the double-convexity contour deformity. Most of these patients also undergo canthoplasty to prevent ectropion (Figs. 29-10 and 29-11).

449

450

Part IV 

Cosmetic Surgery of the Eyelid

Table 29-1  Surgical Options for Lower Blepharoplasty Type of Deformity

Method

Type I

Minimal skin excision, filler, or fat grafting 

Type II

Transconjunctival fat removal only

Type III

Transcutaneous skin excision Fat redistribution Orbicularis oculi muscle suspension

Type IV

Transcutaneous skin excision Fat redistribution Orbicularis oculi muscle suspension Suborbicularis oculi fat elevation Orbitomalar ligament release

Type V

Transcutaneous skin excision Fat removal and redistribution Orbicularis oculi muscle suspension Suborbicularis oculi fat elevation or midface lift Lateral canthopexy or lateral canthoplasty

Type VI

Transcutaneous skin excision Fat removal and redistribution Orbicularis oculi muscle suspension Suborbicularis oculi fat elevation Lateral canthopexy or lateral canthoplasty Midface or cheek lift

Preoperative Assessment A comprehensive preoperative evaluation should be performed, and a detailed surgical plan should be created. It is important for the surgeon to examine the patient thoroughly to determine whether there are any systemic diseases or any anatomic or functional abnormalities in the eyeballs or eyelids that could affect the results of a lower eyelid blepharoplasty (Table 29-1). The surgeon must determine the proper type of lower blepharoplasty to perform for the specific patient (also see Box 29-1). There is a method to determine the rough excision width in which the surgeon fi ds a little upward area on the patient’s skin and pinches the skin to be excised 2 to 3 mm below the lower eyelid eyelashes with a small angulated forceps, marking the skin at several points with gentian violet (Fig. 29-12). Another method to determine the excision width is based on the degree of the incision line that is covered by the lower eyelid during the surgery, as described later. The surgeon should design the lower eyelid incision line to start immediately below the lacrimal punctum and follow 2 to 3 mm below the eyelashes to the point of the lateral canthus, to be parallel to or slope 30 degrees downward from the naturally formed crow’s-feet line (see Fig. 29-11).However, if the skin excision is wide, dog-ears may form toward the medial side; thus, when the incision line is extended toward the medial side, the surgeon must ensure that the extended incision line does not go down farther than the skin layer and into the muscle layer. The length of the incision line lateral to the lateral canthus should not exceed approximately 10 mm; this will vary, depending on the amount of skin to be excised. The excision width should be approximately 4 to

Chapter 29 

Lower Blepharoplasty

Fig. 29-12  The preoperative markings on this woman show the skin resection amount, including the skin resection range, fat resection range, flap dissection range, and pulling direction of the flap.

Table 29-2  Comparison of Skin Flaps and Skin-Muscle Flaps for Lower Blepharoplasty Skin Flap

Skin-Muscle Flap

Indication

Severe skin aging or young patients with many fi e wrinkles

Thi kened orbicularis oculi muscles or severely protruding orbital fat

Ecchymosis or swelling after surgery

Severe

Less severe

Patient satisfaction and longterm results

Acceptable but more contracture than skin-muscle flap

Acceptable

8 mm from the center of the lower eyelid, although this too may vary. The surgeon must determine the fi al excision width when suturing begins, which is after completion of the key suture. Up to 8 or 9 mm may be excised in Westerners; however, the surgeon may want to excise conservatively in Asians.

Surgical Technique The surgical method used in performing lower blepharoplasty can vary slightly based on the patient’s lower eyelid condition. Skin flaps and skin-muscle flaps are summarized and compared in Table 29-2.

Det a chment of Skin Fl aps and Myo cu t aneo us Fl aps

The surgeon must fi st subcutaneously detach the region from the lower eyelid incision site up to 4 to 5 mm. Th s region corresponds to the pretarsal portion of the orbicularis oculi muscle. If only a skin flap is formed when the orbicularis oculi muscle is left intact in this region, normal eyelid function will be protected and the role of support will be maintained. This method of detaching the skin flaps and myocutaneous flaps is quite effective. In addition, there is a tendency for an individual’s facial expression to become harsher as they age, because the projection and curvature of the muscle in front of the tarsal plate decreases. The rejuvenating effect of this method restores a youthful, pleasing curvature. Using a No. 15 scalpel, the surgeon incises the marked incision line from the region of the lateral canthus to the lateral side (Fig. 29-13, A), and inserts the pointed end of a scissors into the incision line toward the area below the lower eyelid skin to subcutaneously detach the tarsal plate up to the vicinity of the medial canthal punctum (Fig. 29-13, B). The subcutaneous detachment is extended up to approximately 4 to 5 mm from the planned incision line to a point 2 to 3 mm below the lower eyelid edge.

451

452

Part IV 

Cosmetic Surgery of the Eyelid

A

B

C

D

E

F

Fig. 29-13  Lower blepharoplasty through a myocutaneous flap. A, Postincisional status. B, Dissection of the tarsal plate with skin. C, Incision of the marked lower eyelid design. D, Exposed orbicularis oculi muscle and the incisional design to approach below this muscle. E, Dissection of the area between the orbicularis oculi muscle and the orbital septum. F, Fat is removed and repositioned.

After completing the subcutaneous detachment, the tip of one side of the scissors is used to incise the lower eyelid skin along the planned incision line toward the medial side (Fig. 29-13, C). Next, 5-0 nylon sutures are used on the lower eyelid edge to produce traction on the edge toward the upper eyelid and then another incision line is made on the exposed orbicularis oculi muscle (Fig. 29-13, D). Th s incision should be placed 4 to 5 mm below the lower eyelid incision site. The muscle is opened with a Bovie or scalpel. The incision ends when the orbital septum can be seen, and the area between the orbicularis oculi muscle and the orbital septum is detached with the hand or a dull scissors, without causing bleeding (Fig. 29-13, E). Although the detachment may vary depending on the patient’s condition, it is generally conducted up to the infraorbital rim, although detachment can continue up to the front of the zygomatic bone or periosteum in patients with severely sagging orbicularis oculi muscles or severely bulging orbital fat. The orbital fat may be removed by opening the orbital septum when necessary, or through fat transfer or orbital septum reinforcement, as described later (Fig. 29-13, F). In the skin flap method, the orbicularis oculi muscle is not incised; rather, a skin flap is detached from the orbicularis oculi muscle to the inferior orbital margin using dull scissors.

Or bit al Fat Removal and Rear rangement

Any bleeding must be controlled, and the orbital fat should be removed by separating or incising approximately 1.5 cm of the center region of the orbicularis oculi muscle and incising the fat that bulges when the upper eyelid is gently pressed (Fig. 29-14). Any excessive fat should be pinched with a forceps and coagulated.

Chapter 29 

Lower Blepharoplasty

Orbital fat is present in three sections of the lower eyelid, and the central fat section contains the largest accumulation of fat. Although the amount of fat to be removed should be determined based on the degree of orbital fat bulging, it is recommended that the fat in the central fat section be removed first, followed by the medial fat section and then the lateral fat section (Fig. 29-15). In Asians, the fat should be removed conservatively. If too much orbital fat is removed, the lateral side of the lower eyelid will be depressed; the lower eyelid will be unattractive, with scleral show. In particular, it is important to conservatively excise the fat in the lateral fat section (Fig. 29-16).

Fig. 29-14  Protruding fat.

Fig. 29-15  Excised medial, central, and lateral

orbital fat.

Fig. 29-16  Lower blepharoplasty by myocutaneous flap with fat removal. The fat in the lateral fat section was conservatively excised.

453

454

Part IV 

Cosmetic Surgery of the Eyelid

Although a local anesthetic solution is injected to minimize pain during fat removal, care must be used when injecting the anesthetic into the deep region of the orbit to avoid damage to the blood vessels and formation of a retrobulbar hematoma. Today methods to move the fat rather than excising it are preferred (Fig. 29-17). If the amount of fat is not excessive, good results can be obtained by detaching the fat, then excising only the skin without removing the fat (Fig. 29-18). Although the orbital septum is generally not sutured after removing the orbital fat, Hamra1 advised that if the orbital septum were sutured and fi ed to the periosteum in the inferior orbital margin, good results could be obtained to correct severe palpebral bags. The detached myocutaneous flap should be pulled with appropriate tension, and the sagging skin should be excised suffici tly, but not excessively.

Fig. 29-17  Lower blepharoplasty by myocutaneous flap with fat reposition.

Fig. 29-18  Lower blepharoplasty by myocutaneous flap and skin excision without fat removal.

Chapter 29 

Skin Fl ap Fix atio n or Lateral

Lower Blepharoplasty

Cantho pl a st y

The myocutaneous flap should be pulled upward and laterally in accordance with eyelid conditions or the degree of sagging of the orbicularis oculi muscle. Part of the orbicularis or the muscle flap should be removed or fi ed, or the myocutaneous flap should be hung to the lateral orbital periosteum or the lateral canthal ligament using 5-0 nylon sutures to prevent early scleral show or ectropion, which may occur from damage to the nerve within the muscle, from postoperative swelling, or from scar contracture caused by incisions on the orbicularis oculi muscle2 (Fig. 29-19, A). When attaching the lateral canthal ligament to the lateral orbital periosteum, I affix t to the periosteum 2 to 3 mm above the lateral raphe, and I draw and attach the fat under the orbicularis oculi muscle in the lower skin flap as well as the fat under the lateral orbital septum or the lateral orbicularis oculi muscle together. If relaxation of the supporting tissue of the lower eyelid is apparent in preoperative examinations, the horizontal length of the eyelid should be shortened with a wedge or pentagonal excision, and the conjunctiva and tarsal plate should be fi mly sutured to prevent ectropion. If the condition is not corrected properly with this method, the surgeon should perform a lateral canthoplasty. Regarding the direction of skin flap traction, it is recommended to draw the skin flap upward and laterally at an angle of approximately 45 degrees; however, the surgeon may want to draw the skin flap vertically while deeply drawing the orbicularis oculi muscle downward. Any skin protruding beyond the superior margin of the incision wound should be removed (Fig. 29-19, B through D).

A

B

C

D

Fig. 29-19  Lower blepharoplasty with a myocutaneous flap. A, Lateral canthoplasty to fix the orbicularis oculi muscle on the periosteum. B, Excision of surplus skin. C, Postexcisional status. D, The patient after suturing.

455

456

Part IV 

Cosmetic Surgery of the Eyelid

Sutur e

The surgeon incises the skin vertically at the region of the lateral canthus with a pair of scissors, places the key suture at the site, and excises any remaining skin and muscle. It is recommended to excise the smallest possible amount of muscle to maintain the pretarsal knoll. When excising the remaining skin after the key suture is placed, if the surgery is performed with a local anesthetic, I recommend that the patient should be asked to open his or her mouth wide and gaze upward, and then the skin flap is pulled upward and laterally to design the excision. If a general anesthetic is administered, the surgeon may want to gently press the eyeball downward to place the eyelid at the neutral position, have the lower eyelid edge come up to the peak position, and excise any part of the skin flap protruding beyond the superior margin of the incision wound in the shape of a long triangle. If the eyelid edge appears to roll into a state of ectropion, the surgeon should loosen the key suture to reduce the excision width. The lower eyelid skin is secured with 6-0 or 7-0 nylon sutures or interrupted sutures, then interrupted sutures are used in the region of the lateral canthus. Suture placement in the lateral side should be somewhat dense, and medial sutures should be placed sparsely. The sutures are removed 3 days later, and I recommend attaching skin tapes to the lateral region of the lateral canthus for approximately 2 weeks after suture removal.

The Skin Fl ap Metho d

Recently, the skin flap method has been used in lower blepharoplasty. Th s method is also indicated in patients with little or no excess muscle tissue. One major shortcoming of the skin flap method is that skin flap contracture may occur during the healing period. Th s is similar to a full-thickness skin graft; however, in most patients, skin flaps with well-developed blood vessels do not contract severely.

Other Sur gical Techniq ues Rel ated t o Lower Lid Blep har opl a st y Technique for Excising Protruding Orbital Fat

Until the 1970s, for a lower blepharoplasty to treat a palpebral bag, the orbital septum was opened and the protruding orbital fat was excised. Although this technique initially yields good results, it may cause senile enophthalmos, or the eyelid can become excessively sunken, because the orbital fat shrinks over time. Therefore the recent trend is to preserve orbital fat unless it is extremely excessive.

Techniques for Reinforcing the Front Supporting Structure of Protruding Orbital Fat Orbital fat begins to bulge as an individual ages, because the orbital septum that supports the orbital fat weakens over time. There are various types of surgery to reinforce the orbital septum. Mendelson3 advised that excessive removal of orbital fat would move the eyeballs posterior-inferiorly, which would make the patient look old and tired. The surgical methods described next are intended to reinforce or excise the orbital septum that surrounds the orbital fat instead of removing the orbital fat itself. Orbital Septum Plication Plication of an orbital septum that has become thin, weak, and stretched tightens the septum to prevent the orbital fat from bulging outward. The middle (Fig. 29-20) or bottom (Fig. 29-21) part of the exposed orbital septum can be plicated and sutured to the periosteum. Capsulopalebral Repair Capsulopalpebral repair is a method of suturing the capsulopalpebral fascia along the inferior edge of the orbit to make a new strong septum to position orbital fat in the orbit.4 Th s surgical method is shown in Fig. 29-22.

Chapter 29 

A

457

Lower Blepharoplasty

B

Fig. 29-20  Huang technique. A, The dashed line indicates where the myocutaneous flap in front of the orbital septum will be dissected by a subciliary incision. B, The drooping septa in the middle of the orbital septum are plicated together to invaginate the protruding orbital fat and tighten the orbital septum. The extra myocutaneous flap in front of the orbital septum is excised and sutured to reinforce the role of the septum.

A

B

Fig. 29-21  Septoorbitoperiostoplasty. A, The orbital fat is protruding to the front. B, The inferior orbital septum has been plicated and sutured to the inferior orbital rim to tighten the orbital septum.

A

B

C

Orbital septum Capsulopalpebral fascia

Capsulopalpebral fascia

Fig. 29-22  Capsulopalpebral repair. A and B, Dissection of the capsulopalpebral fascia of the septoperiosteum. C, Fixation on the lower orbital margin.

K23345_Pu_c29_Lower Bleph_r6_cl_443-466.indd 457

4/3/2015 12:56:46 PM

458

Part IV 

Cosmetic Surgery of the Eyelid

Septoperiosteoplasty Septoperiosteoplasty (septorrhaphy) is a method to reinforce the orbital septum by suturing the lower part of the orbital septum to the periosteum along the inferior orbital margin in a method similar to capsulopalpebral repair or suturing the orbital septa to each other. Because capsulopalpebral repair and septoperiosteoplasty do not have much effect on improving regions below the inferior orbital margin, they are generally effective only in patients with minimal or minor sagging of the transitional region between the eyelid and the cheek. A sliding fat pad is effective in patients with fat under the orbicularis oculi muscle covering the inferior orbital margin or patients with weakened orbicularis oculi muscles.

Techniques for Repositioning Protruding Orbital Fat Beyond the Inferior Orbital Rim A technique to reposition protruding orbital fat beyond the inferior orbital rim was fi st attempted by Loeb5 and generalized by Hamra.1 In this technique the skin is detached up to the inferior margin of the orbicularis oculi muscle as in the skin-muscle flap method, opening the arcus marginalis and removing the orbital fat by sliding it across the inferior orbital margin and suturing it to the periosteum. The orbital fat is generally sutured to a region 1 to 1.5 cm below the inferior orbital margin. Th s method also has the effect of rearranging the orbicularis oculi muscle, the fat under the orbicularis oculi muscle, and the fat on the cheek; thus this method can be performed together with composite facial lifts

Transconjunctival Lower Blepharoplasty Transconjunctival lower blepharoplasty is a simple technique that involves inserting an eye-protecting contact lens, making an incision directly below the tarsal plate of the lower eyelid conjunctiva with a scalpel or Bovie, reaching the orbital septum to remove the medial, central, and lateral fat that protrudes when the eyeball has been gently pressed, arresting any hemorrhaging, and leaving the site alone or suturing it with only one stitch.

Postoperative Care Although in some cases the surgical site is left alone without any particular treatment, some surgeons feel that application of gentle pressure on the surgical site is optimal. If both upper and lower blepharoplasties were performed, the surgeon may want to have the patient keep his or her eyes closed. A patient’s use of a cold pack compress is helpful in reducing ecchymosis or swelling during the fi st 12 to 24 hours postoperatively. If hemorrhage or severe swelling occurs, the site should be reopened and left alone without further treatment, or the site may be covered with gauze.

Chapter 29 

Lower Blepharoplasty

459

Results A successful lower blepharoplasty will produce a more youthful, attractive appearance. However, there are several complications that can result, such as hematoma, epiphora, diplopia and extraocular muscle disorder, exposure keratopathy, eyelid malposition, cicatricial ectropion, asymmetry, and scarring.

Fig. 29-23 Th s 47-year-old woman presented with an aging face. I performed a lower blepharoplasty using skin excision, central-medial fat removal, arcus marginalis release, and orbicularis oculi muscle suspension. She is shown 2 months after surgery with a younger, refreshed appearance.

Fig. 29-24 Th s 52-year-old woman presented with an aging face. I performed a lower blepharoplasty using skin excision, central-medial fat removal, and orbicularis oculi muscle suspension. Eight months after surgery, she has a younger and more attractive appearance.

K23345_Pu_c29_Lower Bleph_r6_cl_443-466.indd 459

4/3/2015 12:56:46 PM

460

Part IV 

Cosmetic Surgery of the Eyelid

Fig. 29-25 Th s 57-year-old man presented with an aging face. I performed a lower blepharoplasty using skin excision, central-medial fat removal, orbicularis oculi muscle suspension, canthopexy, and suborbicularis oculi fat elevation. Th ee months after surgery, he has a younger and more attractive appearance.

Management of Complications Ear l y Pos t opera tive Per io d Hemorrhage and Hematoma

Simple petechiae do not require specific treatment, although hematomas with clear boundaries and sutures may require suture removal and appropriate treatment (Fig. 29-26). A posterior hematoma (retrobulbar hemorrhage) can be a signifi ant complication and can even lead to blindness. An urgent ophthalmic consultation is needed to ensure proper medical management of the hematoma. The sutures of the incision should be removed to release intraocular pressure in the eye, and the surgical wound must be explored for bleeding.

Epiphora or Dry-Eye Syndrome Epiphora, or dry-eye syndrome, is caused by incomplete eyelid closing, temporary eyelid retardation, lagophthalmos, or the phenomenon of evaporation. Epiphora improves spontaneously in several weeks to several months; thus it can be diagnosed as dry-eye syndrome when it persists as a late-phase complication. Th s condition may cause xerotic keratitis in patients in their sixties through eighties as a result of reduced tear generation. If dry-eye syndrome continuously progresses even after surgery, it may develop into keratitis or keratohelcosis, which should be treated through close consultation with an ophthalmologist.

Diplopia and Extraocular Muscle Disorder Patients rarely complain of diplopia after blepharoplasty; however, many patients complain of temporary binocular or uniocular diplopia caused by dry eyes or eyeball irritation resulting from physiologic causes or lacrimation after surgery. Permanent diplopia is caused by direct damage to the extraocular muscles, especially when the orbital septum above the oblique muscle has been penetrated with direct trauma to the muscle. Ophthalmic consultation is usually required for management of diplopia.

Chapter 29 

Lower Blepharoplasty

A

B

C

D

E

F

461

Fig. 29-26  A hematoma occurred 1 day after lower blepharoplasty. Immediate hematoma removal was performed.

A, The patient is seen preoperatively, and B, with preoperative markings. C, A hematoma formed on the lower eyelid of the left ye 1 day after surgery. D, The hematoma was removed. E, Five days after hematoma removal. F, The patient is shown 3 months after surgery, with no cosmetic defects.

Exposure Keratopathy From Incomplete Eyelid Closure Exposure keratopathy occurs as a result of excessive skin excision during a blepharoplasty or an adhesion between the orbital septum and part of the eyelid tissue. The condition can lead to eyelid retardation or lagophthalmos. Therefore it is important to evaluate the patient for Bell’s phenomenon before surgery. Because patients with weak or no Bell’s phenomenon are likely to develop exposure keratopathy, this possibility should be discussed with an ophthalmologist before surgery is scheduled.

Eyelid Malposition There is a tendency for patients to develop ectropion after surgery, because the eyelid is lengthened as a result of paralyzed orbicularis oculi muscles and pulled downward by swelling or hematoma. Ectropion may also be caused by scars or contracture, although it disappears by itself in most cases. If ectropion persists longer than 1 week after surgery, it should be actively treated in most patients. Ectropion that has developed because of lengthened lower eyelids is not easily relieved; in many patients, it requires surgical intervention.

K23345_Pu_c29_Lower Bleph_r6_cl_443-466.indd 461

4/3/2015 12:56:49 PM

462

Part IV 

Cosmetic Surgery of the Eyelid

Late Pos t opera tive Per io d

Recurrence of Malar Festoons (Secondary Bags) If the patient has malar festoons before surgery and is aware of them, it is important for the surgeon to inform the patient that these may remain after surgery. If malar festoons are noted before surgery, the histories of diseases such as thyroid diseases, chronic rhinitis, allergic conjunctivitis, idiopathic general swelling, and renal diseases should be elicited and carefully examined. If the patient has continuous swelling on the buccal region below the lower eyelid but has no renal disease or thyroid disease, it is recommended that the surgeon inform the patient about the possibility of the development of festoons after surgery. Diuretics or oral steroids may be administered immediately after surgery.

Cicatricial Lower Eyelid Bowing, Inferior Scleral Show, and Ectropion Ectropion is one of the most common complications to develop after a lower blepharoplasty, and only careful preoperative evaluation can help prevent this condition. Ectropion can frequently develop because of swelling, particularly chemosis, that develops normally as a result of surgery. However, this will disappear within several days unless eye tension or elasticity increases. Ectropion develops easily when the patient has senile ectropion, high myopia, or protruding eyes as a result of Graves’ oculopathy; thus the surgeon must be careful during the surgery to avoid excessive excision of the lower eyelid tissue (Fig. 29-27). The function of the orbicularis oculi muscle should be carefully evaluated. If the eyelid is sagging and muscle tone is poor, a wedge excision, a lateral suspension of the tarsal plate, or a lateral canthoplasty should be performed. If cicatricial lower eyelid retraction/bowing or inferior scleral show is detected early, it can be treated by pulling the eyelid upward or through repeated massage. After the sutures are removed, the eyelid should be massaged posteriorly in an upward direction three to four times every 5 minutes daily for 10 days.

Fig. 29-27  Ectropion after lower blepharoplasty.

Chapter 29 

Lower Blepharoplasty

463

The lower eyelid retraction that develops from the capsulopalpebral fascia pulling posteriorly and downward is also relieved through massage. If it is still not relieved even after massaging for a long time, the lower eyelid should be pulled through a reverse Frost suture.

Asymmetry and Undercorrection Before surgery, asymmetry is prevented to some extent because the skin sags appropriately and orbital fat increases; thus the asymmetry goes unnoticed. However, because skin and fat are removed during a blepharoplasty, the asymmetry becomes more severe, because it is difficult to remove tissue identically on both sides. A comprehensive physical examination is essential before surgery. It is also important to excise excess remaining skin and orbital tissue, so that both sides are symmetrical during surgery. Undercorrection occurs because the orbital fat or central connective tissue contained in the upper and lower eyelid was not appropriately removed or the remaining skin was insuffici tly excised. In some patients, undercorrection occurs when a large amount of fat is removed but only a small amount of skin is removed, increasing the number of folds, which can make the eyelid look undercorrected. Undercorrection can be treated by a repeat blepharoplasty.

Hypertrophic Scars In general, because the upper and lower eyelids have very thin skin, hypertrophic scars rarely become a problem, except in certain patients. Some scars remain after an epicanthoplasty is performed together with a lower blepharoplasty, and some scars remain in patients who have a hypertrophic scar; however, these scars generally disappear approximately 6 months after surgery. If severe hypertrophic scars develop, a steroidal agent may be injected locally, or scar revision can be performed.

Pearls for Success • A comprehensive preoperative evaluation should be performed. • The surgeon must determine the proper type of surgery to perform for the specific patient. • During a lower blepharoplasty, denervation of the pretarsal orbicularis muscle can be minimized by preserving the orbicularis. • Hematoma could be minimized by using the skin-muscle flap method. • During a lower blepharoplasty, the orbitomalar ligament should be released. • Supporting the lateral canthal area is important to minimize malposition of the eyelids. • Depending on the amount of relaxation of the lower lid, a lateral canthoplasty or lateral canthopexy could be selected. • A superfic al cheek lift is used to reduce complications and improve aesthetic results. • The transconjunctival approach can be used for patients who only have excessive orbital fat.

K23345_Pu_c29_Lower Bleph_r6_cl_443-466.indd 463

4/3/2015 12:56:50 PM

464

Part IV 

Cosmetic Surgery of the Eyelid

Expert Commentary Kenneth C. W. Hui The most common practice for bilateral lower blepharoplasty for Asian patients is fat removal through the transconjunctival approach. Although this approach can offer the quickest recovery with no external scar, it is best suited for a milder deformity without a signifi ant infraorbital hollow deformity and skin laxity. Fat removal through the transconjunctival approach requires precise and expertly performed fat removal, and reoperation may be necessary. In the worst case, the inadvertent overresection of fat can result in a delayed sunken inferior orbital region, which is often accentuated with smiling when the lower fibers of the orbicularis contracts. The resultant hollowness is very difficult to fill with artific al filler injection and autologous fat injection. The skin is thin, and even minor unevenness is noticeable. Furthermore, fat necrosis and hardening are almost impossible to rectify. Instead of fat removal, fat redistribution is gaining popularity, because the three bulging infraorbital fat pads can be utilized to fill the sunken infraorbital groove. Th s approach is best performed through a subciliary skin incision. A plane can be created by elevating the skin off the pretarsal muscle, and then a skin/ muscle flap is developed toward the orbital rim. The orbital-malar ligament is freed, and a wide tunnel is made through blunt dissection, extending 1 to 2 cm below the rim, deep to the orbicularis oculi muscle, and into the cheek (Fig. 29-28, A). After complete hemostasis, the fat compartments are released by opening the orbital septum (Fig. 29-28, B), and the fat is pushed down and stitched to muscle fascia with absorbable sutures (Fig. 29-28, C). On closure, redundant skin below the ciliary margin can be trimmed conservatively if necessary. The fat redistribution method is particularly suitable for more severe (type 3 and 4) lower eyelid deformities, which are commonly seen in the older age group. However, I found fat redistribution to be equally effective for patients in the younger age group who had minimal fat herniation but a deepened groove. The dark shadow half-moon–shaped rim can frequently be flattened.

A

B

C

Fig. 29-28  A, A subciliary approach is used to explore the infraorbital septum and fat compartments. B, An infraorbital fat pad is exposed after releasing the septum. C, Th ee fat pads are redistributed and secured with absorbable sutures.

Because the three fat pads are not detached from their blood supply, fat necrosis and the shrinkage of transferred fat are not expected. An alternative method of fat redistribution through the transconjunctival approach has also been described. Unlike the open subciliary approach, external skin incision can be avoided through the transconjunctival approach. However, because of the tight space used in this approach, it is difficult to secure the fat compartments in the cheek with sutures. Therefore the three fat pads are divided and then pushed under the infraorbital rim as free fat grafts. Because I have encountered cases

Chapter 29 

Lower Blepharoplasty

of fat necrosis resulting in palpable and visible subcutaneous nodules with autologous fat injections in this area, I have not tried this technique. The main disadvantage of this open approach for fat redistribution is the longer recovery time required. Skin numbness, prolonged edema, and rarely conjunctival swelling are expected, but they are more common in the older age group. Dryness and tearing may last for a few weeks in patients with preexisting dryeye conditions. The patient has to be informed preoperatively about these potential complications, so that they can decide on the alternatives and appropriate planning made before undergoing surgery (Fig. 29-29).

Fig. 29-29  An Asian woman presented with the main complaint of a bulging lower eyelid. She is shown preoperatively and 8 days after infraorbital fat redistribution through a subciliary approach.

The preoperative examination for lower eyelid canthal laxity is critical. An additional lateral canthal tightening procedure is indicated when the patient has: (1) horizontal eyelid laxity, (2) lateral canthal tilt (dystopia), (3) lid retraction with or without soft issue deficie cy, or (4) aesthetic correction in conjunction with lower blepharoplasty, if the patient has moderate (3 to 6 mm) or signifi ant (.6 mm) lower eyelid laxity based on the lid snapback test. A lateral canthal tightening procedure (canthopexy or canthoplasty) should be performed during the same surgery as the lower blepharoplasty (Fig. 29-30). Compared with the transconjunctival approach, transient postoperative ectropion is more common. The lateral canthal tightening procedure is performed more frequently, because swelling of the lower eyelid can be more signifi ant. A nonabsorbable suture can be placed between the lateral edge of the lateral canthal cartilage and the periosteum of the internal orbital rim above the midhorizontal line of the orbit. When the sutures are properly placed, there will be a 2 to 3 mm elevation of the lateral canthus and a minimal gap in the lower lid conjunctival space. Readjusting the tightness and anchoring points of the sutures may be necessary. Compression tapes, such as Steri-Strips, can be placed on the lower eyelid skin after surgery to control swelling. Eyedrops and ointment are helpful for the symptomatic relief of dryness and tearing. It is recommended that patients avoid exercise and the elevation of blood pressure for 3 to 4 weeks after surgery. Cold compress for the fi st few days after surgery are helpful to reduce swelling, and contact lenses cannot be worn for the fi st week.

465

466

Part IV 

A

Cosmetic Surgery of the Eyelid

B

Fig. 29-30  A, Canthopexy is indicated if there is moderate lower eyelid laxity with lid distraction between 3 and 6 mm. B, Canthoplasty is indicated if there is signifi ant lower eyelid laxity with lid distraction more than 6 mm.

In conclusion, lower blepharoplasty utilizing redundant infraorbital fat to fill in the hollowed infraorbital groove can provide stable and long-term improvement. Even when fat herniation continues above the orbital rim, the already-flattened infraorbital sulcus remains smooth in comparison, so additional surgery may not be necessary. However, performing a lower blepharoplasty utilizing redundant infraorbital fat is more challenging, requiring precise execution and strict hemostasis. Potential complications including ectropion can be prevented by adding lateral canthopexy before fi al skin closure. The satisfactory rate is high if the patient is informed about the possibility of a long recovery time.

Refer ences 1. Hamra ST. Arcus marginalis release and orbital fat preservation in midface rejuvenation. Plast Reconstr Surg 96:354-362, 1995. 2. Labandter HP. Use of the orbicularis muscle flap for complex lower lid problems: a 6-year analysis. Plast Reconstr Surg 96:346-353, 1995. 3. Mendelson BC. Fat preservation technique of lower-lid blepharoplasty. Aesthetic Surg J 21:450-459, 2001. 4. de la Plaza R, Arroyo JM. A new technique for the treatment of palpebral bags. Plast Reconstr Surg 81:667-687, 1988. 5. Loeb R. Fat pad sliding and fat grafting for leveling lid depressions. Clin Plast Surg 8:757-776, 1981.

K23345_Pu_c29_Lower Bleph_r6_cl_443-466.indd 466

4/3/2015 12:56:53 PM

30 Lower Eyelid Shortening for Vertical Enlargement of the Palpebral Aperture

R

Toshitsugu Hirohi, Kotaro Yoshimura

elatively common features that are unique to the Asian eyelid include a single (nonfolding) upper eyelid, epicanthus, an upward-slanting, narrow eye fissure, and puffiness (Fig. 30-1). Because these distinctive features are considered unappealing, a great many Asian patients desire to improve them. The majority of aesthetic periorbital surgeries for children are focused on the upper eyelids or medial canthus; double eyelid blepharoplasty and medial epicanthoplasty are often performed. Although these operations are well accepted and certainly effective, they do have limitations regarding overall aesthetic surgical outcomes. A large oval palpebral aperture is generally considered aesthetically ideal for Asians. Some Asian women complain of an upslanting and/or narrow palpebral aperture, which is partially caused by the shape and position of the lower lid margin. To correct these conditions that patients find unfavorable, we have developed a surgical solution that focuses on the lower eyelid. The procedure, called the lowering the lower lid (LLL) procedure, allows an inferior transposition of the lower lid margin to correct the size and shape of the palpebral aperture.1 Lower lid descent (lower malposition) has been recognized as a symptom of aging2,3 or devastating functional or cosmetic morbidity after surgery.4-7 In contrast, the LLL procedure is performed to provide a large palpebral aperture with a cosmetically desirable shape, although the candidate pool for the LLL procedure is relatively limited.

Fig. 30-1  Unique features of the Asian eyelid. Th s woman’s eyes have a single (nonfolding) upper eyelid, epicanthus, an upward-slanting and narrow eye fissure, and puffiness.

467

468

Part IV 

Cosmetic Surgery of the Eyelid

Aesthetic Considerations of Palpebral Aperture Shape A large oval palpebral aperture is considered a beautiful configur tion for Asians. In this chapter we will discuss the metrics as well as the means of producing an aesthetically appealing aperture shape.

Palp ebral Aper tur e Size

The mean values of the palpebral aperture size are a width of approximately 30 to 31 mm and a height of approximately 8 to 10 mm (Fig. 30-2).8 The mean height of the palpebral aperture in Asian women has been reported to be 8.2 6 1.1 mm.9

Canth al Til t

The lateral canthus is generally positioned superior to the medial canthus; canthal tilt is the inclination between the medial canthus and the lateral canthus. A canthal tilt of 5 to 10 degrees is considered normal in Asians (Fig. 30-3, A), whereas a canthal tilt of 10 to 15 degrees is considered normal in non-Asians.10,11 Th position of the lateral canthus is normally at the same level as the inferior edge of the pupil (Fig. 30-3, B).

Lower Lid Mar gin: Pos itio n and Shap e

The lower lid margin normally rests at the corneoscleral junction in the primary gaze; the central lower eyelid is at the lowest point, and there is a gently sweeping, upward inclination toward the lateral and medial canthi8 (Fig. 30-4, A). A high-positioned lower lid margin, located 1 to 2 mm above the corneoscleral junction, leads to a narrow palpebral aperture (Fig. 30-4, B). In contrast, a low-positioned lower lid margin presents inferior scleral show (Fig. 30-4, C).

8-10 mm

Fig. 30-2  The mean values of the width and height of the palpebral aperture.

30-31 mm

A

B

Fig. 30-3  Palpebral aperture shape. A, A canthal tilt of 5 to 10 degrees is considered normal. B, The lateral canthus is positioned approximately 2 mm superior to the medial canthus.

5°-10°

2 mm

Chapter 30 

A

Lower Eyelid Shortening for Vertical Enlargement of the Palpebral Aperture

B

C

Fig. 30-4  The positions of the lower lid margin. A, Normally positioned lower lid margin. B, High-positioned lower lid margin resulting in a narrow palpebral aperture. C, Low-positioned lower lid margin resulting in scleral show.

Fig. 30-5  Cross-sectional anatomy

Conjunctiva Tarsal plate Inferior tarsal muscle

of the lower eyelid.

Inferior rectus muscle Lockwood’s inferior suspensory ligament

Scleral

Capsulopalpebral fascia Orbital septum Inferior oblique muscle

Tr iangles

The triangle between the cornea and the lateral canthus is called the lateral scleral triangle, whereas the medial scleral triangle is the area between the cornea and the medial canthus. The medial scleral triangle is usually smaller than the lateral scleral triangle. Although the size of the cornea is comparable among individuals, the shape and size of the scleral triangles may differ. A well-balanced relationship between the cornea and both scleral triangles is essential to eyelid aesthetics.

Anatomy Str uctur es of the Lower Eyelid

The lower eyelid is a trilamellar structure consisting of the anterior, middle, and posterior lamellae (Fig. 30-5). The anterior lamella consists of the skin and the orbicularis oculi muscle, the middle lamella corresponds to the orbital septum, and the posterior lamella contains the tarsal plate, medial and lateral canthal tendons, capsulopalpebral fascia (CPF), and conjunctiva. The key anatomic structures for the LLL procedure are the orbicularis oculi muscle, tarsoligamentous sling, and lower lid retractors.

469

470

Part IV 

Cosmetic Surgery of the Eyelid

Orbicularis Oculi Muscle The orbicularis oculi muscle underlies the dermis, with little to no subcutaneous fat. The muscle is divided in three portions: pretarsal, preseptal, and orbital. The pretarsal portion is firmly adhered to the tarsal plate. In addition to contributing to the structural integrity of the lower lid, contraction of the orbicularis oculi muscle provides dynamic support for the lid margin. When performing lower blepharoplasty, the surgeon must ensure that the pretarsal portion remain attached to the tarsal plate to preserve the lid support necessary to maintain its normal anatomic position.

Tarsoligamentous Sling The tarsoligamentous sling creates the support structure for the posterior lamella. The lower lid tarsal plate is a rigid, cartilaginous structure, measuring 4 to 6 mm vertically, that provides lid stability. Attachments to the lower lid tarsal plate include the pretarsal orbicularis oculi muscle, CPF, and conjunctiva. Lockwood’s ligament arises from the medial and lateral retinaculum and fuses with the CPF anterior to the inferior oblique muscle.

Lower Lid Retractors The lower lid retractors include the CPF and the inferior tarsal muscle, which are closely related to each other. The CPF originates in the inferior rectus fascia, inserts into the lower tarsal plate and dermis, and is lined by the conjunctiva and the inferior tarsal muscle. The CPF is analogous to the levator aponeurosis, and the inferior tarsal muscle is analogous to the Müller’s muscle in the upper eyelid.

Indications for the LLL Procedure The primary indications for the LLL procedure are an upslanting appearance of the palpebral aperture and a high-positioned lower lid margin overriding the inferior corneoscleral limbus. An upslanting appearance of the palpebral aperture typically results from one of two configur tion types: an anatomically positive canthal tilt (an inclination between the medial canthus and lateral canthus of more than 10 degrees) (Fig. 30-6, A), or a normal canthal tilt (5 to 10 degree inclination) accompanied by a steep inclination of the lateral third of the lower lid margin (Fig. 30-6, B). In patients with a canthal tilt more than 15 degrees, a lateral canthoplasty may be indicated to lower the position of the lateral canthus. However, because this procedure is complicated and unpredictable, unfavorable results are frequently observed. The LLL procedure can be performed in place of lateral canthoplasty: a subciliary incision is extended 5 mm laterally across the lateral canthus to lower the lateral canthal position, although the effect is limited. In addition, a steep inclination of the lateral third of the lower lid margin with a normal canthal tilt causes a narrow lateral scleral triangle, and is one of the positive indications for the LLL procedure. A high-positioned lower lid margin overriding the inferior corneoscleral limbus (Fig. 30-6, C) contributes to a vertically narrow palpebral aperture, concealing 1 to 2 mm of the inferior limbus of the cornea. For patients whose lower lid margin is positioned above the inferior corneoscleral junction, the central third of the lower lid margin is the main target of this procedure.

Chapter 30 

Lower Eyelid Shortening for Vertical Enlargement of the Palpebral Aperture

A

B

C

Fig. 30-6  Good candidates for the LLL procedure. A, An anatomically positive canthal tilt. B, A steep inclination of the lateral third of the lower lid margin, in combination with a normal canthal tilt. C, A high-positioned lower lid margin overriding the inferior corneoscleral limbus.

Fig. 30-7  The lid distraction test.

Preoperative Assessment To avoid serious complications such as inferior scleral show or ectropion, the surgeon should carefully evaluate each patient’s lower eyelid tone, eye prominence, and malar support. In patients with hypertrophy of the orbicularis oculi muscle, the clinician should confi m whether the patient wants to reduce the muscle volume.

Lower Eyelid Tone

Lower eyelid tone is generally evaluated using the lid snapback test or lid distraction test.12,13 The lid distraction test is recommended to obtain a precise evaluation of eyelid laxity; the normal distraction range of eyelid laxity is within 3 mm from the globe8 (Fig. 30-7). Although the majority of candidates for the LLL procedure are young women with normal eyelid tone, the lid distraction test must be performed to avoid accentuated results. In patients with poor eyelid tone, less-invasive approaches may be required. Transconjunctival shortening of the posterior lamella without the removal of the anterior lamella can be a safer option to prevent lower eyelid malposition.

471

472

Part IV 

Cosmetic Surgery of the Eyelid

Eye Pr ominence

Eye prominence is generally evaluated by the Hertel exophthalmometer, which measures the distance between the cornea and the orbital rim. Normal eye prominence ranges from 15 to 18 mm (Fig. 30-8, A), a deep-set eye measures less than 15 mm (Fig. 30-8, B), and a prominent eye (exophthalmos) measures more than 18 mm8 (Fig. 30-8, C).

Str uctural

Suppor t by the Mal ar Bone

The anterior projection of the eyeball and malar eminence should be compared on the lateral view.12 Patients whose malar eminence lies posterior to their cornea, in particular negative-vector patients, have poor lower eyelid support14 (Fig. 30-9, A). To prevent overcorrection and scleral show in patients with prominent eyes (negative vector), the surgeon should take great care to shorten the anterior lamella moderately. The amount of resected skin should be 1 to 2 mm less than that in normal cases. In contrast, the LLL procedure tends to have insuffici t efficacy in patients with deep-set eyes (positive vector) (Fig. 30-9, B). In general, the position of the lower lid is primarily adjusted by shortening the posterior lamella, and overresection of the skin should be avoided.

Pr et arsal Or bicul ar is Hyper tr ophy

Hypertrophy of the orbicularis oculi muscle is a unique feature of the Asian population, producing a noticeable bulge in the infraciliary region (Fig. 30-10). 15 The pretarsal bulge is frequently considered to be cosmetically favorable, especially in young people. Therefore the decision of whether to reduce the orbicularis oculi muscle is made based on the patient’s preference. If necessary, the surgeon should trim the anterior portion of the orbicularis oculi muscle without disturbing its tarsal attachment.

Surgical Technique The LLL procedure usually combines partial removal of the anterior lamella with static shortening of the lower lid retractors (posterior lamella).

Pr eo pera tive Des ign

The subciliary incision line is initially marked along the lid margin when the patient is seated with his or her eyes in the primary gaze position. Proper design of the crescent-shaped skin excision is a key factor in achieving good, predictable results and avoiding complications. The vertical width and horizontal length of the skin excision are judiciously determined based on each patient’s condition and preference (see Fig. 30-11,A). A detailed evaluation should be conducted using both the surgeon’s direct visualization and the patient’s life-size, frontal, close-up photograph. Evaluation of the photograph allows the surgeon to make a detailed analysis of the relationship between the lower lid margin and inferior limbus, as well as eyelid symmetry. The crescent-shaped skin to be excised can be determined by drawing the ideal lower eyelid line on the photograph. The lateral endpoint of the crescent is usually at the lateral canthus; the medial endpoint varies, but is frequently located between the medial canthus and medial limbus of the cornea. The maximum

Chapter 30 

Lower Eyelid Shortening for Vertical Enlargement of the Palpebral Aperture

A

B

15-18 mm

473

C

,15 mm

.18 mm

Fig. 30-8  Degrees of eye prominence. A, Normal prominence. B, Deep-set eye. C, Prominent eye.

A

B

Negative vector

Positive vector

Fig. 30-9  Structural support by the malar bone. A, Prominent eye (negative vector). B, Deep-set eye (positive vector).

Fig. 30-10  Hypertrophy of the orbicularis oculi muscle.

K23345_Pu_c30 31_Lower Eyelid_r4_cl_467-482.indd 473

4/3/2015 9:09:06 AM

474

Part IV 

Cosmetic Surgery of the Eyelid

vertical width of the excised skin is determined, although it does not correspond to the actual descending distance of the lower lid margin. In patients with upward-slanting eyes, the maximum width of the excised skin is usually 4 to 6 mm at approximately one-half the distance between the lateral limbus and lateral canthus. In patients with a high-positioned lower lid margin overriding the inferior limbus, the maximum vertical width of the excised skin is usually 2 to 3 mm at the midpupillary line.

Lower ing the Lower Lid Pr o ced ur e

The LLL procedure is routinely performed with a local anesthetic with or without intravenous sedation (Fig. 30-11and Fig. 30-12).

A

B

C

D

E

F

G

H

I

Fig. 30-11  Step-by-step anterior views of the LLL procedure. A, Preoperative design for skin removal. B, The crescent-

shaped skin is excised, leaving the orbicularis oculi muscle intact. C, The traction sutures are placed at the lower lid margin. D, The palpebral conjunctiva is incised at the level below the inferior margin of the tarsus and dissected inferiorly. E, A 5-0 PDS suture is passed through the lower eyelid retractors. F, The PDS suture is passed through the inferior edge of the tarsus. G, The posterior lamella is shortened by tying the suture. H, Th ee tucking stitches (arrows) are placed. I, The skin is closed with a 7-0 black nylon suture.

Chapter 30 

A

Lower Eyelid Shortening for Vertical Enlargement of the Palpebral Aperture

B

C

Fig. 30-12  Sagittal-section schema of the LLL procedure. A, Subciliary skin (anterior lamella; arrow) is removed. B, Th

posterior lamella is shortened by suturing the lower eyelid retractors to the inferior edge of the tarsal plate. C, The lower lid margin is inferiorly transpositioned by shortening both the anterior and posterior lamellae.

Subciliary Skin Excision Through a Transcutaneous Approach A local anesthetic (1% lidocaine with 1:100,000 epinephrine) is injected with a 30-gauge needle into the subcutis of the subciliary region. A few minutes later, the skin excision is made as designed (see Figs. 3011,B, and 30-12).

Lower Lid Retractor Tucking Through a Transconjunctival Approach After a corneal protector has been applied to protect the globe, traction sutures are placed at the lower lid margin (see Fig. 30-11,C). The lower eyelid is everted by pulling the traction sutures, and a local anesthetic is injected. A conjunctival incision is made below the inferior border of the tarsal plate, and conjunctival dissection is extended inferiorly by approximately 8 mm (see Fig. 30-11,D). The lower eyelid retractors are tucked into the inferior edge of the tarsal plate with three stitches using a 5-0 PDS suture (see Figs. 30-11, E through H, and 30-12, B). The proper amount of shortening of the posterior lamella is determined by checking whether the wound edges of the skin are close to each other or slightly overlapping. There is no need to close the conjunctiva; however, overlapping conjunctiva can be trimmed, if necessary.

Skin Closure of the Lower Eyelid After shortening the posterior lamella, the surgeon must determine whether to resect the orbicularis oculi muscle. If the orbicularis oculi muscle is bulky and disrupts skin closure, it should be trimmed minimally, with the surgeon taking care to preserve the lid tone as much as possible. All bleeding vessels in the muscle are meticulously cauterized with a bipolar cautery, and the skin margins are approximated with a 7-0 running nylon suture (see Figs. 30-11,I, and 30-12, C). A fi al check is made with the patient in the sitting position. If asymmetry, overcorrection, undercorrection, or entropion are observed, they are corrected through the transconjunctival approach by adjusting the shortening of the posterior lamella. Taping or other support of the eyelid is unnecessary.

Postoperative Care After surgery, it is recommended that the patient recline at a 30-degree angle with ice packs on the periorbital region to minimize edema. Broad-spectrum antibiotics are prescribed for 5 days after the surgery, and eyedrops (preservative-free artific al tears) and lubricating ointment (for night use) are prescribed for

475

476

Part IV 

Cosmetic Surgery of the Eyelid

2 weeks after surgery. Although lagophthalmos can be caused by periorbital edema, it resolves with time. Conjunctival chemosis is sometimes observed, and can be treated with eyedrops and lubricating ointment. Patients are asked to return for suture removal on postoperative day 5, when the periorbital region appears swollen and both ecchymosis and chemosis may be observed. Patients are asked to avoid using contact lenses until the chemosis has diminished. Patients usually have follow-up visits at 2 and 4 weeks, and at 3 and 6 months.

Results A total of 125 patients underwent the LLL procedure. In all patients, the upslanting lower eyelid margin was lowered and the lateral part of the palpebral aperture was enlarged. No major complications were observed in our series. Minor complications occurred in only a few patients: lagophthalmos in one patient and ectropion in two patients. Eight surgical revisions were required for undercorrection and asymmetry. The results are shown in Figs. 30-13 through 30-16.

A

B

C

Fig. 30-13 Th s 26-year-old woman with deep-set eyes had narrow and upslanting palpebral apertures with a positive canthal tilt (right, 11.5degrees; left, 10.1 degrees). The patient’s lower lid margin was nearly straight and the lateral half was steeply inclined, leading to a narrow lateral scleral triangle. She also had moderate upper lid ptosis, exaggerating the narrowness of the palpebral aperture (Fig. 30-13, A). Th s patient was a challenging case because of her deep-set eyes; therefore the powerful combination of transconjunctival ptosis surgery and the LLL procedure was performed. Regarding her lower eyelids, 6 mm of skin was resected on both sides. Periorbital ecchymosis and signifi ant chemosis were observed on postoperative day 5, when

Chapter 30 

Lower Eyelid Shortening for Vertical Enlargement of the Palpebral Aperture

the sutures were removed (Fig. 30-13, B). The swelling and chemosis diminished by 2 weeks postoperatively, although lower lid asymmetry was still present. At 1 month after surgery, asymmetry had gradually improved and subciliary scarring was concealed with makeup. The patient had cosmetic tinted contact lenses with an opaque color to accentuate the iris rim. The patient’s status was almost stable at 2 months postoperatively, even though slight chemosis remained on her left side. Two years after the procedure, the patient appeared to have vertical enlargement of the palpebral fissure (Fig. 30-13, C); therefore the lower lid lines, resting at the inferior corneoscleral junction, were gently curved.

A

B

C

D

Fig. 30-14 A 32-year-old woman with strabismus complained of her upslanting eyes (Fig. 30-14, A and B). Th s patient’s canthal tilt was 11.0 degrees on the right side and 10.3 degrees on the left sid . Because of her strabismus, an imbalance between the medial and lateral scleral triangles on both sides was evident; therefore she hoped for large oval eyes and correction of the discrepancy between her medial and lateral scleral triangles. The LLL procedure was conducted in combination with double eyelid surgery. The lower eyelid skin was resected, with the maximum width (5 mm) at approximately half the distance between the lateral limbus and lateral canthus. Six months after surgery, the frontal view shows that the patient’s lower lid has a slightly curved line with downward convexity and a peak at the lateral limbus, leading to an S-shaped lower lid margin (Fig. 30-14, C). The oblique view shows signifi ant enlargement of her lateral scleral triangle, resulting in a balanced appearance of the medial and lateral scleral triangles and less conspicuous strabismus (Fig. 30-14, D).

477

478

Part IV 

A

Cosmetic Surgery of the Eyelid

B

Fig. 30-15 Th s 34-year-old woman had upslanting eyes and a high-positioned lower lid margin overriding the inferior corneoscleral limbus (Fig. 30-15, A). Unexpectedly, the patient’s canthal tilt was within normal limits (right, 9.1 degrees; left, 9.3 de rees). The upslanting appearance was caused by the lateral third of her lower eyelid and was further exaggerated by the shape of the medial portion of her upper eyelid. Therefore we performed the LLL procedure in combination with transconjunctival partial levator shortening of her upper eyelid. In the LLL procedure, her skin was resected throughout the entire length of the lower lid margin on both sides, with the maximum width of 5 mm at the lateral limbus. At 14 months, her lower lid margin showed a gentle curved line with a downward convexity accompanied by a larger lateral scleral triangle (Fig. 30-15, B).

  A

B

C

D

Fig. 30-16 Th s 24-year-old woman complained about upslanting eyes with positive canthal tilt (right, 11.6 degrees; left, 11.2 de rees) (Fig. 30-16, A and B). Th s patient underwent the LLL procedure only; the maximum width of the excised skin was 5 mm at the lateral limbus of the cornea on both sides.

Chapter 30 

Lower Eyelid Shortening for Vertical Enlargement of the Palpebral Aperture

Eighteen months after surgery, on frontal view it can be seen that her postoperative lower lid margin is located at the corneoscleral junction, with the peak of the curvature approximately at the lateral limbus, resulting in the S-shaped line that the patient desired (Fig. 30-16, C). The oblique view shows a widening of the previously narrow lateral scleral triangle, although the lateral canthal position remained almost unchanged (Fig. 30-16, D). As a result, this patient’s upslanting appearance and narrow palpebral aperture were signifi antly improved.

Discussion Man a gement of Complica tio ns

Revision may be necessary depending on the type of postoperative complication.

Chemosis Conjunctival chemosis usually occurs immediately after the operation, and is the most common early complication. Patients sometimes complain of irritation, foreign-body sensation, and mild visual alteration, which usually lasts up to 2 weeks. Persistent chemosis can be treated with 2.5% phenylephrine and dexamethasone eyedrops, which alleviate these symptoms in many cases.16

Lower Lid Malposition Shortening of the middle lamella, generally caused by scarring contracture or adhesion to the CPF, is considered the most common cause of lower eyelid malposition.4,16 In the LLL procedure, the middle lamella (orbital septum) is preserved intact to minimize the risk of cicatricial or adhesional shortening of the middle lamella. No major complications, such as ectropion or scleral show, were observed in our study.

Entropion Entropion is caused by an imbalance between anterior lamella removal and posterior lamella shortening (excessive shortening of the posterior lamella), and was rarely observed in our study. No treatment is usually required; however, posterior lamella shortening should be loosened immediately if the eyelash irritates the cornea.

Iss ues fo r Revis io n

Revision operations are required for aesthetic complications, including undercorrection, overcorrection, and asymmetry. In the case of undercorrection, additional shortening of the anterior lamella by a few millimeters, in combination with posterior lamella tucking, is performed depending on the patient’s condition. We found that a total of 8 mm was the greatest amount of lower eyelid skin that was safely excised. There have been no revision operations for overcorrection in our study. If revision surgery is required for mild overcorrection, it should be performed at least 3 months after the primary operation. Slight overcorrection may be improved with upward massage. However, once serious overcorrection causes exposure keratitis, a salvage operation is immediately required. Lower lid margin asymmetry in shape or position can occur. The primary cause is usually an incorrect amount of excised anterior lamella as a result of inaccurate preoperative planning. Th s asymmetry can usually be corrected by removing additional skin.

479

480

Part IV 

Cosmetic Surgery of the Eyelid

Pearls for Success • Lower lid position and shape are crucial determinants of eyelid aesthetics. • The optimal lower lid margin for Asians is a gently curved line with a small downward convexity, and a canthal tilt of 5 to 10 degrees. • Although poor lower lid tone is rare, a less-invasive approach may be required for patients with this condition. Transconjunctival shortening of the posterior lamella without removing the anterior lamella may be an option to prevent lower eyelid malposition. • When treating patients with prominent eyes (negative vector), the surgeon should take great care to moderately resect the anterior lamella to prevent overcorrection and resulting scleral show. The amount of excised skin is usually 1 to 2 mm less than that in normal patients. • The LLL procedure tends to have insuffici t efficacy in patients with deep-set eyes (positive vector). • The pretarsal bulge from orbicularis hypertrophy is usually accepted as expressive eyes, particularly in young people. The orbicularis oculi muscle can be surgically reduced based on the patient’s preference. • The LLL procedure can be employed as an ancillary procedure to enhance the aesthetic outcome of other blepharoplasty procedures. • If the patient complains of eye asymmetry, remember to evaluate the lower lid margin. We have found that asymmetry is often caused by the lower lid margin’s shape and position, which can be positive indicators for the LLL procedure. • Because the design of skin excision is a key factor in determining the surgical outcome, the surgeon’s detailed evaluation of a patient should also include analyzing a life-size, frontal close-up photograph. • During preoperative design, the relationship of the lower lid margin to the inferior limbus should be noted to avoid scleral show. The life-size photograph will assist the surgeon in making the precise evaluation that is necessary. • Excessive skin removal may cause abnormalities of eye fissure shape. During the primary operation, it is advised that skin excision width not exceed 6 mm.

Refer ences 1. Hirohi T, Yoshimura K. Vertical enlargement of the palpebral aperture by static shortening of the anterior and posterior lamellae of the lower eyelid: a cosmetic option for Asian eyelids. Plast Reconst Surg 127:396-406, 2011. 2. Yaremchuk MJ. Restoring palpebral fissure shape after previous lower blepharoplasty. Plast Reconstr Surg 111:441450; discussion 451-452, 2003. 3. Zarem HA, Resnick JI. Expanded applications for transconjunctival lower lid blepharoplasty. Plast Reconstr Surg 103:1041-1043; discussion 1044-1045, 1999. 4. McCord CD Jr, Ellis DS. The correction of lower lid malposition following lower lid blepharoplasty. Plast Reconstr Surg 92:1068-1072, 1993. 5. Jelks GW, Jelks EB. Repair of lower lid deformities. Clin Plast Surg 20:417-425, 1993. 6. Mommaerts MY, De Riu G. Prevention of lid retraction after lower lid blepharoplasties: an overview. J Craniomaxillofac Surg 28:189-200, 2000. 7. Lelli GJ Jr, Lisman RD. Blepharoplasty complications. Plast Reconstr Surg 125:1007-1017, 2010. 8. Codner MA, Mejia JD. Lower eyelid blepharoplasty. In Nahai F, ed. The Art of Aesthetic Surgery: Principles & Techniques, vol 1, ed 2. St Louis: Quality Medical Publishing, 2011. 9. Park DH, Choi WS, Yoon SH, et al. Anthropometry of Asian eyelids by age. Plast Reconstr Surg 121:1405-1413, 2008. 10. Park DH, Boulos PR. Medial epicanthoplasty and lateral canthoplasty. In Park JI, Toriumi DM, eds. Asian Facial Cosmetic Surgery. Philadelphia: Saunders, 2007.

K23345_Pu_c30 31_Lower Eyelid_r4_cl_467-482.indd 480

4/3/2015 9:09:10 AM

Chapter 30 

Lower Eyelid Shortening for Vertical Enlargement of the Palpebral Aperture

481

11. Spinelli HM. Eyelid malpositions. In Spinelli HM, Lewis A, Elahi E, eds. Atlas of Aesthetic Eyelid and Periocular Surgery. Philadelphia: Saunders, 2003. 12. Carraway JH, Mellow CG. The prevention and treatment of lower lid ectropion following blepharoplasty. Plast Reconstr Surg 85:971-981, 1990. 13. Rees TD. Prevention of ectropion by horizontal shortening of the lower lid during blepharoplasty. Ann Plast Surg 11:17-23, 1983. 14. Wolfe SA, Kearney R. Blepharoplasty in the patient with exophthalmos. Clin Plast Surg 20:275-283; discussion 283-284, 1993. 15. McCurdy JA. Lower blepharoplasty in the Asian. In McCurdy JA, Lam SM, eds. Cosmetic Surgery of the Asian Face, ed 2. New York: Thie e, 2005. 16. McCord CD Jr, Nahai F. Avoidance and treatment of complications of aesthetic eyelid surgery. In Nahai F, ed. The Art of Aesthetic Surgery: Principles & Techniques, vol 1, ed 2. St Louis: Quality Medical Publishing, 2011.

K23345_Pu_c30 31_Lower Eyelid_r4_cl_467-482.indd 481

4/3/2015 9:09:10 AM

K23345_Pu_c30 31_Lower Eyelid_r4_cl_467-482.indd 482

4/3/2015 9:09:10 AM

31 Management of Sunken Eyelid

I

David Daehwan Park

n recent years there has been an increasing desire among Asians to westernize their eyelids. The anatomic structures of the upper and lower eyelids are very different between Asians and Westerners (see Chapter 24). Many of the aesthetic plastic surgeries that are now being performed in Asian countries are upper eyelid operations, such as procedures to correct double eyelid folds. Many Asians have puffy eyelids that they want to westernize through the removal of orbital fat or orbital soft tissue; as a consequence, a hollowed, prematurely aged eyelid may develop over time in many of these patients. The condition described as sunken eyelids is characterized by upper lids that are depressed and have a cosmetically poor appearance. A patient with sunken eyelids looks tired, may have difficulty opening his or her eyes, and has eyelid skin retraction. In addition, a patient with sunken eyelids frequently has high or multiple eyelid folds. In this chapter, I describe the common causes of sunken eyelids, preoperative assessment of the patient, surgical correction, management of complications, revision surgery, and alternative procedures.

Common Causes of Sunken Eyelids Sunken eyelids may have either a congenital or an acquired cause. Acquired causes can be further categorized as involutional and traumatic.

Congenit al Caus es

In a patient with congenitally sunken eyelids, the lids are depressed as aging progresses because of a decrease in collagen, elastic tissue, and subcutaneous fat. The upper eyelid may be ptotic, or there may be no double eyelid fold and the eyelid functions are weak, though the lids are not ptotic. In addition, a patient who has protruding bony orbital framework from genetic factors may have sunken eyelids. Sunken eyelids also occur more frequently in a patient with very thin upper eyelid skin.

483

484

Part IV 

Cosmetic Surgery of the Eyelid

Fig. 31-1  A, When the fat or the orbicularis oculi muscle is excessively excised during blepharoplasty, B, enophthalmos or triple eyelid folds may appear.

Fig. 31-2  The proper volume of the upper eyelid can make for a more attractive appearance.

Ac quir ed Caus es

Acquired sunken eyelids may develop as a sequela of an upper eyelid operation. Enophthalmos or triple eyelid folds may occur in a patient in whom there was excessive excision of eyelid fat or of the orbicularis oculi muscle during blepharoplasty (Fig. 31-1).Another cause is orbital fracture.

Preoperative Assessment Individuals with full upper eyelids with a gradual curve have a youthful appearance (Fig. 31-2). Th s is the look many patients request when they present for consultation, concerned about the effects of aging on their eyelids. To correct sunken eyelids, a number of methods have been used, including free fat grafts dermal fat grafts, fascia and scalp aponeurosis grafts, cartilage grafts, autologous fat injections, fillers, and suture fixation of autologous dermal tissues to the periosteum on the superior margin of the orbit, as well as direct surgical corrections such as adhesiotomy and refix tion. Among these operative methods, correction should be performed based on the cause of the sunken eyelids.

Surgical Technique There are two primary methods for treating the causes of sunken eyelids (Table 31-1): repositioning the existing tissues (Fig. 31-3), or filling the sunken eyelid area with new tissue.

Chapter 31 

Management of Sunken Eyelid

Table 31-1  Methods for Correction of Sunken Eyelids Procedure

Technique

Indications/Contraindications

Orbital fat transposition

Orbital fat suture fix tion to supraorbital rim

No acquired or congenital ptosis

Tissue transposition by ptosis correction

Aponeurosis advancement or plication

Acquired or congenital ptosis

Dermal fat graft

Free dermal fat graft

Severe sunken eyelid

Autologous fat injection

Free fat graft

Moderate sunken eyelid

Fillers

—

Mild sunken eyelid

Tissue Transposition

Tissue Filling

A

B

C

Fig. 31-3  Technique for upper eyelid fat transposition surgery. A, Preoperative view. B, Upper eyelid fat transposition. C, Orbicularis oculi muscle fix tion to the periosteum on the superior orbital rim.

Tiss ue Repos itio ning Metho d

Fig. 31-4 shows that good results can be obtained by repositioning upper eyelid fat upward as if it is being grafted instead of removing the fat in a double-fold formation. The tissue repositioning method corrects sunken eyelids by detaching the tissue that is adherant to the sunken region and repositioning other tissues such as orbital fat, or by conducting a double-fold revision operation (Figs. 31-4 and 31-5), or ptosis correction (Figs. 31-6 and 31-7).

Tiss ue Filling Metho d

In the tissue filling method, autologous tissues or alloplastic materials are grafted onto the eyelid. When necessary, the tissue repositioning method and the tissue grafting method can be used in combination (Fig. 31-8).

485

486

Part IV 

Cosmetic Surgery of the Eyelid

Sunken eyelids may occur as a sequela of double-eyelid surgery in which excessive skin was detached and orbicularis oculi muscle removed, excessive orbital fat was removed, or the orbital septum was damaged. When performing surgery on a patient with sunken eyelids, the surgeon must remove the adherent tissues and scars and fill the remaining space with autogolous tissues to prevent readhesion and outward bulging of the lid. Sunken eyelids and triple eyelid folds resulting from irregular adhesion of the skin may be corrected by detaching the adhesion and moving the fat in the area, using an orbicularis oculi muscle skin flap or by grafting dermal fat. The method most frequently used for tissue filling is fat grafting with dermal fat grafts or free fat grafts. In addition, there is a method to graft fillers such as hyaluronic acid (Restylane) and acellular human cadaveric dermis (AlloDerm) to replenish the spaces of lost tissues.

A

B

Fig. 31-4  Technique for correcting a sunken eyelid with a double fold. A and B, The tarsal plate is fix ted to the dermis to create the double fold.

A

Fig. 31-5  Correction of a sunken eyelid in a patient with a double fold. A, Technique for the double-fold procedure. B, Preoperative view. C, Postoperative result.

B

K23345_Pu_c31_Mgmt Sunken Eye_r5_cl_483-496.indd 486

C

4/3/2015 12:38:02 PM

Chapter 31 

A

487

Management of Sunken Eyelid

B

C

Fig. 31-6  Blepharoptosis correction by advancement of the levator palpebrae superioris muscle. A, Sectional view. B, Intraoperative view. C, After suturing is completed.

Fig. 31-7  Th s patient had blepharoptosis and sunken eyelids. A levator palpebrae superioris muscle advancement procedure was performed.

Fig. 31-8  Levator aponeurosis advancement and fat grafting were performed on this man’s upper eyelids. He still needs lower blepharoplasty and correction of the glabella wrinkle.

K23345_Pu_c31_Mgmt Sunken Eye_r5_cl_483-496.indd 487

4/3/2015 12:38:03 PM

488

Part IV 

Cosmetic Surgery of the Eyelid

Fat Grafting The use of free fat grafts (Fig. 31-9) has increased since Coleman demonstrated the likely success of these procedures when performed skillfully1,2 (Fig. 31-10). The harvested fat can be strained (see Fig. 31-10, B), but it is usually centrifuged. The harvested fat is subjected to centrifuge for 3 to 5 minutes at 3000 rpm in the tumescent method3 (Fig. 31-11). Free fat grafts re widely used, because there is less risk of an allergic or rejection reaction compared with artific al graft aterials, recovery is rapid, and outcomes are good.4 The degree of engraftment versus absorption is difficult to predict, and it is more complicated to inject accurate amounts for free fat grafts compared with dermal fat grafts. With a free fat graft, the surface of the eyelid can become uneven, and many fat cells may be destroyed during the grafting process. However, the use of a free fat graft an be advantageous, because induration does not last long, the graft s tes naturally harmonize with the surrounding tissues, and scars are not left on the donor sites.5

A

B

Fig. 31-9  Sagittal section view of a fat graft A, Preoperative view. B, Postoperative view.

A

B

D

C

E

Fig. 31-10  A, The fat harvest site. B, Equipment for purifying the harvested fat. C, Harvested, processed fat. D, Graft cannulas. E, The processed fat is transferred into syringes.

Chapter 31 

489

Management of Sunken Eyelid

A

B

C

Oil Fat Blood, tumescent solution, debris

D

E

G

F

H

Fig. 31-11  A, The lipoaspirate is centrifuged at 1660 3 g for 3 to 5 minutes. B and C, Before processing, the harvested fatty tissue contains three layers: oil, fat, and a layer consisting of blood, tumescent solution, and debris. D-H, The bloody and oil layers are removed, leaving the viable fatty tissue for grafting.

K23345_Pu_c31_Mgmt Sunken Eye_r5_cl_483-496.indd 489

4/3/2015 12:38:04 PM

490

Part IV 

Cosmetic Surgery of the Eyelid

There are two methods of injecting fat, depending on the injection site: the fat graft is injected on the septum of the eyelid, or the fat graft is injected on the aponeurosis of the levator muscle. Injecting the fat on the septum of the eyelid may make the eyelid look thicker than when fat is injected on the aponeurosis of the levator muscle. Fig. 31-12 shows the fat graft s tes, and Fig. 31-13 shows a grafting method in which a parcel of fat is transferred to the eyelid rather than injected. “Blind” methods were formerly used for correction of a sunken eyelid, but such approaches caused many problems: damage to the surrounding tissues such as the blood vessels, palpable nodules of injected fat,

A

B

Fig. 31-12  Fat graft below the orbicularis oculi muscle. A, Preoperative view. B, Postoperative view.

A

B

C

D

Fig. 31-13  Fat transfer to the upper eyelid. A, The recipient’s eyelid is prepared for the transfer. B, A fat parcel is positioned and trimmed. C, The trimmed fat parcel is tucked into the eyelid pocket. D, The eyelid is ready for suturing.

Chapter 31 

Management of Sunken Eyelid

491

and fat embolism. I have found that the double-eyelid lines have to be corrected in many of the patients with sunken eyelids. When performing a double-eyelid surgery, good results can be obtained by exposing the orbital septum, making incisions, and then directly injecting the fat into the orbital septum.

Fat Har ves t and Fat Grafting

A local anesthetic is used to harvest fat by liposuction and to perform fat grafting. Fat is usually collected from the abdomen with access through the umbilicus. The surgeon makes an approximately 5 mm skin incision and injects an appropriate amount of tumescent solution into the site, from which the fat will be collected through the incision line. Thirty minutes later, the fat is collected through negative pressure suction. A 20 cc syringe and a 3 mm diameter suction tube are used with care to minimize damage to the tissues, and the fat is gently collected. Th s lipoaspirate is purifi d for 3 to 5 minutes at 3000 rpm with a centrifuge without washing the fat, and then the middle fat layer is transferred to a 1 cc syringe. An incision approximately 1 to 2 mm long is made using a No. 11 scalpel on the lateral canthal site or the lateral margin of the orbit, and the purifi d fat is injected through a syringe. With 40 to 50 strokes per 1 cc injection, the fat is injected along the supraorbital margin or below the margin primarily into the deep region, an orbital fat layer medial to the orbital septum, and then into the superfic al layer, a fat layer on the rear of the orbicularis oculi muscle. When injecting fat into multiple layers in the deep region of the orbicularis oculi muscle and directly below this region, the surgeon must avoid injecting the fat into the orbicularis oculi muscle or the superfic al layers in the subcutaneous tissues. The fat is released while the syringe is withdrawn, and the injection is performed with great accuracy. Overcorrection must be avoided, and the amount of postinjection absorption of fat kept in mind. Fat should be injected judiciously to correct any insuffici cy of the eyelids. After fat grafting is complete, the remaining purifi d lipoaspirate should be stored at 220° for up to 12 months. During follow-up visits, if it is determined that the patient has insuffici tly corrected regions or fat has been excessively absorbed in some areas, the cryopreserved fat is thawed at room temperature, and additional injections can be performed in the same manner as described. The harvest site incision is sutured with 5-0 nylon sutures.

Postoperative Care Compressive self-adhering foam tape, such as Reston 3M, is placed over the incision site and kept in place for 2 or 3 days. The eyelid incision is closed with 6-0 nylon sutures, which are removed 2 or 3 days later. No compressive dressing is placed over the eyelids.

Management of Complications After correction of sunken eyelids, some patients have minor bruises, tenderness, swelling, minor bilateral asymmetry, or temporary ptosis. These usually resolve within 2 months after the procedure. In a patient with a microfat graft who had an irregular upper eyelid skin surface, absorption of the grafted fat often occurred with lid massage as the only additional treatment to correct the skin irregularity. In one patient in whom the fat was injected shallowly, induration where the injected fat that was hardened could be palpated, the boundaries of the correction were evident, and irregular bulges were observed. However, these

K23345_Pu_c31_Mgmt Sunken Eye_r5_cl_483-496.indd 491

4/3/2015 12:38:05 PM

492

Part IV 

Cosmetic Surgery of the Eyelid

A

B

C

Fig. 31-14  Sunken eyelid correction using levator advancement and fat grafting. A, Preoperative view. B, Immediately after surgery. There were minor bruises, tenderness, swelling, minor bilateral asymmetry, and temporal ptosis. C, At 6 months after surgery, these effects had resolved.

resolved within 2 months without further treatment. In a patient in whom some induration continued, the induration was not a signifi ant problem when the patient’s eyes were open. Subjective satisfaction was high for most patients. Some patients showed minor bruising, tenderness, swelling, slight bilateral asymmetry, and temporary ptosis. However, these resolved with no further treatment, and there were no serious complications such as hematoma, infection, or persistant ptosis (Fig. 31-14).

Dermal Fat Grafting Dermal fat grafts are frequently used in secondary surgery of a patient with a double-eyelid formation or for blepharoplasties6,7 (Fig. 31-15).However, dermal fat grafts produce scars at the donor site, and the gravitational effects of the weight of grafted tissues on the eyelids can be problematic. Fig. 31-16 shows a method for harvesting dermal fat from between the buttocks. Th s method is associated with lower postoperative absorption rates than those of free fat grafts r fat injections, and a sunken eyelid site can be accurately corrected. Thus it is easier to predict the postoperative results with this harvesting method. Because dermal layers are densely affixed to surrounding tissues during dermal fat grafting to prevent the fat layers from protruding from the upper eyelid skin, the kind of protrusion deformation that can occur with free fat grafts or fat injections is less likely to occur (Fig. 31-17). In dermal fat grafts, it is not necessary to worry about lethal complications, such as an embolism, that may appear in the case of free fat injections. Scars are not a problem, because the donor site for the dermal fat graft s the region between the anus and the coccyx, where the dermal layers are relatively thicker than other regions, and postoperative scars are hidden in this region. The complication of failure to heal or slow healing in this donor site can occur, but it is rare. After surgery, overcorrection is adjusted relatively easily through triamcinolone injections, which shrink the overcorrected area.

Chapter 31 

A

Management of Sunken Eyelid

493

B

Fig. 31-15  Dermal fat grafts are useful in secondary surgery to correct a double-eyelid formation or for blepharoplasties. A, Preoperative view. B, Postoperative view.

Fig. 31-16  A method for harvesting a dermal fat graft from between the buttocks.

B A

C

Fig. 31-17  Procedures of dermal fat graft. The protrusion deformation that can occur with free fat grafts or fat injections is less frequent with a dermal fat graft, because dermal layers are densely affixed to the surrounding tissues during grafting to prevent the fat layers from protruding to the upper eyelid skin. A, Harvested dermal fat. B, Preparation for fix tion of the dermal fat graft C, External fix tion of the dermal fat graft.

K23345_Pu_c31_Mgmt Sunken Eye_r5_cl_483-496.indd 493

4/3/2015 12:38:06 PM

494

Part IV 

Cosmetic Surgery of the Eyelid

Results The majority of my patients have had satisfactory results. However, some complications, such as asymmetry, overcorrection, and undercorrection, can occur.

Fig. 31-18 Th s 46-year-old woman underwent a levator resection. She is shown before surgery and immediately after surgery.

Fig. 31-19 Th s 60-year-old man underwent levator advancement. He is shown before surgery and 6 months after surgery.

K23345_Pu_c31_Mgmt Sunken Eye_r5_cl_483-496.indd 494

4/3/2015 12:38:07 PM

Chapter 31 

Management of Sunken Eyelid

495

Revision Surgery If these complications persist or the correction of the sunken eyelid is not satisfactory, revision surgery can be considered. First, however, a careful, comprehensive assessment of the patient must be conducted. The timing of the revision operation should also be considered. Revision surgery is typically performed after the complete maturation of the scar tissue in the upper eyelid. However, when the appearance of the upper eyelid affects the patient’s psychological or functional well-being, such as with a retracted upper eyelid, ptosis, lagophthalmos, and so on, early correction—within 2 weeks after the surgery—should be considered.

Alternative Procedures Aut ol o go us Dermal Graft Fix atio n t o the Per ios teu m Autologous dermal graft fix tion to the periosteum is an alternative that can be performed in a patient in whom a deep sunken eyelid appears after undergoing eye exenteration or another ophthalmologic surgery. Th s type of fix tion is implemented by rolling an appropriate amount of autologous dermal tissues through double-eyelid-line incisions and suturing these dermal tissues to the periosteum on the superior orbital margin. Autologous dermal grafts have abundant blood vessels, are thick, can be easily obtained repeatedly in similar regions, are inexpensive, and are not associated with the risks of rejection or the propagation of infections. These grafts are advantageous in that the recovery of donor sites is faster than with autologous femoral fascia, absorption or atrophy after surgery is less frequent, and inflammations do not develop easily, because the tissues are strong and flex ble. The auxiliary organs in dermal grafts are denatured within 1 to 5 months, and the sebaceous glands are denatured within 3 months. I think that fix tion of a dermal graft to the periosteum can be a very effective and safe method to correct deep upper eyelid furrows. However, long-term follow-up with more clinical cases is essential to determine the efficacy of a dermal graft to the periosteum.

Ar tifici al Mater ials Graft

There are many artifi ial materials, such as Restylane and AlloDerm, that can be used to refill the spaces left by lost or atrophied tissues. These materials are advantageous for their simplicity of use, but they have the disadvantages of potentially inducing hypersensitivity reactions and ptosis, propagating infection, and requiring that the injections be repeated frequently, since the substances are eventually absorbed.

Pearls for Success • Before sunken eyelids are corrected, a complete and comprehensive assessment of the patient must be performed, including a clear understanding of the causes of the sunken eyelid. • When performed properly, autologous fat grafts and dermal fat grafts with fix tion can be effective procedures to correct a sunken eyelid deformity. • Postoperative complications such as asymmetry and ptosis usually disappear within 2 months after the surgery. If they persist, revision surgery should be considered.

K23345_Pu_c31_Mgmt Sunken Eye_r5_cl_483-496.indd 495

4/3/2015 12:38:07 PM

496

Part IV 

Cosmetic Surgery of the Eyelid

Refer ences 1. Pu LL, Coleman SR, Cui X, Ferguson RE Jr, Vasconez HC. Autologous fat grafts harvested and refined by the Coleman technique: a comparative study. Plast Reconstr Surg 122:932-937, 2008. 2. Frileck SP. The lumbrical fat graft: a replacement for lost upper eyelid fat. Plast Reconstr Surg 109:1696-1705; discussion 1706, 2002. 3. Kim YK, Lim SY, Lee SJ. Correction of sunken eyelid using autologous microfat graft. J Korean Soc Plast Reconstr Surg 12:79, 2006. 4. Chajchir A, Benzaquen I. Fat-grafting injection for soft- issue augmentation. Plast Reconstr Surg 84:921-934; discussion 935, 1989. 5. Guyuron B, Majzoub RK. Facial augmentation with core fat graft: a preliminary report. Plast Reconstr Surg 120:295302, 2007. 6. Little JW. Applications of the classic dermal fat graft in primary and secondary facial rejuvenation. Plast Reconstr Surg 109:788-804, 2002. 7. Kim YW, Park HJ, Kim S. Secondary correction of unsatisfactory blepharoplasty: removing multilaminated septal structures and grafting of preaponeurotic fat. Plast Reconstr Surg 106:1399-1404; discussion 1405-1406, 2000.

K23345_Pu_c31_Mgmt Sunken Eye_r5_cl_483-496.indd 496

4/3/2015 12:38:07 PM

32 Periorbital Rejuvenation

P

David Daehwan Park

eriorbital aging is a typical presentation for patients seeking facial rejuvenation only for the upper face. It can be a common concern for Asian patients, because the early signs of aging usually present around the eye. Therefore combined procedures, such as upper and lower blepharoplasties with a brow lift r fat grafting, may be needed to correct periorbital aging. The degree of brow ptosis should be evaluated to determine whether a brow lift should be performed along with a blepharoplasty, or whether an upper lid blepharoplasty alone is suffici t.1,2 Although a brow lift through a bicoronal incision was performed in the past, an endoscopic brow lift with only a few small incisions and placement of advanced fixation devices to the frontal bone have rapidly developed and replaced the previous technique. Good or excellent results have been achieved, with much less invasive surgery and a quick recovery. In addition, using a forehead lift pproach, an upper blepharoplasty can be performed to treat excess orbital fat without any eyelid skin incision.3 Furthermore, with an upper blepharoplasty approach, a brow lift can be performed without additional scalp incisions. Brow ptosis can be corrected, and the brow can be fi ed in the desired positon.4 A subeyebrow skin lift and upper lid blepharoplasty have been performed simultaneously on many Asian patients who have eyebrow tattoos so that excess upper eyelid skin can be excised from the two separate regions, respectively, and thus these women can achieve a more natural appearance from their periorbital rejuvenation.5 In this chapter, I discuss the anatomy of periorbital aging, selection of an appropriate procedure or combination of several procedures, and the operative technique for each procedure or adjunctive procedure.

Anatomy of Periorbital Aging A cross-sectional view of the periorbital structure is shown in Fig. 32-1. The periorbital structure changes over time; the most signifi ant, progressive changes are laxity and sagging of these components. To safely and effectively perform surgery, the surgeon must understand the anatomy and changes in the periorbital structure. Senile upper eyelid changes are closely related to the sagging of the upper structures rather than the upper eyelids only, and thus a satisfactory outcome cannot be obtained with only correction of the upper eyelid in many patients. As shown in Fig. 32-2, the natural shape of the eyes and eyebrows can be restored only when the sagging structures have been lifted to approximate their original positions.

497

498

Part IV 

Superior rectus muscle

Cosmetic Surgery of the Eyelid

Levator palpebrae superioris muscle

Orbital septum Whitnall’s ligament Levator aponeurosis Müller’s muscle Tarsus

Inferior tarsal muscle Orbicularis oculi muscle Capsulopalpebral fascia Lockwood’s ligament Inferior rectus muscle

Orbital septum Inferior oblique muscle

Fig. 32-1  Cross-sectional view of the normal periorbital structure.

Frontalis muscle

Fig. 32-2  Restoration of the natural shape of the eyes and eyebrows.

There is only one brow elevator, the frontalis, whereas many muscles act as brow depressors. Those muscles at the medial side of the eyebrows are the corrugator supercilii, depressor supercilii, procerus, and orbicularis oculi. However, the lateral third of the eyebrow mainly sags because the brow elevator, the frontalis muscle, is not attached to this area and because of the orbicularis oculi. The lateralmost layer (orbital portion) of the orbicularis oculi muscle is known to exert the most significant downward pull on the eyebrows.6

Chapter 32 

499

Periorbital Rejuvenation

The classifi ation of eyelid deformities that result from aging was established by Castañares.7 Castañares8 divided eyelid deformities into the following six types: 1. Blepharochalasis: a condition in which the upper eyelid skin is sagging and muscle tension has disappeared, which results in a limited visual fi ld during upward gazing. 2. Dermatochalasis: a condition in which the upper eyelid skin becomes thinner and loses elasticity, sagging downward, thereby creating folds as an individual ages. The folds do not include fat but are formed from excessive, inelastic skin on the upper eyelid. 3. Hypertrophy of the orbicular muscle of the eye: a thickening of the bulging muscle that runs horizontally along the lower eyelid immediately below the eyelashes. 4. Herniated orbital fat: a pseudoherniation caused by a weakened tarsal membrane, which is common in young patients. 5. Ptosis of the eyebrow: this pulls down the upper eyelid to obstruct the visual fi ld. 6. Senile lid: the aforementioned classifi ations and degenerative changes in the eyelid structures are combined.

Preoperative Assessment Several important considerations should be noted in the preoperative assessment when a patient seeks periorbital rejuvenation. The surgeon should decide whether the patient should undergo surgery and then select an appropriate procedure or combination of procedures. In this way postoperative complications or unrealistic expectations can be avoided. The two most important things to determine are the aspects of the facial appearance that the patient dislikes and the patient’s expectations for the postoperative result. These can be determined by having the patient look in a mirror and point out the periorbital characteristics that he or she dislikes. Sometimes the patient may overemphasize extremely minor imperfections while overlooking rather large flaws. These should be pointed out by the surgeon. Box 32-1 summarizes the important considerations in the preoperative assessment for periorbital rejuvenation.

Box 32-1  Considerations for Preoperative Assessment • Allergies and swelling ȤȤ The patient should be asked about his or her medical history (for example, thyroid disease, heart disease, and bleeding tendency). • Hemorrhagic complications ȤȤ These can be prevented by discontinuing the use of antiinflammatory agents (for example, aspirin, ibuprofen, vitamin E, and anticoagulants) the week before surgery. • Appropriate examination of the eyes, eyeballs, and auxiliary organs ȤȤ If there is oculomotor paralysis, the eyes should be carefully examined. ȤȤ If Bell’s phenomenon does not appear, any damage to the cornea and ulcers may be induced after surgery. ȤȤ Bulging eyeballs and paralysis of the superior levator palpebrae muscle are indications of Graves’ disease. Continued

500

Part IV 

Cosmetic Surgery of the Eyelid

Box 32-1  Considerations for Preoperative Assessment—cont’d • Senile eyelids ȤȤ Eyelid tone is identifi d by the snapback test (for example, hypotonic lids, horizontal lid shortening by tarsal suspension considered together). • The relationship between dry eye syndrome and blepharoplasty ȤȤ Dry eye contributes to insuffici t tear production from smoking, menopause, an abnormal thyroid, aging, and drugs. ȤȤ The results of Schirmer’s test indicate the degree of water absorption that occurs on filter paper in 5 minutes. Normal values are 15 to 30 mm. ȤȤ Abnormalities in the orbit and surrounding structures could become factors (for example, proptosis, loose lower eyelids, a hypoplastic upper jaw, and pectin sclera). • Two types of eyelid elasticity tests ȤȤ The pinch test (Fig. 32-3) should be performed to determine whether changes in the lower eyelid are caused by relaxation of the orbicularis oculi or the skin, The patient should close his or her eyes tightly. While pinching the skin and orbicularis oculi with the thumb and index fi ger so that the orbicularis oculi contracts, the surgeon will see the degree of adhesion between the lower eyelid skin and orbicularis oculi and the degree of relaxation of the skin. ȤȤ A snapback test should be performed to determine the need for horizontal shortening of the lower eyelid. To perform the snapback test, tension on the lower eyelid can be assessed by pinching the lower eyelid skin to pull the lower eyelid margin off the eyeball and seeing how fast the lower eyelid returns to its original position when it is released. The distance between the eyeball and eyelid margin when the lower eyelid is pulled is measured as follows: 3 to 5 mm: Normal eyes 10 to 12 mm: Senile involutional ectropion 25 mm: Marked lid relaxation • If the eyelid margin is greater than 10 to 12 mm, shortening the horizontal length of the lower eyelid should be considered.

Fig. 32-3  Pinch test. The remaining skin should be grasped with forceps to measure the amount of skin that will be removed.

Chapter 32 

Periorbital Rejuvenation

Indications As the term brow lift implies, the indications can be observed by the effect obtained from lifting the brows. If the forehead and eyebrows sag downward, this will affect the eyes, and the eyelids will appear to sag. In this case, if a brow lift is performed without identifying the cause, the eyes will look heavier, double eyelid folds will become deeper, creating a harsher appearance, and wrinkles around the eyes and nasal root will be connected to the double eyelid folds and be more prominent than before surgery. Asymmetry of the eyebrows may be present because of facial nerve paralysis or differences in muscle strength, or the patient’s habitual use of the muscles around the eyebrows. Eyebrow symmetry can be restored by employing different degrees of dissection on the two sides. A brow lift will make the forehead wider in patients with a narrow forehead, because the uplift will expand the forehead. If the forehead is flat, the use of an implant or fat grafting to make the forehead convex will enhance the lifted effect. In aging patients with a facial palsy, brow lifts are sometimes done by excising an appropriate amount of skin above the eyebrow so that the eyebrow can be lifted. Although a single palsy of the temporal branch of the facial nerve is the best indication, this suprabrow skin excision can also be performed in patients with partial paralysis or total paralysis (Fig. 32-4). The main indications for a subbrow skin excision are blepharochalasis, thick eyelids, or women over 40 years of age with eyebrow tattoos whose upper eyelids are bulging and sagging, with inner double eyelid folds. If there is no inner fold, double eyelid folds can be created at least 3 months after brow lift surgery, when the shape of the double eyelid fold has been completely determined. Th s will result in more naturallooking eyelids.

A

B

C

D

Fig. 32-4  Upper blepharoplasty by suprabrow excision. A, Preoperative view. B, Postoperative view. C, Surgical design. D, Closure.

501

502

Part IV 

Cosmetic Surgery of the Eyelid

Fig. 32-5  Aspects of a baggy eyelid. The orbital fat protrudes and the skin sags, causing coverage of the eyelid line. Th s results in a senile eyelid.

The sagging of the eyelid skin and crow’s-feet in the lateral canthal areas are an inevitable part of eyelid aging. If the orbital fat protrudes, an eyelid deformity called baggy eyelids appears (Fig. 32-5). In addition, the lid fissure may narrow to block the visual fi ld and the levator aponeurosis may be weakened, resulting in senile ptosis. Procedures to completely or partially correct these changes may make patients look younger and are collectively called blepharoplasty. These procedures not only correct the cosmetic appearance of the eyelid, but they also improve eyelid function by removing any obstacle in the visual fi ld that results from sagging eyelids.

Surgical Technique For ehead-B r ow Lift

An endoscopic brow lift s described in Chapter 21. Thus the surgical technique is described only briefly here.

Preoperative Markings Before surgery, the surgeon should mark the following: the midline, the incision line as the extension line of the highest point of the eyebrows (paramedian line), the temporal incision lines, the positions in which the supraorbital and supratrochlear nerves are divided, the temporal lines, and the temporal branching positions of the facial nerve of the eyebrow when the patient is in the sitting position.

Anesthesia A nerve block and local anesthetics with epinephrine should be administered to reduce pain, facilitate dissection, and reduce hemorrhage during surgery.

Chapter 32 

Periorbital Rejuvenation

503

Incisions For an endoscopic brow lift, five 1.5 cm long incisions (median line, regions around 4 to 5 cm lateral from the median line and temporal region) are made. In the frontal area, deep incisions are conducted to pass the periosteum and touch the bone. In the temporal area, the region between the temporoparietalis and deep temporal fascia becomes the incision surface.

Dissection In the frontal area, the surgeon should dissect below the periosteum from the vertex of the scalp to the orbital bone and glabella. The periosteum and frontal bone are loosely attached in these regions, although they are attached tightly above the orbital bone. In the temporal area the surgeon draws a line approximately 2 cm lateral from the lower tragus and eyebrow, as a virtual running line of the facial nerve’s frontal branch, to dissect along the line. The dissected layer should be between the superfic al layers of the temporoparietalis and deep temporal fascia. Endoscopic dissections begin in the temporal area. To facilitate the dissections, the temporal line is dissected to connect the frontal and temporal areas. The temporal line should be dissected from the temporal to the frontal area. If done the other way, the temporalis muscle may be separated from the temporal bone. The frontal area dissection should go down to the orbital bone. The area of orbital bones on both sides and the median line should be dissected up to the nasal root point, and the periosteum should then be separated. The deep and superfic al branches of the supraorbital nerve should be carefully separated from the surrounding tissues. The supratrochlear nerve should then be separated from the muscle fibers at the origin of the corrugator supercilii to facilitate muscle modifi ation.

Muscle Modifications If there is hypertrophy of the corrugator supercilii, it is better to remove the muscle, but if not, the muscle may be partially transected. After the corrugator supercilii is removed, if the dissection is continued toward the skin, thin blood vessels and nerves will be seen along with hidden muscle fibers. If they are transected, the medial side of the eyebrow will be lifted, and the glabellar folds will become shallower. The procerus muscle will then be transected to lift the medial side of the eyebrow and improve the horizontal folds near the nasal root. Finally, if the lateral side of the eyebrow has pronounced sagging, the lateral side will be lifted if the lateral upper orbicularis oculi is partially transected (orbitotomy).

Fixation Fixation is necessary to lift and maintain the dissected tissues in the desired positions. Because most Asian skin is thick, the skin flaps will lower to their original positions if the dissected frontal and temporal skin flaps are not fi ed. Fixation in the frontal area is performed by making a cortical tunnel on the frontal bone, and the frontal skin flap is fi ed to the tunnel with 2-0 PDS sutures. I prefer to use this technique rather than an Endotine device because of the cost effectiveness. Fixation is done in the paramedian area and not in the eyebrow body or center to avoid creating a surprised look. In the temporal region the temporoparietalis is fi ed to the deep temporal fascia with 3-0 PDS sutures.

K23345_Pu_c32_Periorb Rejuv_r3_cl_497-5020.indd 503

4/3/2015 9:41:58 AM

504

Part IV 

Cosmetic Surgery of the Eyelid

Postoperative Care A compression dressing is not needed after an endoscopic brow lift. Only antibiotic ointment is applied to all incision sites. The hair may be washed the day after surgery, and the sutures are removed 1 week later.

Suprabr ow and Subbr ow Excis io ns

The suprabrow excision is a direct brow lift that improves not only a drooping brow, but also a drooping upper lid. The main indication is a drooping brow and sagging upper lid. It is important to excise the region immediately above the eyebrow to a position a little higher than the uppermost point of the brow when the eyes are seen upward. Regarding skin excision of the upper eyelid, simple excision of the sagging skin on both sides is suffici t in many patients. The suprabrow excision corrects a sagging upper lid and brow ptosis. A noticeable scar is the most common complication. A beveling incision, meticulous wound closure, and no extension of the scar beyond the eyebrow hair are needed to minimize the scar. A subbrow excision is a rejuvenation surgery that excises the skin immediately below the eyebrows to lift sagging upper eyelids. A subbrow excision is performed in some patients, because if only double eyelid surgery is performed, it may give these patients an angry appearance, and a natural appearance is not easily obtained unless a forehead lift is performed.

Preoperative Markings The surgeon should fi st draw a line in the center of the glabella, mark the location of the supraorbital nerve 2.5 cm lateral to the center, and mark the location of the supratrochlear nerve 1 cm medial to the markings. To allow tweezing of the eyebrow in women, the surgeon should leave about a fourth of the eyebrow at the medial side and mark only three fourths at the lateral side. The medial side of the incision should begin from the same location as the origin of the supratrochlear nerve, and the lateral side of the incision should be completed at the point at which the eyebrow or tattoo ends, making a 4.5 to 5.2 cm long straight line (Fig. 32-6).

A

B

Fig. 32-6  A, Markings for a suprabrow excision. B, Markings for a subbrow excision.

Chapter 32 

Periorbital Rejuvenation

Surgical Technique The amount of excess skin to be excised in a suprabrow or subbrow procedure can be determined in the same way as for a blepharoplasty. The overall area of excision should be mapped into a fusiform, making the length of the widest point approximately 8 to 12 mm. If the region above the fusiform excision line is incised, the region should be incised obliquely to be parallel to the direction of the hair follicles. Care should be taken to avoid damage to the hair follicles, which will allow the eyebrow to cover the scar so that it will not be easily visible. If the region below the fusiform excision line is incised, the surgeon should make a vertical incision in a straight line that passes the orbicularis oculi and the posterior fascia of the orbicularis oculi. At the lateral side of the fusiform excision line, the surgeon should make an en bloc incision in the skin, orbicularis oculi, and posterior fascia, incising only the skin from the point of origin of the supraorbital nerve so that the supraorbital and supratrochlear nerves are not damaged. In the region above the fusiform excision, the dissection should be performed between the orbicularis oculi along its posterior fascia and submuscular fat. A subcutaneous tunnel about 5 mm wide is marked between the supraorbital nerve and origin of the supratrochlear nerve, and 5-0 PDS sutures are used for fixation. Three horizontal sutures are used over the area lateral to the supraorbital nerve. One vertical suture is used between the estimated site of the supraorbital and supratrochlear nerves to avoid injury to these nerves.

Blep har opl a st y

Both upper and lower lid blepharoplasties are described in Chapters 24 and 29. Therefore each procedure is described only briefly in this chapter. When a blepharoplasty is performed, the surgeon should carefully excise excess upper eyelid skin while excising lower eyelid skin conservatively. Excess skin should be excised mainly from the lateral upper side of the lower eyelid, and the skin should be sutured to the periosteum. In patients in whom excision of orbital fat is unnecessary, simple excision and suturing of the skin will yield good results. In 1987 Oh et al9 advised that in Korean patients undergoing blepharoplasties, the amount of excised skin should be less than that of white individuals. Fat excision should be done several times; a small amount rather than a large amount of fat should be removed each time to avoid irreversible overexcision, and lateral incision lines should not extend outward too far so that the approximations on both sides will exactly match when the skin is sutured. Some of the important steps and procedures in upper blepharoplasty are as follows: 1. Determining the width for skin excision (Fig. 32-7) 2. Managing the orbicularis oculi muscle (Fig. 32-8) 3. Managing the orbital fat (Fig. 32-9) 4. Wound closure

505

506

Part IV 

A

Cosmetic Surgery of the Eyelid

B

6-8 mm

C More than 10 mm 3-5 mm

Skin excision

Muscle excision

6-8 mm

Fig. 32-7  A, Measuring the amount of skin for removal in blepharoplasty. Th s is easily done with Green forceps. B, Th normal height of the supratarsal fold is approximately 6 to 8 mm. C, Markings for an upper blepharoplasty.

A

B

C

Fig. 32-8  A, Incision of the orbicularis oculi. B, Excision of the orbicularis oculi. C, After excision of the orbicularis oculi.

K23345_Pu_c32_Periorb Rejuv_r3_cl_497-5020.indd 506

4/3/2015 9:42:00 AM

Chapter 32 

Periorbital Rejuvenation

A

B

Fig. 32-9  Design of an upper blepharoplasty and tissue excision. A, The amount of tissue that is excised in a younger patient is minimal. B, The amount of tissue that is excised in an older patient is greater.

A

B

Fig. 32-10  Blepharoplasty without forming a double eyelid fold. A, Preoperative view. The patient had discomfort and visual disturbance caused by an upper eyelid crease, which he did not want. Marking an incisional line 3 mm over the inner eyelashes and suturing the skin and tarsal plate on this line made it possible to hide the double eyelid line while opening the eye. B, Postoperative view.

If the patient does not want a double eyelid fold created during an upper blepharoplasty (Fig. 32-10), sutures between the dermis and levator palpebrae or tarsal plate are not needed10 (Fig. 32-11).In this case, to make the thick upper eyelid tissue thinner, the tissue located in front of the levator palpebrae, the orbital fat, central connective tissue, tarsal membrane, orbicularis oculi, subcutaneous fat, and the skin should be excised at different degrees, depending on the thickness of the upper eyelid. In a patient who also has a sagging senile eyelid, the levator palpebrae aponeurosis should be exposed to facilitate an appropriate repair of the ptosis. The upper eyelids of men are different from those of women. In men, the edge above the orbit protrudes and the area immediately above the edge is depressed (Fig. 32- 12). Men’s eyes are more deepset than women’s, and the pretarsal show of men’s eyes is narrower than that of women. In addition, men’s eyebrows are lower than women’s (Figs. 32-13 and 32-14). Therefore excessive lifting of the eyebrows should be avoided in men undergoing forehead lifts to avoid a perpetually startled expression. The common presentations of lower eyelid aging in Asian patients include palpebral bags, tear trough deformity, and suborbital malar hypoplasia or malar retrusion. The surgical technique for lower lid blepharoplasty varies, depending on the quality of the patient’s lower eyelid. Although the skin-muscle flap approach has been used in many lower blepharoplasty procedures, the skin flap approach is also indicated in patients with few or no hypertrophic muscles.

507

508

Part IV 

A

Cosmetic Surgery of the Eyelid

B

Fig. 32-11  A, Exposure of the tarsal plate. B, Suturing the dermis of the tarsal plate.

Male

Female

Male

Female

Fig. 32-12  A CT reconstruction showing the differences between male and female facial bone structure. The male’s supraorbital margin protrudes more than the female’s. In the lateral view, the male’s supraorbital margin is somewhat recessed, whereas the female’s is not.

A

B

Fig. 32-13  Sex difference in facial contour. A, Male. B, Female.

K23345_Pu_c32_Periorb Rejuv_r3_cl_497-5020.indd 508

4/3/2015 9:42:01 AM

Chapter 32 

A

509

Periorbital Rejuvenation

B

Fig. 32-14  A, Male. B, Female. The surgeon should not excessively lift the eyebrow when the forehead is lifted in a male patient.

1-1.5 cm

1-1.5 cm 0.5 cm

0.5 cm

0.5 cm

0.5 cm

Fig. 32-15  Botox injections for crow’s-feet in the lower eyelid margin.

The transconjunctival approach for orbital fat removal can be done in younger patients who do not have excessive lower eyelid skin. Other lower lid blepharoplasty techniques include excision of protruding orbital fat, reinforcement of the front supporting structure of the protruding orbital fat, and repositioning of protruding orbital fat beyond the inferior orbital rim. In addition, a lateral canthopexy should usually be added if the patient has lower eyelid laxity. Fat grafting to the lid and cheek junction or a midface lift can also be combined with lower blepharoplasty.

Bot ox Injectio n

A botulinum toxin A (Botox) injection can be a relatively simple procedure to address fi e lines and wrinkles, such as crow’s-feet in the periorbital region, with minimal downtime for the patient11 (Fig. 32-15). However, repeated injections are needed every 6 months in the periorbital area. To treat wrinkles below the eyes, Botox is injected directly below the eyelashes of the lower eyelid to flatten the orbicularis oculi in the lower lid margin so that those fi e lines and wrinkles temporarily disappear and the eyes appear larger. In general, a relatively small amount of Botox (2 units) is injected. The units are divided into two separate injections, and each unit is injected to a point approximately 0.5 cm below the lower eyelid margin, based on the center of the pupil and a point slightly lateral to the corneal margin (Fig. 32-15). For random fi e lines and wrinkles on the lower eyelid, Botox may be injected slightly away from the lower eyelid margin. It is helpful when a Botox injection is combined with blepharoplasty and filler. To treat wrinkles in the lateral canthal area, Botox is injected 1 to 1.5 cm away from the lateral canthus to eliminate orbicularis oculi action so that the crow’s-feet can also disappear temporarily. In general, a relatively small amount of Botox (6 units) is injected. The 6 units are divided into three separate injections of 2 units each and are injected (1) at the lateral point about 1 to 1.5 cm away from the lateral canthus, (2) at the upper point, and (3) at the lower point. The most common complication after Botox injection is bruising. To avoid this, the injection should be performed as slowly as possible, and compression of the area is required immediately if any bruising appears during the injection.

510

Part IV 

Cosmetic Surgery of the Eyelid

Filler Injectio n

There are two main types of facial wrinkles—dynamic wrinkles, which are formed when facial expressions are made, and static wrinkles, which are always visible. Botox injections are mainly effective for the treatment of dynamic wrinkles, whereas filler products are effective for correcting static wrinkles. Therefore fillers can be used to treat fi e lines and wrinkles around the orbit, or tissue defic ts in any depressed areas around the orbit. Restylane is a hyaluronic acid product that has commonly been used as a semipermanent filler. Restylane does not require a skin reaction test and can be easily injected into depressed areas in the periorbital region and offers minimal downtime for recovery. Recently a combination of Botox and fillers has been used for noninvasive periorbital rejuvenation in selected patients. For aging patients or patients with thin skin, autologous fat grafting or a skin peel can be a good option for periorbital rejuvenation. Both procedures are covered extensively in Chapters 8 through 11.

Results In our series, most patients were satisfi d with their results after invasive and noninvasive combined periocular rejuvenation. However, some patients had complications. The overall success rate was approximately 90%. The complication rate was approximately 5% and was usually related to an invasive procedure. The revision rate was about 3%. Functional and anatomic concepts must be kept in mind when periorbital rejuvenation is performed in Asian patients. An accurate preoperative plan and the proper selection of an invasive versus a noninvasive procedure are essential to achieve successful periorbital rejuvenation. I perform upper blepharoplasties for a variety of indications. For instance, if the patient clearly has double eyelid folds with sagging skin, only the excess skin is excised. In some patients, small double eyelid folds can be created from skin excision and buried sutures below the tarsal plate.

Fig. 32-16 Th s woman complained about brow ptosis and sagging of the upper eyelid. She underwent an endoscopic brow lift nd upper lid blepharoplasty. She was satisfi d with the result. She is seen preoperatively and 10 months postoperatively.

Chapter 32 

Periorbital Rejuvenation

511

Fig. 32-17 Th s woman complained about sagging of the upper lateral portion of both of her eyelids. She underwent a subbrow lift and an upper blepharoplasty. She is seen preoperatively and 9 months postoperatively, with a decreased distance from the eyebrow to the upper lid margin and improved sagging.

Fig. 32-18 Th s man appeared to have senile ptosis, with a margin reflex d stance 1 (MRD1) of approximately 1 mm on both sides. He underwent an upper eyelid blepharoplasty and ptosis repair. His MRD1 has improved to 2 mm, and his visual fi ld has improved. He is seen preoperatively and 21 months postoperatively.

K23345_Pu_c32_Periorb Rejuv_r3_cl_497-5020.indd 511

4/3/2015 9:42:03 AM

512

Part IV 

Cosmetic Surgery of the Eyelid

Fig. 32-19 Th s man complained about baggy lower lids, drooping upper lids, and wrinkling of the lower lids. He underwent upper and lower blepharoplasty with a lateral canthopexy. His baggy lower lids were corrected, and his drooping upper lids were improved. He is seen preoperatively and 6 months postoperatively.

Fig. 32-20 Th s woman complained about the wrinkles on her forehead. She required Botox injections only; no other periorbital procedures were performed. She is seen preoperatively and 1 month after her forehead was injected with Botox, with improvement of her forehead wrinkles.

K23345_Pu_c32_Periorb Rejuv_r3_cl_497-5020.indd 512

4/3/2015 9:42:03 AM

Chapter 32 

Periorbital Rejuvenation

513

The plan for blepharoplasty with skin excision only. The skin is excised, then the septum is opened and fat removed. Skin closure is performed without fix tion. Note the lateral reference point. The sutured lid is shown.

Fig. 32-21 Th s man underwent a blepharoplasty with skin excision only. In some patients, after skin excision, double eyelid folds are created by suturing the skin in this order: (1) skin, (2) tarsal plate, (3) skin.

K23345_Pu_c32_Periorb Rejuv_r3_cl_497-5020.indd 513

4/3/2015 9:42:04 AM

514

Part IV 

Cosmetic Surgery of the Eyelid

Blepharoplasty by skin–tarsal plate suturing method without a buried suture; double eyelid fold is created by adhesion between skin and tarsus or aponeurosis 7 days after surgery

Blepharoplasty technique with buried sutures on lower tarsal plate

Fig. 32-22 Th s man underwent the blepharoplasty technique with buried sutures on the lower tarsal plate.

K23345_Pu_c32_Periorb Rejuv_r3_cl_497-5020.indd 514

4/3/2015 9:42:05 AM

Chapter 32 

Periorbital Rejuvenation

515

Fig. 32-23 I used a nonincisional double fold method using a bead combined with skin excision in this patient; the sectional views show each stage. She is seen preoperatively, when she had requested double eyelid folds. The skin was sutured to the upper margin of the tarsal plate, and the sutures were inserted through the small hole in the bead. After the sutures were removed, a permanent eyelid line was made along the suture, forming extensive fibrosis.

K23345_Pu_c32_Periorb Rejuv_r3_cl_497-5020.indd 515

4/3/2015 9:42:05 AM

516

Part IV 

Cosmetic Surgery of the Eyelid

Fig. 32-24 In some patients, double eyelid folds are created through upper blepharoplasty by suturing the upper end of the tarsal plate or the levator palpebrae aponeurosis after skin excision. Th s man underwent blepharoplasty with buried sutures on the lower tarsal plate, thus creating small double eyelid folds.

K23345_Pu_c32_Periorb Rejuv_r3_cl_497-5020.indd 516

4/3/2015 9:42:06 AM

Chapter 32 

517

Periorbital Rejuvenation

Anchoring of levator aponeurosis

Double fold line after skin excision Double fold suture and ptosis correction suture are different

Anchoring of levator aponeurosis

Double fold suture and ptosis correction suture placement

Fig. 32-25 In patients with acquired lid ptosis, upper lid blepharoplasty can be combined with ptosis correction. This man underwent an upper blepharoplasty for senile ptosis.

K23345_Pu_c32_Periorb Rejuv_r3_cl_497-5020.indd 517

4/3/2015 9:42:06 AM

518

Part IV 

Cosmetic Surgery of the Eyelid

Fig. 32-26 Th s man underwent upper blepharoplasty with moderate ptosis correction.

Fig. 32-27 Some patients requesting an eyebrow lift and upper lid blepharoplasty do not want upper eyelid skin incisions. Th s patient, who selected the subbrow upper blepharoplasty technique, is shown before and during surgery.

K23345_Pu_c32_Periorb Rejuv_r3_cl_497-5020.indd 518

4/3/2015 9:42:07 AM

Chapter 32 

Periorbital Rejuvenation

519

Fig. 32-28 Th s patient is shown before and after subbrow upper blepharoplasty.

Combined Approach: Brow Lift and Upper Blepharoplasty Placing the eyebrows in the proper position is critical when periorbital rejuvenation surgery is performed. If the eyebrows are set too low, fullness is added to the upper eyelids. The surgeon must determine whether there is true excess skin and fat of the upper eyelid. The proper aesthetic shape of the eyebrows and eyes must be determined to determine which of these factors caused the upper eyelid fullness. In the preoperative consultation, the surgeon should place the eyebrows in the proper aesthetic position and then have the patient open and close his or her eyes. In this way the amount of upper eyelid fullness can be accurately assessed. When the eyebrows are elevated to the proper position, if all of the upper eyelid fullness corrected, this means that the fullness is caused by low eyebrow position and the solution to correct this condition is a brow lift and not an upper blepharoplasty. In this scenario, if an upper blepharoplasty is performed, it will cause the eyebrows to be lower after the procedure. If this happens, a brow lift ften cannot be performed, because there simply is not enough skin on the upper eyelid to allow the eyes to close properly when the eyebrows are elevated. Th s can result in serious complications, such as corneal exposure. If the eyebrows are elevated, some of the upper eyelid fullness may still remain. Th s indicates that a brow lift is needed to remove some but not all of the fullness, and an upper blepharoplasty should be performed as part of a combined procedure to improve the cosmetic outcome. If the eyebrows are already in the proper position and all of the fullness remains, this indicates that an upper blepharoplasty alone is the procedure of choice.

K23345_Pu_c32_Periorb Rejuv_r3_cl_497-5020.indd 519

4/3/2015 9:42:07 AM

520

Part IV 

Cosmetic Surgery of the Eyelid

Revision Procedures If eyelid depression is signifi ant, the double eyelid line may be depressed, and thus double eyelid folds may not be formed, or three or more double eyelid lines may be formed. In these patients free dermal fat grafting can be done, or filler can be injected below the orbicularis oculi muscle. To manage complications after double eyelid surgery in Asian patients, scar tissue should be completely removed. I correct the soft tissue defic t with a dermal fat graft. fter a suffici tly wide cavity is made behind the orbicularis oculi in the incision site, a small dermal fat graft can be inserted into the cavity to correct the depression. Additional techniques to revise problems and complications after upper blepharoplasty are discussed in detail in Chapters 24 and 25.

Pearls for Success • Comprehensive preoperative evaluation is important and should be performed properly and completely. • There are many procedures for periorbital rejuvenation. However, the proper selection of an indicated procedure or a combination of procedures is critical to success. • The proper position of the eyebrows in relation to the upper eyelid is important to ensure a satisfactory result after periorbital rejuvenation. • The operative technique for periorbital rejuvenation should be performed based on the anatomic structures and their relationship. • The operative procedure can be modifi d based on the degree of periorbital aging. • Conservative removal of orbital fat during upper or lower blepharoplasty should be done to prevent hollowness of the periorbital structure. • The incision over an upper eyelid for upper blepharoplasty should not exceed 10 mm from the eyelid margin. • Noninvasive rejuvenation, such as botulinum toxin and filler, are good options for periorbital facial rejuvenation.

Refer ences 1. Flowers RS, Caputy GG, Flowers SS. The biomechanics of brow and frontalis function and its effect on blepharoplasty. Clin Plast Surg 20:255-268, 1993. 2. Flowers RS. Upper blepharoplasty by eyelid invagination. Clin Plast Surg 20:193-207, 1993. 3. Dingman DL. Transcoronal blepharoplasty. Plast Reconstr Surg 90:815-819; discussion 820, 1992. 4. McCord CD, Doxanas MT. Browplasty and browpexy: an adjunct to blepharoplasty. Plast Reconstr Surg 86:248254, 1990. 5. Yun ES, Yun SH, Oh JW, et al. Sub-eyebrow skin lifts in ersons with tattoos. J Korean Soc Aesthet Plast Surg 2:32-42, 1996. 6. Gonzalez-Ulloa M, Stevens EF. The treatment of palpebral bags. Plast Reconstr Surg 27:381-396, 1961. 7. Castañares S. Blepharoplasty for herniated intraorbital fat; anatomical basis for a new approach. Plast Reconstr Surg (1946) 8:46-58, 1951. 8. Castañares S. Classifi ation of baggy eyelids deformity. Plast Reconstr Surg 59:629-633, 1977. 9. Oh GS, Park CG, Kim JH. Clinical review of blepharoplasty. Korean Soc Plast Reconstr Surg 14:357-366, 1987. 10. Sugimoto T. Blepharoplasty in Orientals: aging eyelids. Probl Plast Reconstr Surg 1:510-519, 1991. 11. Ahn KY, Park MY, Park DH, et al. Botulinum toxin A for the treatment of facial hyperkinetic wrinkle lines in Koreans. Plast Reconstr Surg 105:778-784, 2000.

Part V

Primary or Secondary Rhinoplasty

K23345_Pu_c33p_Consid Cosmetic Rhino_r4_dc_150401.indd 521

4/3/2015 9:26:11 AM

K23345_Pu_c33p_Consid Cosmetic Rhino_r4_dc_150401.indd 522

4/3/2015 9:26:11 AM

33 Special Considerations in Asian Cosmetic Rhinoplasty Charles S. Lee

R

hinoplasty is a popular cosmetic procedure for Asians and is commonly performed in combination with upper blepharoplasty to enhance the facial appearance among this large but diverse ethnic population. Its indications and expectations after the procedure are quite different from those of Westerners. The focus of this chapter will be on Asian groups along the Pacific Rim, including northeastern and southeastern Asia, because there are common characteristics among these populations that can assist the surgeon in approaching the Asian nose.

Anatomic Considerations for Asian Noses The nasal characteristics of Asians and whites are compared in Table 33-1.

Skin

The nasal skin of Asians varies from medium thickness to thick, with varying degrees of subcutaneous fat. The thicker fibrofatty nature of the nasal tip skin provides some (although amorphous) structural support, making up for the relatively weaker lower lateral cartilage. The thicker skin allows more flex bility in tip-

Table 33-1  Comparison of Nasal Characteristics in Asian and White Individuals Asian

White

Skin

Thi k

Thi

Tip cartilage

Weak

Firm

Dorsum

Low

High

Nasal length

Short

Long

Septum

Weak, limited volume

Firm, abundant volume

Nostrils

Wide, flared

Narrow

523

524

Part V 

Primary or Secondary Rhinoplasty

grafting techniques, because the skin better camouflages the added cartilage. The thicker skin also reduces the surgeon’s ability to create the fi e architectural contour that might otherwise be achieved.

Car til a ge

The upper and lower lateral cartilages as well as the septum in Asians tend to be softer and less supportive than in the noses of white patients. The weak lower lateral cartilage leads to an underprojected tip. A caudal septal deficie cy leads to a retrusive columella. The weaker upper lateral cartilage leads to an underprojected dorsum and occasionally mild saddling in the preoperative state. Although there are exceptions, the small and weak septal cartilage renders the material unsuitable for grafting or support.

Bon e

The radix in Asians tends to be low and the rhinion is of variable height, from underprojected to overprojected.

Na sal Length

There is a tendency for the Asian nose to be short because of the underdeveloped cartilaginous nose (septum, upper and lower lateral cartilages). A dependent tip, commonly encountered because of the weak alae, can mask a short nose.

Nos tr il Fl ar e and Excess Wid th

There is a component of both excess width as well as flare of the nostrils in Asians. Invariably, there is some degree of asymmetry of either or both components. For example, one nostril may have signifi ant flaring and the other mainly a width component. Symmetry is difficult to obtain in such a situation. In addition, the lower lateral cartilage influences the shape of the nostril and must be evaluated for correction in addition to the alar soft tissues correction.

Common Indications and Techniques for Asian Rhinoplasty Prototypical Asian rhinoplasty has three components: dorsal augmentation, tip projection and defin tion, and alarplasty, whereas in rhinoplasty in white patients, the emphasis is typically on dorsal reduction and tip refi ement (Table 33-2 and Fig. 33-1).

Skin

Defatting the skin is frequently employed to obtain better tip defin tion; 10 mg of topical triamcinolone (Kenalog) is injected deep into the nasal tip (Kenalog 20 mg/cc, 0.5 cc total), and a layer of fat is left n the lower lateral cartilage during the elevation of skin and soft tissue.1 The fat is then dissected off the cartilage. Meticulous hemostasis, combined with conservative defatting, reduces the risk of an overthinned, scarred nasal tip in thick-skinned patients. Patients who bleed more profusely during surgery are given desmopressin (DDVAP) intraoperatively to enhance platelet function.2

Car til a ge

Because the septum is too soft in many Asian patients, auricular cartilage remains the popular graft material. It is harvested from a postauricular approach, and bolster dressings are applied. The cymba and cavum

Chapter 33 

Special Considerations in Asian Cosmetic Rhinoplasty

concha, along with the triangular fossa, are harvested. To maintain the auriculocephalic angle, the vertical, projecting portion of the cymba concha is left intact, and only the flat portion is harvested. In some patients, septum may be usable. In such cases, at least 1.5 cm of caudal and dorsal support should be left behind. If the cartilage is particularly soft, it should not be used. Costal cartilage is used in cases of inadequate alternative cartilage (Fig. 33-2).

Table 33-2  Contrasting Indications for Rhinoplasty Asian

White

Dorsum

Augmentation

Reduction

Tip

Underprojected

Overprojected

Skin thickness

Defatting

Thin skin; fascia overlay/thicken

Nasal length

Lengthening graft

Shortening maneuvers

Septum

Conservative resection

Aggressive resection

Ala

Alar base excess

Alar rim deficie cy

Fig. 33-1  Comparison of typical rhinoplasty in a white and an Asian patient. Note that the white patient has relatively

thin nasal tip skin compared with the thicker skin of the Asian patient. The thinner skin more readily reveals the underlying nasal skeleton. The underlying cartilaginous structures are generally fi m and require less structural support than for Asian patients. Typically, the tip complex also requires cephalic rotation, whereas the Asian nose requires derotation. (Photo courtesy of Donald B. Yoo, MD. [email protected])

A

B

Fig. 33-2  A, Auricular donor site. B, Harvested auricular cartilage.

525

526

Part V 

Primary or Secondary Rhinoplasty

Fig. 33-3  CT scan showing an implant placed on an irregular dorsal surface. Frequently the nasal dorsum is irregular, with a high rhinion and a low radix. Placing a rigid implant on an uneven surface produces an unstable implant that will displace to the side or result in a seesaw effect. Minor degrees of this problem can be resolved by lowering the rhinion. When the irregularity is more severe, a radix graft or other autologous tissues are required.

Bon e

Because the nasal bone in Asians is frequently of irregular height, usually refl cted as a deficie cy of the radix (most commonly a low radix combined with a high rhinion), one of two strategies can be employed. Either the rhinion is lowered to accommodate a straight graft or implant, or differential augmentation can be employed to produce a smooth dorsum. One such technique is to use fi ely diced cartilage.3,4 The diced cartilage can be used in isolation or be wrapped in Surgicel or temporalis fascia. Segmental augmentation using an alloplast is not possible, because the borders will be visible as a result of capsule formation (Fig. 33-3).

Sho r t Na sal Length

The cause of a short nose is either cartilaginous or a skin–soft issue defic t, or a combination of the two. Cartilaginous causes are addressed directly by altering the shape of the lower lateral cartilage, using a backstopped shield graft, a septal extension graft, or a combination of these techniques5,6 (Fig. 33-4). When signifi ant lengthening results in alar notching, a lateral crural strut graft r an alar rim graft r a lateral crural repositioning technique is employed. L-shaped alloplasts, which are used to correct a short nose, have a high rate of extrusion.

Nos tr il Wid th

Nostril width is accompanied by a component of nostril flare. In very wide noses, even if there is no flaring, signifi ant narrowing will result in alar excess, which will require a reduction. In most patients, an alar sill excision is combined with an alar wedge resection.

Chapter 33 

Special Considerations in Asian Cosmetic Rhinoplasty

527

A

B

Paired spreader grafts

Direct extension graft

C

Fig. 33-4  A, Extended spreader graft for nasal lengthening. B, Septal extension graft C, Extended backstop graft (my

preferred technique). (A Adapted from Guyuron B, Varghai A. Lengthening the nose with a tongue-and-groove technique. Plast Reconstr Surg 111:15 33-1539; discussion 1540-1541; B adapted from Byrd HS, Andochick S, Copit S, et al. Septal extension grafts: a method of controlling tip projection shape. Plast Reconstr Surg 100:999-1010, 1997.)

K23345_Pu_c33p_Consid Cosmetic Rhino_r4_dc_150401.indd 527

4/3/2015 9:26:14 AM

528

Part V 

Primary or Secondary Rhinoplasty

Fig. 33-5  Th s woman had excess nostril width and flare, which were both corrected by alarplasty. A midcolumellar incision open rhinoplasty was employed for other components of her rhinoplasty. The patient had the prototypical features of southeastern Asians: a low dorsum, short nose, weak nasal tip, thick skin, and wide alae. An open approach was used to lengthen the nose with a septal extension graft, and the dorsum was augmented with diced cartilage graft

Wid e Pir ifo rm Fossa

In patients with a low dorsum and short nose with wide nostrils, I prefer nasal bone infracture. There are many benefits of nasal bone infracture (usually low to high) in this situation. Dorsal height can be increased approximately 1 to 2 mm by recruiting adjacent bone. There is loosening of the soft issue from the underlying nasal skeleton, allowing more flexibility with grafting techniques to lengthen the nasal tip. Finally, the periosteal soft issues that attach to the alae are medialized, augmenting the narrowing affect of an alarplasty (Fig. 33-5).

Controversies in Asian Rhinoplasty Techniques Cl os ed Vers us Open Appr oa ch

The open rhinoplasty approach became popular in the early 1990s as an approach to complex problems of the nasal tip. Similarly, in the Asian nose, an external or endonasal approach provides access for addressing the dorsum and augmenting the nasal tip. Either approach can be used, depending on the surgeon’s preference.

Chapter 33 

Special Considerations in Asian Cosmetic Rhinoplasty

Fig. 33-6  Preoperative and postoperative basal views of a midcolumellar incision. The open rhinoplasty incision is almost imperceptible with meticulous closure. Extensive tip work is virtually impossible without the visualization afforded by open access.

Advocates of the closed approach point out that this is a simpler procedure than an open rhinoplasty that avoids potentially visible scarring and maintains skin tension in the tip area, allowing greater accuracy in palpation and quicker recovery time. For rhinoplasties relying primarily on an alloplastic dorsal augmentation that may or may not extend into the tip area, an endonasal approach offers unparalleled simplicity. Th s approach may be the most common approach currently used in Asian rhinoplasty. Advocates of the open procedure cite several shortcomings of the closed approach. They note that a midline dissection is rendered more difficult through the closed approach and that visibility in the tip area is limited. Many surgeons fi d that complex problems in the nasal tip are more easily addressed using an open approach. Septal extension grafts, alar contouring suture techniques, and lateral crural repositioning and/or grafts, to name a few examples, are quite difficult to perform endonasally. Advocates of the open approach also argue that the midline scar, when properly executed, is barely visible. Although most advocates will concede that there is added recovery time and additional costs related to the added complexity of open rhinoplasty, they think that many, if not most, noses require an open approach for an optimal outcome. In summary, either technique is suitable for rhinoplasties involving primarily the dorsum and the less complex requirements at the nasal tip. Complex tip maneuvers are more easily addressed with an open procedure (Fig. 33-6).

All opl a st s in Asian Rhino pl a st y

The use of alloplasts is an unavoidable topic when discussing Asian rhinoplasty. Alloplasts remain the most popular form of dorsal augmentation, with silicone plastic (Silastic) implants being the most frequently used. These implants are popular for their low cost, ease of customization, and relatively inert characteristics. Frequently the bridge is augmented with Silastic and the tip is addressed using a cartilage tip graft. In other instances, an implant will extend from the radix to the nasal tip. When the nasal tip is short or offers little structural support, an L-shaped implant is used. Popular alternatives to silicone are expanded polytetrafluoroethylene or Gore-Tex and porous polyethylene implants (Medpor). The microporous nature of these materials allows better stability than silicone does, but they have the disadvantages of being more difficult to remove and potentially harboring bacteria in the micropores.

529

530

Part V 

Primary or Secondary Rhinoplasty

Alloplasts have several shortcomings. First, the possibility of infection or extrusion persists for the lifetime of the implant. Second, a midline placement of the implant is not a trivial procedure. Although a symmetrical placement of the implant would appear to be a matter of creating a midline cavity, the threedimensional nature of the nose makes the underlying topography an important element in implant stability. In other words, a rigid Silastic implant requires a stable platform to sit on. Th s requires that either the dorsum be made level by removing signifi ant amounts of healthy bone or that the implant be carved to accommodate the irregular dorsum, which is not an easy task. In addition, signifi ant tip work is frequently required to lengthen the characteristic short nose. The settling of grafts uring healing can alter the original positioning of a Silastic implant, displacing it from the midline. The alternative of L-shaped or extended dorsal implants gives rise to the undesirable issue of a high rate of extrusion.

Dorsal Augment atio n With Aut ol o go us Tiss ue

The primary advantage of autologous tissue dorsal augmentation is its low rate of infection and extrusion after vascular ingrowth and the attendant cartilaginous cellular viability. Common sources for autologous tissue include auricular and costal cartilage. Septal cartilage is generally inadequate for the volume of augmentation required. Cranial bone is not commonly used because of its rigid nature. Costal cartilage has recently received much attention for its use in augmentation. Despite advances in techniques to reduce warping, donor site morbidity remains a signifi ant hindrance to the widespread acceptance of costal cartilage by both surgeons and patients in primary cases. There are advocates of either autologous or alloplastic dorsal augmentation for straightforward situations. Certain situations exist, however, in which autologous augmentation is advantageous or even essential: • Multiple prior failed alloplastic augmentations: Capsule formation around alloplasts occurs in varying degrees. Some patients cannot tolerate alloplasts. Autologous tissue augmentation is preferred for this group of patients. • Segmental dorsal deficiency: Because of capsule formation around the periphery, alloplasts require augmentation along the entire length of the dorsum to prevent implant visibility at the cephalic and caudal edges. Difficulties with full-length augmentation occur when patients have insufficiencies limited to only a segment of the dorsum, such as patients with isolated radix deficie cy and those with a high bony but low cartilaginous dorsum. In such patients, segmental augmentation, such as using diced cartilage with perichondrium, greatly simplifies the correction. • The short nose: The use of L-shaped alloplasts is a common method of lengthening the short nose. Th s is accomplished by positioning the implant so that it places pressure on the soft tissue. However, unless the implant is perfectly positioned, the result of any miscalculation is either that the soft issue pushes against the implant and distorts it, or the implant pushes against the soft issue until an extrusion occurs.

Fig. 33-7  An L-shaped Silastic implant has been removed and will

be replaced by diced cartilage with perichondrium. Silastic implants continue to be the most common type of material used for dorsal augmentation. L-shaped implants are used when the nose has inadequate length or tip support. However, the rate of extrusion and displacement is relatively high.

K23345_Pu_c33p_Consid Cosmetic Rhino_r4_dc_150401.indd 530

4/3/2015 9:26:15 AM

Chapter 33 

Special Considerations in Asian Cosmetic Rhinoplasty

When autologous grafts are used for lengthening the nose, some settling is expected to occur during healing. When an alloplastic implant is placed along the lengthened dorsum, displacement can occur as a slight relapse happens. For this reason, autologous dorsal augmentation is preferred when lengthening the short nose (Fig. 33-7).

Expected Outcomes Patients generally anticipate an enhanced dorsum, well-defi ed tip, and proportionate alar width. In many cases, the order of priority of each component will be self-evident. The surgeon’s and patient’s goals for surgery should be aligned, and should be clearly discussed and documented before surgery. Preoperatively the surgeon should determine the degree of improvement the patient seeks and that the patient’s expectations are realistic. A proportionate nose is generally the goal, but occasionally a patient will request a Westernized appearance with an emphasis on dorsal height and narrow nostrils. Such patients can sometimes be accommodated, but a distinct radix should always be retained to prevent a “Greek” nose, which is ethnically incongruous. As in all plastic surgery, if the patient’s aesthetic ideas violate the surgeon’s own aesthetics, the procedure should not be performed (Fig. 33-8).

Management of Complications The most common complications after dorsal augmentation encountered with my technique are overgrafting of the dorsum or an irregular contour. The need to reoperate occurs in approximately 5% of patients for these problems. Minor issues can be corrected using a percutaneous 16- or 18-gauge needle. Visibility of the diced cartilage, warpage, and resorption have not been issues in my patients. The most common issue requiring repeat surgery after alarplasty is undercorrection. Overcorrection is a much more difficult problem, and every effort must be made to preserve the round alar contour. Excising too high on the alar wedge resection can lead to a pasted-on look that is unmistakable and difficult to correct. Scarring is also possible if the alar wedge excision is carried too far cephalically.

Fig. 33-8  The expected outcome for most patients is a higher bridge, better tip defin tion, and appropriate-sized nos-

trils. An overall narrower appearance from the frontal view and a balanced profile are the primary goals. The results should be natural and ethnically congruent.

531

532

Part V 

Primary or Secondary Rhinoplasty

Overdefatting with excessive nasal tip scarring may occur. The key to avoiding this problem is meticulous hemostasis and judicious use of triamcinalone (Kenalog) in the deep nasal tip. Defatting should also be conservative. Overrotation of the nasal tip can be a problem. Contributing factors include standard maneuvers that cause tip rotation on an already short nose: a columellar strut and shield graft for tip projection rotates the nose cephalically, as does an aggressive alarplasty. Countermeasures to off et the rotation must be incorporated into the grafting techniques. Such maneuvers include the extended columellar strut, the backstop shield graft, and septal extension grafts Infection of the graft material is rare. More commonly, methicillin-resistant Staphylococcus aureus (MRSA) in the nasal lining has been a more difficult problem to identify and treat. The index of suspicion for this must remain high. Mupirocin ointment is used for suspected cases of MRSA infection.

Pearls for Success • The Asian nose is characterized by a relatively low dorsum, amorphous tip, and wide nostrils. • The goals of rhinoplastic surgery are to bring each component into proportion—through dorsal augmentation using autografts or alloplastic materials, with tip-plasty through an open or endonasal approach, and alarplasty when required. • A clear understanding of nasal anatomy in Asians and their expectations for their surgical result is critical to the success of the rhinoplasty procedure. • Complications or a less desirable outcome may lead to the need for reoperation, but early communication between the surgeon and patient regarding the patient’s expectations and how complications will be managed if they occur is an important component to the art of Asian rhinoplasty.

Refer ences 1. Erol OO. Tip rhinoplasty in broad noses in a Turkish population: Eurasian noses. Plast Reconstr Surg 130:185-197, 2012. 2. Gruber R, Stepnick D. Rhinoplasty: current concepts. Preface. Clin Plast Surg 37:xiii-xiv, 2010. 3. Erol OO. The Turkish delight: a pliable graft for rhinoplasty. Plast Reconstr Surg 105:2229-2241; discussion 22422243, 2000. 4. Daniel RK, Calvert JW. Diced cartilage grafts in rhinoplasty surgery. Plast Reconstr Surg 113:2156-2171, 2004. 5. Guyuron B, ed. Rhinoplasty. Philadelphia: Elsevier, 2012. 6. Byrd HS, Andochick S, Copit S, et al. Septal extension grafts: a ethod of controlling tip projection shape. Plast Reconstr Surg 100:999-1010, 1997.

K23345_Pu_c33p_Consid Cosmetic Rhino_r4_dc_150401.indd 532

4/3/2015 9:26:17 AM

34 Alloplastic Implants for Rhinoplasty

I

Fuan Chiang Chan, Yong-Chen Por, Yu-Ray Chen

n Asian rhinoplasty, alloplastic implants are mainly used for augmentation of a flat or concave nasal dorsum and to improve nasal tip projection. The most signifi ant recent advances in Asian rhinoplasty include the strong emphasis on dorsal augmentation, and advances in implant material and nasal tip surgery using autologous cartilage. The traditional nasal tip-plasty in Asian rhinoplasty has been achieved with an L-shaped implant, together with dorsal augmentation. However, in recent years, autologous cartilage grafting has been advocated for nasal tip-plasty. Nevertheless, the use of alloplastic material has remained an essential component of Asian rhinoplasty. In this chapter we discuss the three most commonly used implant materials for nasal augmentation in Asians and provide a review of the relevant English literature on alloplastic implants for rhinoplasty.

Alloplastic Material An alloplastic material is defi ed as “an inert foreign body used for implantation into tissue.” The implant material must mimic the attributes of the tissue it seeks to replace, augment, or support. The ideal alloplastic implant must not only enhance the appearance of the area but also feel like the anatomical part that it is augmenting. It should be chemically inert, biocompatible, noncarcinogenic, nonallergenic, nontoxic, sterilizable, and readily shaped to the desired form. The ideal alloplastic implant should integrate well into soft tissue or bone, and it should not support the growth of microbes or interfere with radiological investigations. Ideally, the best implants are well tolerated and retain their intended function for the entire lifetime of the patients. The biocompatibility of an alloplastic material is important, because every implant, like any foreign body, stimulates an inflammatory response that must be minimized.1 It is influenced by factors such as the host reaction to the physical characteristics of the implant material, the site of implantation, and the surgical technique of placement. The undesirable aspects of graft resorption, limited tissue availability, and donor site morbidity in autologous tissue transfer need to be clearly addressed by the surgeon performing applications of an alloplastic material. On the other hand, the advantages of alloplastic materials include their unlimited supply compared with autologous donor tissue and the reduction in operative time and use of resources, because graft or tissue harvesting is unnecessary. Additional advantages of alloplastic materials

533

534

Part V 

Primary or Secondary Rhinoplasty

are their potential for implant customization, and the fact that patient safety is well protected with alloplastic materials, because there is no potential for disease transmission.

Alloplastic Implants for Rhinoplasty One alloplastic material that is frequently used in Asian rhinoplasty is polymer, which is a large molecule composed of repeating structural units connected by covalent bonds. Polymer’s nonabsorbable alloplastic implant material is mainly used because its shape and form are easy to predict and maintain, which is crucial to preserve the patient’s long-term aesthetic outcome. Detailed implantology information on various alloplastic materials is widely available in the literature.

Silic one

Silicones are synthetic polymers containing a repeat silicone-oxide backbone with organic groups (most commonly methyl) attached directly to the silicone atom. Silicone has been developed for many medical applications for approximately 50 years and has remained as the most commonly used solid alloplastic implant for facial skeletal augmentation. Silicone polymers are formed by long-repeating chains of dimethylsiloxane, which may take the form of a fluid, gel, or rubber, depending on the length of the polymer chain and the degree of cross-linking. Solid silicone implants are available for any region of the facial skeleton. They are inert, nontoxic, chemically stable, nonimmunogenic, and simple to use, and they have excellent biocompatibility. The smooth surface of solid silicone implants does not allow vascular or soft issue ingrowth; hence a capsule is formed and may facilitate implant removal when required. However, this capsule formation may also be deleterious, because the capsule can thicken and be subjected to bacterial colonization under the effects of micromotion and chronic inflammation. The long-term implantation of silicone nasal implants has also been reported to be associated with delayed contour changes from calcifi ation of the capsule and implant. In addition, solid silicone is easily sterilized by steam autoclave or irradiation, and it is easily sculpted intraoperatively and stabilized by suture or screw fix tion. The solid silicone currently used in rhinoplasty is softer and comes in various shapes and sizes (Fig. 34-1). Silicone remains the most popular augmentation material among surgeons in Asian countries. The reported complications after augmentation rhinoplasty vary greatly in the literature, occurring in approximately 4% to 36% of patients.2,3 These complications include discoloration, dislocation, extrusion, contraction resulting from the reaction of a foreign body, and infection. In our study, the patients who received the largest volume, and the thickest and longest implants—sizes E and D, respectively—had the highest rates of extrusion and infection.3 Selection of the proper implant size is crucial, because an excessively large implant is often reported as a signifi ant risk factor for serious com-

Fig. 34-1  Silicone implants are available in various shapes and sizes used in nasal augmentation.

Chapter 34 

Alloplastic Implants for Rhinoplasty

plications such as extrusion and perforation. In our experience, excessive pressure, particularly at the columella and nasal tip, has been associated with higher rates of implant perforation and extrusion, necessitating removal.3,4 Eighty percent of the implant extrusions in our study occurred late, after 30 days postoperatively. Th s indicates that the processes of tissue ischemia in the skin overlying the prosthesis, leading to necrosis and eventual extrusion, are indeed gradual and progressive. Silicone fluid, however, is not biocompatible with human tissue, because it can be broken down into smaller particles, resulting in macrophage phagocytosis, leading to a chronic inflammatory response and foreign body granulomas. Therefore the injection of silicone fluid into the face is not recommended.

Expand ed Pol yte trafl uo r oethylene

Expanded polytetrafluoroethylene, better known as Gore-Tex, has a carbon-ethylene backbone to which four fluorine molecules are attached. The fluorine-carbon bonds are not enzymatically degradable in the body; thus they are extremely stable. The surface of Gore-Tex is very nonadherent and has antifrictional properties. The pore size is 10 to 30 mm in diameter, which allows limited tissue ingrowth, less fibrous encapsulation, and fewer tendencies for migration. Gore-Tex is easily cut to the required shape, can be resterilized (stable at temperatures up to 163° C), and can be easily anchored to adjacent tissues by screws or sutures. Gore-Tex is available in sheet, strip, strand, and mesh forms, in blocks, and as preformed implants. GoreTex is spongy in consistency, inert, and does not change shape or resorb with time. Early animal studies documented strong anchoring of the implant into surrounding tissues, minimal tissue inflammatory response, and low rates of infection and other complications.5 More recent reports have described the use of fibrillated Gore-Tex implants for aesthetic surgery on the face, including nasal augmentation. The use of Gore-Tex in nasal augmentation has been reported with favorable outcomes. Its use may still be desirable in revision rhinoplasty, for which it must be contemplated more carefully. Like all alloplastic materials, Gore-Tex should be used with caution when placed in areas with little soft tissue cover. Implant extrusion is relatively uncommon as a result of the fibrous ingrowth seen on histologic evaluation, because the fibrous ingrowth provides the implants with early and continued stabilization over time. Inflammation and infection are the most common complications after Gore-Tex implant placement and are largely responsible for the need for implant removal. The overall reported removal rates range from 1.5% to 8.4%.6 Revision surgery may be indicated for a number of reasons, including overaugmentation, implant deformation causing contour deformities, supratip deformity, irregularity, and excessive scarring. As with silicone implants, overaugmentation is one of the commonly cited reasons for revision after fibrillated Gore-Tex placement, with subsequent revision seen in as many as 5.8% of patients.7 In a study with 31∕2 years of follow-up, Gore-Tex implants showed a consistent natural contour and reliable fix tion as a result of good long-term tissue ingrowth. It has been suggested that minor overcorrection, rather than undercorrection, should be performed to counterbalance the effect of slight long-term implant shrinkage.6,8

High-D ens it y Pol ye thylene

More commonly known as Medpor, high-density polyethylene (HDPE) is a stable, extremely inert, porous implant that was first developed in the 1970s. HDPE constitutes 54% of the total implant volume; the remainder consists of pore space volume. HDPE is the most commonly used form of medical-grade porous polyethylene; in addition, it is nonresorbable and highly biocompatible, with no tendency for chronic

535

536

Part V 

Primary or Secondary Rhinoplasty

inflammatory reactions. The pore sizes of HDPE range from 100 to 300 mm in diameter. It allows ingrowth of both bony and soft issue, which minimizes capsule formation and anchors the implant to the skeletal surface. HDPE also maintains the local host immune response.9,10 These factors indirectly result in lower infection and extrusion rates. HDPE is technically easy to work with, because it is thermoplastic; that is, it can be contoured in hot, sterile saline and shaped intraoperatively to achieve the optimal result. HDPE can be loaded with antibiotics before being inserted through syringe vacuum impregnation, which displaces the air within the material. It can be readily drilled and is most commonly fi ed with metal screws to the bone. HDPE is available in block and sheet forms as well as preformed implants. It has been used successfully for the repair of defects of the orbital wall and for correction of microtia. Multiple series have reported a successful outcome with this alloplastic material in dorsal augmentation rhinoplasty.12,13 HDPE has the advantage of not showing through the overlying tissue. It possesses long-term stability, does not resorb, and allows additional fix tion with sutures, surgical wire, or screws, if necessary. The long-term stability of HDPE has been attributed to many factors: the thick skin−soft issue envelope of the Asian nose, the implant’s proper size to avoid undue tension, and fibrovascular ingrowth into the porous structure of the implant. However, HDPE’s inherent properties, such as stiffness, can create an unnatural appearance over the nasal dorsum, and its rough surface can make insertion cumbersome. The infection rate with HDPE is lower than that of other popular alloplastic materials, such as silicone or Gore-Tex.11,12 But when the skin cover under which HDPE is placed is thin, it can be subjected to extrusion resulting from trauma or infection. In the event of extrusion, the implant material can be partially resected up to areas where normal tissue infiltration into the pores is seen.13 The availability of numerous alloplastic implant materials is increasing rapidly, and selection of the proper one is frequently confusing. For the surgeon, it is important to understand the specific iophysical properties of the alloplastic materials to achieve the optimal result for each patient (Table 34-1). In pure augmentation rhinoplasty, almost all alloplastic implant materials are appropriate for the surgical goal of achieving stability and symmetry. When trying to determine which alloplastic implant material to use, the surgeon should carefully consider the size, consistency, and ease of customization. Prefabrication often is desirable, because it reduces operative time and minimizes handling of the implant.

Table 34-1  Indications and Use of Alloplastic Materials Versus Autologous Grafts in Asian Rhinoplasty Alloplastic Materials

Autologous Grafts

Silicone

Gore-Tex

Medpor (HDPE)

Rib Cartilage

Nasal-Septal Cartilage

Ear Cartilage

Loose, thick skin

1

1

1

1

6

6

Tight, thick skin

2

2

2

1

6

6

Loose, thick skin

1

1

6

1

1

1

Tight, thick skin

2

2

2

1

1

1

Hypoplastic piriform area

2

2

1

1

2

2

Indication

Depressed Dorsum

Low Nose Tip

HDPE, High-density polyethylene.

Chapter 34 

537

Alloplastic Implants for Rhinoplasty

Discussion Alloplastic materials work relatively well with Asian augmentation rhinoplasty patients (Table 34-2). The reason may be that there is a specialized soft tissue envelope in the Asian nose, consisting of dense fibromuscular and fatty layers above the nasal bone and nasal septum cartilage.3 A recent meta-analysis of nasal implants revealed that the removal rate of silicone implants (6.5%) was higher than that of Gore-Tex or Medpor implants (3.1%).12 However, a closer look reveals that the data were comparable only as far as the implant material was concerned; the data were not comparable in terms of patient population, shape of implant, position of implant placement, amount of overlying nasal soft tissue, or tissue tension at the end of implant insertion, among other things. These factors should be standardized to draw any meaningful comparisons or conclusions. Hong et al6 revealed that Gore-Tex implants seemed to have a lower implant removal rate (3.4%) than silicone implants (3.9% to 9.7%). The use of a Gore-Tex implant should be restricted to dorsal augmentation only, because its use in the nasal tip area is potentially extruded in the future and autologous materials should only be used for nasal tip-plasty. The overall complication rates seemed to be similar when Gore-Tex and silicone implants were used for augmentation rhinoplasty in Asian patients.6 The present fi dings suggest that Gore-Tex is a good alternative to a silicone implant, but it does not have defin te advantages over a silicone implant. The use of silicone, the most extensively used alloplast, in rhinoplasty has been widely criticized. Opponents of alloplastic nasal augmentation argue that a silicone prosthesis, because of its lack of incorporation into host tissues, leads to higher infection rates and even possible extrusion. However, the advent of softer-compound silicone implants has helped to decrease the complication rates. Recently, a hybrid of Gore-Tex and silicone has been introduced mainly for aesthetic rhinoplasty (Fig. 342). This new design, in which a layer of Gore-Tex is added over the silicone, provides the advantage of a silicone implant in ease of handling without resorption and the advantage of Gore-Tex in reducing implant

Table 34-2  Inherent and Clinical Characteristics of the Th ee Most Commonly Used Alloplastic Materials in Asian Populations Material

Pore Size

Physical

Resterilization

Shaping

Fixation

Explantation

Partial Removal

Silicone

Nil

Firm to soft

Autoclave

Less easy

Easy

Easy

No

Gore-Tex

10-30 mm

Flexible

Autoclave

Easy

Easy

Less easy

No

Medpor

100-300 mm

Mostly fi m

No

Least easy

Easy

Least easy

Possible

Fig. 34-2  A hybrid of Gore-Tex and

silicone that has been introduced mainly for aesthetic rhinoplasty.

538

Part V 

Primary or Secondary Rhinoplasty

migration. The Gore-Tex and silicone hybrid also avoids the operated look in thin-skinned patients. However, the hybrid’s advantages over either silicone or Gore-Tex independently have not yet been examined. Insertion of any foreign material, whether subsequently encapsulated or with tissue ingrowth, will be subject to a small rate of complications such as infection, extrusion, and deformity. Reports without complications should be viewed with caution.

Pearls for Success • Alloplastic materials work relatively well with Asian augmentation rhinoplasty patients. • The present fi dings suggest that Gore-Tex is a good alternative to a silicone implant. • Insertion of any foreign material will be subject to a small rate of complications such as infection, extrusion, and deformity.

Refer ences 1. Coleman DL, King RN, Andrade JD. The foreign body reaction: a chronic inflammatory response. J Biomed Mater Res 8:199-211,1974. 2. Graham BS, Thi inger JK, Barrett TL. Nasal tip ulceration from infection and extrusion of a nasal alloplastic implant. J Am Acad Dermatol 44(2 Suppl):362-364, 2001. 3. Tham C, Lai YL, Weng CJ, Chen YR. Silicone augmentation rhinoplasty in an Oriental population. Ann Plast Surg 54:1-5; discussion 6-7, 2005. 4. Erlich MA, Parhiscar A. Nasal dorsal augmentation with silicone implants. Facial Plast Surg 19:325-330, 2003. 5. Neel HB III. Implants of Gore-Tex. Arch Otolaryngol 109:427-433, 1983. 6. Hong JP, Yoon JY, Choi JW. Are polytetrafluoroethylene (Gore-Tex) implants an alternative material for nasal dorsal augmentation in Asians? J Craniofac Surg 21:1750-1754, 2010. 7. Owsley TG, Taylor CO. The use of Gore-Tex for nasal augmentation: a retrospective analysis of 106 patients. Plast Reconstr Surg 94:241-248; discussion 249-250, 1994. 8. Jung YG, Kim HY, Dhong HJ, et al. Ultrasonographic monitoring of implant thickness after augmentation rhinoplasty with expanded polytetrafluoroethylene. Am J Rhinol Allergy 23:105-110, 2009. 9. Menderes A, Baytekin C, Topcu A, et al. Craniofacial reconstruction with high-density porous polyethylene implants. J Craniofac Surg 15:719-724, 2004. 10. Spector M, Flemming WR, Kreutner A. Bone growth into porous high-density polyethylene. J Biomed Mater Res 10:595-603, 1976. 11. Yaremchuk MJ. Improving aesthetic outcomes after alloplastic chin augmentation. Plast Reconstr Surg 112:14221432; discussion 1433-1434, 2003. 12. Peled ZM, Warren AG, Johnston P, et al. The use of alloplastic materials in rhinoplasty surgery: a meta-analysis. Plast Reconstr Surg 121:85e-92e, 2008. 13. Berghaus A, Stelter K. Alloplastic materials in rhinoplasty. Curr Opin Otolaryngol Head Neck Surg 14:270-277, 2006.

K23345_Pu_c34 35_Alloplastic Implants_r4__533-538.indd 538

4/3/2015 9:44:58 AM

35 Autologous Cartilage Grafts for Rhinoplasty

I

Dong Hak Jung

mplants and autologous grafting material are commonly used in rhinoplasty. Each material has distinctive advantages and disadvantages. In East Asia, however, implants are still very widely used for dorsal augmentation, whereas autologous grafting material is used for the tip. There is also a recent trend toward the use of autologous graft aterial for the dorsum. Th s material can largely be divided into soft issue, cartilage, and bone grafts. Currently available soft tissue grafts include dermofat, temporalis fascia, adipose tissue, and others. Bone grafts can be divided into long bone grafts, such as iliac bone grafts, and membranous bone grafts, such as calvarial bone. The biggest disadvantage of bone grafts is a high absorption rate. Ear, septal, and costal cartilages can be used for cartilage grafts. ar and septal cartilages are considered ideal grafting materials for surgery, because they can be easily harvested. However, often there is not enough volume for patients in whom bridge augmentation is required. On the whole, the cartilage resorption rate is low; therefore it is a useful material for structural, augmentation, or onlay/camouflage grafting. Costal cartilage requires significant time for harvesting and carving before use as a graft, but its large volume and low absorption rate make it an excellent material for grafting in rhinoplasty.1 In this chapter, the pros and cons of using various types of autologous cartilage, such as ear, septal, and costal cartilage, along with their harvest and preparation, will be discussed. Methods that can be used to prevent complications during rhinoplasty will also be discussed.

Disadvantages of Various Implants Implants that are currently used include silicone, expanded polytetrafluoroethylene (ePTFE), Medpor, Mersilene polyester fiber mesh, and others.2 Silicone is manufactured in various designs and shapes that are stable and easily inserted into the body, and silicone is still widely used today. However, it may cause infection and trigger an immunologic reaction in the host. Other complications of rhinoplasty include transparency of inserted silicone, contraction, calcifi ation, and extrusion (Fig. 35-1). Contraction in particular occurs because of capsular formation that develops with the use of silicone implantation as a result of a host immunologic reaction.

539

540

Part V 

Primary or Secondary Rhinoplasty

Fig. 35-1  Extrusion through the skin after the use of a silicone implant. Th s can occur when an excessively long silicone implant is used in an attempt to lengthen the patient’s nose.

A

B

Fig. 35-2  A, Medpor with extrusion. B, Silicone has been used on the dorsum, and Medpor has been used on the tip in this patient.

ePTFE (Gore-Tex) comes in both a hard and a soft orm. The hard form is available in a prefabricated shape, which essentially is no different from prefabricated silicone implants. The soft form provides a more natural appearance after surgery. With the use of ePTFE, there is no capsular formation; therefore it has a lower incidence of side effects. However, compared with silicone, ePTFE may be associated with a slightly higher rate of infection and is more difficult to remove during secondary rhinoplasty because of its perforated texture.3 Also, rarely, late inflammation or delayed immunologic reactions may occur with ePTFE. 4 If late inflammation occurs, the implant must eventually be removed because of repeated swelling. Although Medpor is used in tip surgery, it often results in an unnatural appearance because of the hardness of the material. Other problems include difficult explantation, extrusion, and removal of overlying soft tissue during explantation because of tissue ingrowth into the large pores on the surface of the Medpor (Fig. 35-2).

Autologous Cartilage Grafts Autologous cartilage is most suitable for rhinoplasty because it has a relatively low absorption rate compared with bone graft Structurally, cartilage can be divided into fibrous, elastic, and hyaline. Auricular cartilage is a form of elastic cartilage, whereas septal and costal cartilages are hyaline cartilage structures. Cartilage has a low rate of resorption, because chondrocytes survive by diffusion and do not require a direct blood supply. A low absorption rate occurs as long as the perichondrium is attached. The absorption rate increases if the cartilage is damaged from being diced or crushed.

Chapter 35 

Autologous Cartilage Grafts for Rhinoplasty

Fig. 35-3  Th black area represents the harvestable portion of the auricular cartilage. The dotted line just anteromedial to the antitragus marks the site where the incision is to be made.

A

B

C

Fig. 35-4  A, Ear deformation caused by damage to the antihelix. Frontal view of the ears where signifi ant asymmetry has resulted from auricular cartilage harvest. B, Deformed right ear. C, Normal left ear.

Aur icul ar Car til a ge

Auricular cartilage can be easily harvested with minimal donor site morbidity and no visible scarring. Auricular cartilage can be harvested through an anterior or posterior approach. Auricular cartilage should be obtained from the innermost area of the ear, concha cymba, and cavum concha without infringement on the supporting structures of the ear, namely, the antihelix and crus of the helix (Fig. 35-3). In general, auricular cartilage is concave, which limits its use as a structural graft If structurally important areas of the auricular cartilage are damaged during harvest, the ear may undergo deformation after the cartilage has been harvested (Fig. 35-4). When the anterior approach is used, the incision is placed just anteromedial to the antitragus. If the incision is made here, the site will be concealed by the antitragus, and the entire harvestable cartilage can be harvested without complications (Fig. 35-5).

541

542

Part V 

Primary or Secondary Rhinoplasty

A

B

C

D

Fig. 35-5  A, Incision made just inside of the antitragus. B-D, With this incision, the entire conchal cartilage can be obtained.

A

B

C

D

Fig. 35-6  For a safe posterior approach, an incision is made near the postauricular sulcus to harvest the cartilage after marking out the structurally important portions of the auricular cartilage for preservation with 26- to 30-gauge needles.

K23345_Pu_c35 36_Autolog Cart_r5_cl_539-554.indd 542

4/3/2015 9:54:22 AM

Chapter 35 

Autologous Cartilage Grafts for Rhinoplasty

With the posterior approach, the incision is made along the postauricular sulcus. Because the posterior surface of the conchal cartilage is smoother and more featureless compared with the anterior surface, landmarks for the preservation of the structurally important areas of the auricular cartilage are less readily identifiable (Fig. 35-6). One side of the perichondrium should be left attached to the conchal cartilage during harvest. For the anterior approach, the surgeon should proceed in a subperichondrial plane on the anterior surface of the conchal cartilage, harvesting the conchal cartilage with the perichondrial layer attached to the posterior surface. If the perichondrium is attached on one side, there will be less absorption, and the possibility of fragmentation during harvest can be reduced; the graft will also be less fragile during sculpting. The anterior approach allows total conchal harvest with clearly identifiable anatomic boundaries for harvest from the front. These anatomic boundaries are less clear with the posterior approach, which may predispose the auricular cartilage to injury and subsequent deformity. Therefore it is a safe practice to mark out the structurally important areas of the auricular cartilage for preservation along the inner aspect of the antihelical fold at 1 cm intervals with 26- to 30-gauge needles before harvest (see Fig. 35-6). The correct planes are created through hydrostatic dissection; lidocaine with 1:100,000 epinephrine is injected in the subperichondrial plane for the anterior surface and in the subcutaneous plane for the posterior surface 15 minutes before dissection (for the anterior approach). Th s facilitates dissection and full separation of the cartilage in the correct planes. Even when the harvest has been carefully executed, there is a possibility of subsequent scarring and deformity. In addition, hematoma after harvest can occur; therefore it is advisable to perform quilting sutures or to apply a pressure dressing with dental rolls and through-and-through 3-0 nylon sutures (Fig. 35-7).

Fig. 35-7  Pressure dressing with dental rolls and through-and-through nylon sutures.

543

544

Part V 

Primary or Secondary Rhinoplasty

Sept al Car til a ge

Septal cartilage is the most reliable material for rhinoplasty, and it is used most widely for tip surgery. Septal cartilage is quadrangular shaped and tends to be flat and rigid, making it suitable for structural grafting in rhinoplasty5 (Fig. 35-8, A). Hydrostatic pressure is used to dissect the area for septal harvest by injecting 1% to 2% lidocaine with 1:100,000 epinephrine in the submucoperichondrial plane before septal cartilage is harvested. For the endonasal approach, a hemitransfi ion incision is made 1 to 2 mm inside the caudal septum, and subperi-

A

C

B

1.5 cm

1.5 cm

D

Fig. 35-8  A, Quadrangular cartilage is ideal for tip surgery because it is flat with adequate rigidity. B-D, Septal cartilage

is harvested, leaving behind a 1.5 cm dorsal and caudal strut. Septal cartilage is harvested only posterior to a line drawn from the nasal spine to the keystone area. Cartilage anterior or caudal to this line must be preserved for the structural support of the tip and middle one third of the nasal dorsum.

Chapter 35 

Autologous Cartilage Grafts for Rhinoplasty

chondrial dissection is carried out to harvest the cartilage. For the external approach, surgical landmarks are made to harvest the nasal septum after identifi ation of the anterior septal angle. Nasal septal cartilage is harvested after at least a 1.5 cm width of dorsal and caudal septa is retained in an “L” shape (dorsal and caudal strut) (Fig. 35-8, B and C). In any case, it is important not to harvest any cartilage from the caudal septum anterior to a line drawn from the nasal spine to the keystone (see Fig. 35-8, B). Th s weakens the structural support of the nose and predisposes to saddling. Often large amounts of cartilage are harvested to obtain large grafts, but this can compromise the structural support of the nose. Previously saddle nose deformity was a common complication of aggressive submucosal resections and harvest (see Figs. 35-15and 35-16). Complications of septal cartilage harvest can lead to saddle nose deformity, hematoma, septal perforation, and intranasal synechiae. Mucosal lacerations occur more commonly with a septal spur; in cases of a large, long, or through-and-through laceration, repair with Vicryl sutures is recommended. To prevent hematoma formation and facilitate mucosal adhesion to the remaining septum after septal harvest, it is advisable to carry out quilting sutures with 5-0 Vicryl and splint the septum on both sides with Silastic sheets. With a signifi ant developmental or traumatic septal deviation, the amount of usable septal cartilage that can be obtained is frequently limited. Septal cartilage in Asian patients is frequently paper-thin, weak, and small; therefore obtaining suffici t grafts in such cases can be difficult. As previously mentioned, nasal septal cartilage can be obtained from a single operative fi ld, and thus there is no additional morbidity from a second operative site. However, a limitation is that an insuffici t amount of graft may be available. Compared with auricular cartilage, it is relatively straight and rigid and more suitable for structural grafting in the nose.

Cos t al Car til a ge

Von Mangoldt6 fi st used costal cartilage in 1889. Since then, costal cartilage has been widely used to augment the severely low nose when adequate septal or auricular cartilage cannot be obtained. Sherris and Kern7 used both the ninth and tenth costal cartilage, with skin incisions made directly over the harvest site for severe saddle nose deformity. In patients with less severe saddle noses, the authors used either the eighth costal cartilage or the fi h and sixth costal cartilages, which are hidden under the breast folds for female patients. Other authors such as Furlan8 used the eighth and ninth costal cartilage, whereas Gunter et al9 usually used the fi h and sixth costal cartilages. The large volume of costal cartilage available makes it a suitable material to harvest for autologous rhinoplasty. It has good sculpting qualities and a low absorption rate. Therefore it is the graft f choice when a large amount of material is needed, when a signifi ant amount of augmentation is needed, or in cases of revision in which the patient has had poor results and complications with other synthetic graft material. The disadvantages of using costal cartilage include the separate surgical site for harvesting, donor-site morbidity including scarring, and the risk of cartilage warping. Because of these disadvantages, it is important to fully understand the indications for costal cartilage in rhinoplasty, the underlying anatomy, the complications associated, and their management.

545

546

Part V 

Primary or Secondary Rhinoplasty

Appropriate Rib Harvest for Rhinoplasty Of the 12 ribs, only the fi st 10 contain cartilage. In the fi st to fi h ribs, cartilages exist independently and are not fused. From the sixth to ninth ribs, the ribs are often fused to each other. The fi st costal cartilage is often signifi antly ossifi d and yields little if any cartilage. The seventh rib cartilage has the longest and thickest available length. In addition, its proximity to other harvestable ribs makes it easy to extract other surrounding ribs when additional rib graft material is needed after the seventh rib is harvested. The biggest problem when using costal cartilage is warping. Therefore it is important to use the straight, noncurved portions of the rib for grafting (Fig. 35-9). Jung et al10 conducted a cadaveric study on 44 cadavers to determine the most appropriate costal cartilage for rhinoplasty. In this study the seventh rib was not only the thickest and longest among all the costal cartilages, but the straight portion of the rib was also the most abundant (Table 35-1). In addition, the incidence of intrathoracic complications while extracting the cartilage is reduced because the seventh rib is located under the diaphragm, and any perforation that occurs in this region is less likely to result in a pneumothorax (Fig. 35-10). Even though the internal mammary vessels (internal thoracic artery) run adhering closely to the costal cartilage, from the sixth rib, they curve medially and close to the posterior portions of the sternum, placing them out of harm’s way when the seventh rib is harvested. The other advantage, as previously mentioned, is that the sixth, eighth, and ninth costal cartilages can be harvested through the same incision when an insuffici t amount of material is harvested through the seventh rib alone.

Fig. 35-9  Explanted, warped costal cartilage that

has been removed during secondary rhinoplasty. Severe delayed warping is shown.

Table 35-1  The Available Length and Thi kness of Costal Cartilage Right Rib

First

Length (mm)

Left

Available Length (mm)

Length (mm)

Available Length (mm)

Right

Left

Thickness (mm)

Thickness (mm)

7.5

7.5

8.7

8.7

17.3

17.1

Second

27.9

27.9

27.3

27.3

14.8

14.7

Thi d

34.1

33.8

34.0

33.6

15.1

14.9

Fourth

42.8

40.8

41.6

40.1

15.7

15.9

Fifth

54.2

49.7

52.0

47.9

16.3

16.4

Sixth

76.5

65.5

75.0

62.7

17.5

17.3

Seventh

108.2

90.7

106.7

89.6

17.6

17.5

Eighth

81.8

76.3

81.2

74.9

13.8

13.8

Ninth

64.0

55.1

63.0

54.1

11.1

10.9

Tenth

32.6

29.4

30.9

28.1

10.6

10.5

Chapter 35 

Autologous Cartilage Grafts for Rhinoplasty

B

C

A

Fig. 35-10  A, Internal view of the chest wall demonstrating the diaphragm (arrows) and its relationship to the rib carti-

lages. B, The diaphragm is attached to the area of the sixth costal cartilage. The seventh costal cartilage is mainly positioned on the abdominal cavity so there is less risk of a pneumothorax. The margin of the cartilage is shown. C, Internal thoracic artery (arrow) and vein descend closely behind the costal cartilages and course medially from the sixth costal cartilage.

Fig. 35-11  Because the rectus abdominis muscle originates from the sixth costal cartilage, more soft tissue dissection is required to expose the seventh costal cartilage anteriorly.

A disadvantage of the use of the seventh costal cartilage is that the rectus abdominis muscle originates from the sixth rib onward. Thus a greater amount of muscle and soft tissue dissection may be required to free the seventh rib anteriorly (Fig. 35-11). The seventh costal cartilage is considered the most suitable material in available length, safety, and volume.10 The inframammary fold incision is useful in that it is cosmetically favorable to most women. The fi h and sixth rib cartilages can be harvested through an inframammary incision. However, the amount of harvestable cartilage is limited because of the small size and length of the fi h and sixth costal cartilages, and the risk of a pneumothorax is higher. The costal cartilages are usually harvested from the right side of the chest to avoid cardiac injury and confusing postoperative chest pain with pain resulting from other cardiac problems.

547

548

Part V 

Primary or Secondary Rhinoplasty

Surgical Technique to Harvest Rib Cartilage In preparation to harvest rib cartilage, it is advisable to surface mark the seventh rib by counting from inferior to superior, by taking the separated tenth rib as an initial landmark. On confi ming the position of the seventh rib, the skin is infiltrated with 1% lidocaine with 1:100,000 epinephrine after surface marking. A 2.5 to 3 cm incision is made on the skin and deepened to the level of the extrathoracic muscle. The muscle fascia is opened, and the muscle fibers are carefully split along the direction of the muscle fibers without any tearing (Fig. 35-12). Excessive muscle dissection leads to signifi ant postoperative pain. The anterior surface of the rib is exposed, and a subperichondrial dissection plane is developed around the rib. Fusions to the superior and inferior ribs are separated. A Doyan’s elevator is used to elevate the inferiormost perichondrium off the inferior surface of the rib. The rib is harvested laterally from the costochondral junction and as far medially as possible. A minimum of 6 cm of rib cartilage is usually harvested. It is important to try to keep the inferior perichondrium intact to prevent injury to the pleura and intercostal vessels that lie deep to the perichondrium. A strip of perichondrium overlying the anterior surface of the costal cartilage can be harvested with the rib cartilage graft for subsequent use as a camouflage “blanket” over the dorsum and tip in patients with thin or compromised soft tissue (Fig. 35-13).Usually parallel incisions are made at

A

B

Fig. 35-12  A, The incision to harvest the seventh costal cartilage. Counting begins inferiorly (at the tenth costal cartilage) to confi m the position of the seventh costal cartilage. B, An incision is made medial to the midclavicular line.

B

C

A

Fig. 35-13  A, Harvested perichondrium. B and C, After structuring and on-lay grafting with costal cartilage, the perichondrium can be used to camouflage the irregular surface of the skin.

Chapter 35 

549

Autologous Cartilage Grafts for Rhinoplasty

the upper and lower edges of the rib to harvest the perichondrium. After harvest, hemostasis and inspection for any breech of the perichondrium are carefully carried out. The cavity is filled with normal saline solution, and the anesthetist is asked to perform a Valsalva maneuver to check for release of air bubbles from the lungs, which indicates the presence of a pneumothorax.

Indication for the Use of Rib Cartilage General indications for the use of rib cartilage are shown in Box 35-1. If an augmentation of more than 7 mm is required, excessive skin tension will result in unnatural skin transparency if synthetic implants are used. Therefore rib cartilage is the best choice in such a circumstance. Patients with an extremely small or contracted nose who need major restructuring require a large amount of cartilage; thus costal cartilage offers suffici t volume for major structural grafting (Fig. 35-14). Patients with multiple previous surgeries and multiple complications from rhinoplasty are recommended to consider autologous grafting. Rib harvest is also indicated in a cartilage-depleted patient undergoing revision rhinoplasty with no harvestable septum and conchal cartilage. Frequently the use of costal cartilage is

Box 35-1  Indications for Costal Cartilage in Rhinoplasty • Augmentation more than 7 mm • Severely small and contracted nose • Patient with graft depletion • Rhinoplasty in an infected fi ld • Deformed and complicated nose • Patient undergoing repeated revision surgery • Septal and nasal reconstruction • Patient’s preference

A

B

C

D

Fig. 35-14  A and C, Contracted nose before surgery. B and D, Postoperative views.

550

Part V 

Primary or Secondary Rhinoplasty

recommended when there is a nasal septal defect, because nasal reconstruction and rhinoplasty are needed concomitantly (Figs. 35-15and 35-16). The indications may also include patients with nasal defects associated with a congenital abnormality, such as cleft ose, or patients who desire immediate revision rhinoplasty in an infected fi ld (for example, infection after implantation with silicone or ePTFE). Recently there has been an increasing trend of patients requesting elective rhinoplasty with rib cartilage, because they do not want synthetic implants used.

A

B

Fig. 35-15  A, Reconstruction of the septum with costal cartilage. B, Graft carved for augmentation.

A

B

C

D

Fig. 35-16  A and C, Preoperative photos of a patient with damaged septal cartilage. B and D, Postoperative views.

Chapter 35 

Autologous Cartilage Grafts for Rhinoplasty

Rib Cartilage Carving and Precautions in the Use of Costal Cartilage Because of the possibility of warping, costal cartilage should be placed in normal saline solution after the harvested rib is sculpted into the preliminary grafts hat will be used for the rhinoplasty. The sculpted cartilage is left o warp in normal saline solution for at least 45 minutes while other aspects of the rhinoplasty are performed. Most warping will occur during this time, and any warping in the grafts is addressed through resculpting before their use. Often calcification can occur within the grafts, and thus bone-cutting forceps or a drill may be required to sculpt the rib cartilage. Once truncated, costal cartilage, even when stitched back together carefully, will not contour the same way when placed under the skin; very often doing so will result in irregularities in the overlying skin. Therefore meticulous planning and sculpting are required when costal cartilage is used (Fig. 35-17, A). To minimize cartilage warping, the straight part of the costal cartilage should be used if possible. The longest and straightest part must be used for dorsal augmentation, and the rest can be used for tip surgery. Appropriate portions of the rib are then chosen for use as extended spreader grafts or struts (Fig. 35-17, B). For a patient in whom staged surgery is required (for example, a patient with a contracted nose), unused cartilage can be banked within the subcutaneous layer of the chest through the harvest incision after closure of the muscle layer. Th s cartilage can be quickly harvested during a secondary operation.

A

B

Fig. 35-17  A, Cartilage design for augmentation and tip surgery. B, After carving according to the design.

551

552

Part V 

Primary or Secondary Rhinoplasty

Complications Resulting From Use of Rib Cartilage and Proposed Solutions War ping

The most important complication associated with the use of costal cartilage is warping. The incidence varies between 3% and 5%7 (see Fig. 35-9). Gibson and Davis11 described ways to prevent warping; however, in reality, application is much harder. Gunter and Rohrich12 used K-wires to skewer their cartilage grafts, but this has been shown to be technically difficult, and its use is fairly limited in Asian patients, because the graft for augmentation needs to be carved in a boat shape, making skewering through the whole length difficult. In addition, warping can still occur with K-wiring as long as the differences in tension forces continue to exist between the cortical and medullary portions of the rib graft. Diced cartilage wrapped in deep temporalis fascia is also used; however, lengthy preparation time and long-term unevenness of the skin remain a disadvantage. My method for addressing warping involves using the straightest portion of the rib cartilage, and after sculpting, making deep hatching incisions all around the four sides of the graft to prevent warping (Fig. 35-18). If warping occurs, the graft s fi st removed and then reinserted after a hatching incision is made and a small cartilage graft is inserted into the concavity of the warped portion to restore straightness (Fig. 35-19).

Fig. 35-18  Warping can be prevented by placing deep hatching incisions. Th s should be placed as deeply as possible without transecting the cartilage on all four sides of the graft

Chapter 35 

A

B

Autologous Cartilage Grafts for Rhinoplasty

C

Fig. 35-19  A, Once warping occurs, the warped graft is removed. B, A hatching incision is made on the concave side. C, A small wedged-shaped cartilage graft (arrow) is inserted and fi ed to this incision to straighten the warping.

Fig. 35-20  Donor site scarring that occurred after rib harvest.

Dono r Site Scar

The donor site scar can be a problem in Asian patients (Fig. 35-20). Serious scar-related complications occur in approximately 10% of patients. Intralesional triamcinolone injection is used to treat complications, but meticulous closure and preoperative counseling are necessary, because it is likely that signifi ant scarring will remain.

Pneu motho ra x

Pneumothorax may occur during surgery; a hissing sound may alert the surgeon to this complication. In a minor pleural defect, a small red rubber catheter is inserted through the defect, followed by placing a purse-string suture around the defect. The catheter is then slowly withdrawn, and the purse-string suture is tightened while the anesthetist maintains the patient on a Valsalva maneuver. For larger pleural defects, chest tube insertion with a connection to an underwater seal is necessary while waiting for the chest to reexpand.

553

554

Part V 

Primary or Secondary Rhinoplasty

Ser omas

Seromas are a rare complication. They are seen in patients with extensive muscle dissection. Sometimes severe postoperative pain occurs with seromas. This may be the result of injuring or suturing the intercostal neurovascular bundle. Injection of bupivacaine solution (6 to 8 ml of 0.25% bupivacaine with 1:200,000 epinephrine) before closure helps reduce immediate postoperative pain. A postoperative chest radiograph is not routinely performed after costal cartilage harvesting. However, in case of a pneumothorax, a chest radiograph is mandatory.

Pearls for Success • Auricular or septal cartilages can be harvested with minimal donor-site morbidity; this makes septal and conchal cartilages the fi st choices in obtaining autologous cartilage grafts for rhinoplasty. • Although some disadvantages are associated with the use of a costal cartilage graft or rhinoplasty, including warping and donor-site scarring, it is indicated in several clinical scenarios of rhinoplasty. • The low absorption rate of costal cartilage, high cartilage volume, and the ease of carving make it an attractive choice for autologous rhinoplasty. • Although there are differing opinions regarding which rib is the best to harvest, the seventh rib offers the longest available length and thickness for grafting, with a low risk for developing a pneumothorax because it lies under the diaphragm. For these reasons, the seventh rib is my preferred rib of choice for harvesting autologous rib cartilage.

Refer ences 1. Yilmaz M, Vayvada H, Menderes A, et al. Dorsal nasal augmentation with rib cartilage graft: long-term results and patient satisfaction. J Craniofac Surg 18:1457-1462, 2007. 2. Jung DH, Jung YK, Lee WW, et al. A study on grafts and implants materials in augmentation rhinoplasty. Korean J Otolaryngol 39:250-257, 1996. 3. Jang TY, Choi JY, Jung DH, et al. Histologic study of Gore-Tex removed after rhinoplasty. Laryngoscope 119:620627, 2009. 4. Hubmer MG, Hoffmann C, Popper H, et al. Expanded polytetrafluoroethylene threads for lip augmentation induce foreign body granulomatous reaction. Plast Reconstr Surg 103:1277-1279, 1999. 5. Der Sarkissian R. Cartilage grafting in rhinoplasty and nasal reconstruction. In Azizzadeh B, Murphy MR, Johnson CM Jr, et al. Master Techniques in Rhinoplasty. Philadelphia: Elsevier, 2011. 6. von Mangoldt. Correction of saddle nose by cartilage transplantation. Verh Dtsch Ges Chir 29:460, 1900. 7. Sherris DA, Kern EB. The versatile autogenous rib graft in septorhinoplasty. Am J Rhinol 12:221-227, 1998. 8. Furlan S. Correction of saddle nose deformities by costal cartilage grafts—a technique. Ann Plast Surg 9:32-35, 1982. 9. Gunter JP, Cochran CS, Marin VP. Dorsal augmentation with autogenous rib cartilage. Semin Plast Surg 22:7489, 2008. 10. Jung DH, Choi SH, Moon HJ, et al. A cadaveric analysis of the ideal costal cartilage graft or Asian rhinoplasty. Plast Reconstr Surg 114:545-550, 2004. 11. Gibson T, Davis WB. The distortion of autogenous cartilage grafts: its cause and prevention. Br J Plast Surg 10:257, 1958. 12. Gunter JP, Rohrich RJ. Dorsal augmentation. II: The use of autogenous rib cartilage. In Proceedings of the Fourteenth Annual Dallas Rhinoplasty Symposium, Dallas, Feb-Mar 1997.

K23345_Pu_c35 36_Autolog Cart_r5_cl_539-554.indd 554

4/3/2015 9:54:30 AM

36 Primary Closed Rhinoplasty Raymond C.W. Goh, Yong-Chen Por, Fuan Chiang Chan, Yu-Ray Chen

T

he   approach to aesthetic enhancement of the Asian nose differs from that of traditional rhinoplasty in many aspects, including patient expectations, cultural issues, preoperative analysis, nasal anatomy, and surgical techniques used. It is imperative that rhinoplasty surgeons appreciate the various aspects of aesthetic beauty among Asians. For these existing structures, patients typically seek augmentation rather than reductive procedures. The surgeon also must understand and respect the various opinions that patients have regarding cultural aesthetics and possess the appropriate operative techniques to achieve a successful and racially congruent result for each patient. In our experience, Asian patients often seek improvement and refi ement of their Asian features, rather than radical changes toward the more characteristic features of whites. The main focus in this chapter is the endonasal approach to cosmetic rhinoplasty in the Asian population. A culturally sensitive approach toward Asian rhinoplasty is strongly advised for rhinoplasty surgeons, including those surgeons treating patients outside Asian countries. The endonasal approach to augmentation rhinoplasty in Asians is probably one of the most popular and widely used techniques available; this is a testament to the versatility and ability of the endonasal approach to achieve most of the surgical goals of primary augmentation rhinoplasty.

Commonly Used Prostheses for Augmentation Rhinoplasty Silicones are synthetic polymers containing a repeat silicone-oxide backbone with organic groups (most commonly methyl) attached directly to the silicone atom. Silicone polymers are formed by long repeating chains of dimethyl siloxane, in which the polymer viscosity is dependent on the value of n (total chain length) and the degree of cross-linkage.1 Silicones may be fluid, gel, or rubber, depending on the length of the polymer chain and the degree of cross-linking. They are inert, nontoxic, chemically stable, nonimmunogenic, and simple to use, and they have excellent biocompatibility. The smooth surface of solid silicone implants does not allow vascular or soft issue ingrowth, hence a capsule is formed that may facilitate implant removal when required. However, this may also be deleterious, because this capsule can thicken and be subjected to bacterial colonization when there is micromotion and chronic inflammation. 2 In addition, solid silicone is easily sterilized by steam autoclave or irradiation. It is easily sculpted intraoperatively and stabilized by suture or screw fix tion. The solid silicone used in rhinoplasty is now softer

555

556

Part V 

Primary or Secondary Rhinoplasty

Fig. 36-1  The modern solid silicone used in rhinoplasty.

and comes in various sizes and shapes, with the L-shaped and I-shaped implants being the most common nasal implants (Fig. 36-1). Medpor, a high-density polyethylene (HDPE), is a stable, extremely inert, porous implant that was fi st developed in the 1970s. HDPE constitutes 54% of the total implant volume; the remainder consists of pore space volume. HDPE is nonresorbable and highly biocompatible, with no tendency for chronic inflammatory reactions. The pore sizes of HDPE range from 100 to 300 mm in diameter. It allows ingrowth of both bony and soft tissue, minimizing capsule formation and anchoring the implant to the skeletal surface. HDPE also maintains the immune response of the local host. Both silicone and HDPE implants are widely used in Asian rhinoplasty. The possible reasons for the popularity of these alloplastic nasal prostheses are the ease of the operative procedure required, their lack of donor site morbidity, and the fact that the dense fibromuscular and fatty layers of the Asian nasal bone and septal cartilage prevent these implants from extrusion.

Pertinent Anatomy The Asian nasal anatomy is frequently described as having the following characteristics: • A low or flattened nasal dorsum • Wide alar cartilage • A low piriform base with a round or drooping tip • A short, underprojecting, and retracted columella3 • Characteristically thick dermoglandular tissue over the tip and supratip with ill-defi ed lower lateral cartilages (Fig. 36-2); this reduces the surgeon’s ability to enhance tip-defini g points by cartilage manipulation Anatomic dissection has revealed that there is a superfic al musculoaponeurotic system (SMAS) layer on the nose.4 The nasal SMAS layer has been described by Wu5 as a vascular fibromuscular layer. In our practice, the pocket for the nasal implant is created under the SMAS layer, over the perichondrium at the middle and lower thirds of the nose, and under the periosteum over the nasal bones in the upper third. The thick soft tissue cover that is typical of the Asian nose is inherently benefic al in helping to reduce the rate of implant extrusion.6 It is also because of this thick soft tissue that the Asian nasal tip lacks the definition seen in the noses of whites. In Asians, a slightly improved tip defin tion can be readily obtained by the use of an appropriately shaped nasal and tip implant with an L-strut.

Chapter 36 

Primary Closed Rhinoplasty

Fig. 36-2  Preoperative photographs of a patient with characteristic Asian nasal anatomy.

Preoperative Assessment In preoperative counseling of the Asian rhinoplasty patient, the surgeon must not only be conscious of cultural concerns but also identify cosmetic concerns and functional complaints. The Asian nose is assessed in the frontal, profile, and basal views. In the frontal view, the nasal symmetry, dorsal aesthetic lines, tip defin tion, and alar width are assessed. In the profile view, the nasofrontal angle, radix, height of the dorsum, length of the nose, nasal tip–lobule complex, tip projection, columella-lobule angle, columella height, and nasolabial angle are determined. The basal view will reveal the relationship of the columella to the lobule ratio, alar width, and flaring. The radix in the Asian nose frequently originates at or below the medial canthal region. Khoo7 described the golden point, which is the point where the ideal radix should arise at the midpoint between the medial canthus and the medial brow. More recently, reports have mentioned that the nasofrontal angle should lie between the upper lash line and the supratarsal fold. Another method used to determine the level of the nasal radix is the horizontal midpupillary line.8 All of these points are in close proximity to each other, allowing the surgeon to assess the appropriate position of the radix in relation to other facial features. Physical assessment of the nose is necessary to determine the presence of nasal obstruction, if any, such as septal deviation and inferior turbinate hypertrophy; therefore an assessment of the laxity of the skin overlying the nasal dorsum and a nasal tip–lobule distraction test are performed (Fig. 36-3). The skin overlying the nasal dorsum is pinched and pulled upward to assess the skin’s ability to accommodate the intended implant height. If the skin is tight and shiny, the skin is probably thinner and may not be able to accommodate a signifi antly larger implant. Similarly, the nasal tip−lobule complex is displaced upward with two cotton swabs to assess the degree of attachment of the lower lateral cartilage to the upper lateral cartilages. Patients can be divided into two groups: those with tight attachment between the upper and lower lateral cartilages, resulting in minimal upward displacement, and those with a looser attachment between the upper and lower lateral cartilages, resulting in more upward displacement. A looser attachment between the upper and lower lateral cartilages will allow insertion of a larger implant. When the nasal tip−lobule is held between the examiner’s index fi ger and thumb, it can be pulled downward and displaced from side to side to assess the maximal potential soft issue movement under minimal tension. Th s step is necessary not only in primary rhinoplasty cases, but also in secondary cases to assess scarring of the soft tissues.

557

558

Part V 

A

Primary or Secondary Rhinoplasty

B

Fig. 36-3  A, Assessing the laxity of the skin overlying the nasal dorsum. B, Performing the nasal tip–lobule distraction test. Both of these assessments are performed to determine the patient’s suitability for implant augmentation and to estimate the potential implant size.

Surgical Technique Primary closed rhinoplasty is routinely performed with a local anesthetic on an outpatient basis. A solution of 1:200,000 epinephrine with lidocaine is injected to anesthetize the infraorbital nerves; it is injected directly over the nasal dorsum to anesthetize the external branches of the anterior ethmoid nerves. Th s is followed by additional local anesthetic injections over the tip, columella, and intended incision site for hydrodissection. The nasal hairs are clipped and gauze is lightly packed into both nostrils to prevent aspiration of blood.

Incis io ns

We prefer the paracolumellar incision and the hemitransfixi n incision (Fig. 36-4). Selection of the incision depends on the type of implant used. If an I-shaped implant is selected, the hemitransfixi n incision should be used. If an L-shaped implant is selected, the paracolumellar incision should be used. The hemitransfixi n incision is placed at the upper border of the caudal septum. Th s incision extends from below the intended pocket to just above the anterior nasal spine. It is made in this location so that the implant pocket is slightly superior to the apex of the incision; therefore this incision helps to prevent extrusion of the implant. The advantage of this incision is that it does not disrupt the nasal tip−lobule complex anatomy, so it prevents a change in the appearance of the nasal tip and lobule. The paracolumellar incision is placed just behind the columella but anterior to the caudal margin of the medial crura of the lower lateral cartilage; this location enables direct access for dissection of the pocket for the L-shaped implant. The pocket required includes a space between the medial crura just anterior to the caudal septum. Both of these incisions allow dissection of the implant pockets in the midline; thus the potential for implant deviation from an unequal pocket dissection is minimized. Other endonasal incisions include the intercartilaginous, intracartilaginous, and infracartilaginous incisions. Each of these incisions can be used to access and dissect the implant pocket. The intercartilaginous incision is performed when the most direct approach to the nasal dorsum is needed, especially when there is no need to alter the nasal tip–lobule complex. Th s incision can be extended downward into a hemitrans-

Chapter 36 

A

Primary Closed Rhinoplasty

Septal cartilage

B

Hemitransfixion incision

Fig. 36-4  A, The marking for the hemitransfixi n incision. B, The scissor dissection above the septal cartilage after incision.

A

B

Fig. 36-5  A, Dissection of the subperiosteal pocket over the nasal bone using a Joseph elevator. B, The upper margin of dissection is indicated by the index fi ger of the surgeon’s other hand.

fixi n incision to access or create a pocket at the area of the caudal septum. The intracartilaginous incision is performed if a cephalic trim is necessary, because it is a direct approach to resecting the cephalic end of the lower lateral cartilages. The incision is marked directly on the lower lateral cartilages, where at least 5 mm of the caudal border of the lower lateral cartilage should be preserved to ensure that there is enough support for the tip and superior ala. The infracartilaginous incision with an extension into the vestibule is probably the most popular incision for insertion of a nasal implant with a columellar strut. The incision can be lengthened caudally into a paracolumellar incision (placed anterior to the medial crura), which will further facilitate dissection of the region between the medial crura.

Diss ectio n and Po cke t

The pocket for the nasal dorsum is prepared by dissecting in the supraperichondrial plane just below the vascular fibromuscular layer. Th s is an easy plane to dissect. Once the nasal bones are reached, a sharp scissors is used to cut through and abrade the nasal bone periosteum. Then a Joseph elevator is used to create a subperiosteal pocket for the implant over the nasal bone. It is difficult to elevate the periosteum beyond the depression of the original radix because of the change in the angle, so the surgeon should proceed slowly when dissecting this area (Fig. 36-5).

559

560

Part V 

Primary or Secondary Rhinoplasty

Fixation of the implant under the periosteum will prevent dorsal and lateral migration and will anchor the nasal radix at its intended position. The pocket for the placement of the columellar strut is placed in between the medial crura and caudal to the caudal border of the caudal nasal septum. If a hemitransfixi n or paracolumellar incision is used, implant deviation resulting from an unequal pocket dissection is minimized, because the approach is in the midline. If another incision is used, the pocket dissection should be made equally on both sides to reduce the risk of implant malposition; this allows the forces of contraction during healing to act equally to maintain the implant in the central position. For example, if an infracartilaginous incision is made on the right side, the pocket on the left side is more easily dissected and consequently becomes larger. The surgeon should make a conscious effort to equilibrate these two pockets. Another method of creating equal pockets is to make incisions on both sides to enable an easier approach to the contralateral side. When making an incision on both sides, the incision on the contralateral side can be reduced in length or can be a different type. For example, a vestibularparacolumellar incision can be made on the right side where the implant is going to be inserted, and a rim or infracartilaginous incision can be made on the left side solely for access to dissect the implant pocket.

Impl ant Selectio n and Pl a cement

First, the appropriate implant length is selected based on the length between the new radix and the tip. Then the thickness of the dorsum is selected. A method of assessing the adequacy of the implant size and its height is to place the implant on the nasal dorsum of the patient. In the patient who requires augmentation of the radix, the implant should sit comfortably at the bony nasion so that no dead space exists between the implant and bone (Fig. 36-6). The width of the implant as well as the tip augmentation can also be selected separately. The selected implant is inserted into the pocket, and then its effect on the nasal augmentation of the dorsum and tip is assessed. Any irregularities resulting from an incongruous implant and tissue interface can be shaved or carved away. Once the nasal dorsum is deemed satisfactory, the nasal tip projection is assessed. The limitation is that an excessively long L-strut will result in pressure necrosis and implant extrusion over the nasal tip, or a deviation of the L-strut toward the incision with a resultant extrusion. The challenge is to decide the ap-

Fig. 36-6  The implant should sit comfortably on the nasal bone, with no dead space in between.

Chapter 36 

A

Primary Closed Rhinoplasty

B

Fig. 36-7  An I-shaped prosthesis was inserted in the nasal tip as in Fig. 36-6. (See also Fig. 36-4.) A, Before insertion. B, After insertion.

propriate length of the I- or L-strut to achieve the appropriate tip projection without causing excessive pressure on the nasal tip (Fig. 36-7). One frequently used method to prevent excessive nasal tip pressure is to look for blanching of the nasal tip skin, because blanching may indicate that there is excessive pressure over the nasal tip. Another method is to prevent the columellar strut from resting directly on the bony anterior nasal spine. In addition, a cap of conchal cartilage graft may be sutured on the tip of the implant to increase the surface area of contact and to add another layer of protection with the nasal tip tissues to reduce the risk of implant extrusion. Closure of the incision is performed using interrupted Vicryl 5-0 sutures. The implant can also be used without the L-strut. Commonly called the I-shaped implant, this implant is used when only the nasal dorsum needs augmentation and when the nasal tip is adequate in size, shape, projection, and dimensions. Superiorly, the I-shaped implant is fi ed under the nasal periosteum at the nasal radix; inferiorly, it extends to the region just above the superior border of the lower lateral cartilages. Once the appropriate length of the I-implant is decided, the L-strut and nasal tip on the L-shaped prosthesis are removed. The inferior end of the I-shaped implant is shaved to remove any palpable ridges on the implant nose interface. The I-shaped implant can also be designed to preserve the nasal tip component and to remove the L-strut only. However, without the stabilization of the L-strut, there is a risk that capsules could form around the implant over the long term, causing capsular contracture and deviation or proximal migration of the implant. The I-shaped implant can also be combined autologously to enhance the nasal tip, which may be easier to perform through an open-tip rhinoplasty. The lack of an L-strut and the use of autologous material in the nasal tip may be the two reasons why the I-implant is thought to reduce the risk of implant extrusion.

Postoperative Care The patient is instructed to keep the operated area clean with antibiotic ointment and to avoid blowing his or her nose for at least 2 weeks. The nasal strap, which is removed between the fi h and seventh postoperative days, helps to reduce swelling and implant deviation, and it reminds the patient to be careful against nasal trauma during the recovery period.

561

562

Part V 

Primary or Secondary Rhinoplasty

Results The long-term results of augmentation rhinoplasty in ethnic noses using silicone implants have been excellent, despite the common beliefs by Western surgeons that alloplastic implants to the nasal dorsum are doomed to failure.6,9

Fig. 36-8 Th s 30-year-old woman underwent a right hemitransfixi n incision and I-shaped augmentation rhinoplasty. She is shown preoperatively and 5 months postoperatively.

Chapter 36 

Primary Closed Rhinoplasty

563

Fig. 36-9 Th s 50-year-old woman underwent a hemitransfixi n incision and I-shaped augmentation rhinoplasty. She is seen preoperatively and 3 years postoperatively.

K23345_Pu_c36_Prim Closed Rhino_r4_cl_555-566.indd 563

4/3/2015 9:57:39 AM

564

Part V 

Primary or Secondary Rhinoplasty

Fig. 36-10 Th s 40-year-old woman underwent a right hemicolumella incision and L-shaped augmentation rhinoplasty. She is seen preoperatively and 18 months postoperatively.

Discussion Asian augmentation rhinoplasty primarily uses an appropriately sized and shaped implant to augment both the nasal dorsum and the tip-lobule–columella complex. The endonasal approach is performed through hidden incisions in the nasal vestibule to access and create a pocket over the nasal tip and dorsum. This approach requires supraperichondrial dissection over the middle and lower thirds of the nose to take advantage of the thick soft tissue covering of Asian skin to prevent implant extrusion, and subperiosteal dissection over the nasal dorsum to immobilize the implant.3 The determinants of good surgical outcomes are the assessment of the patient’s soft issue adequacy, selection of the appropriate implant size, intraoperative assessment of excessive pressure on the skin, and patient education. Appropriate follow-up intervals are also necessary to detect and prevent complications such as early extrusion or infection, including late complications that may require secondary rhinoplasty (Fig. 36-11). Potential complications include implant deviation, mobility, displacement, deformity, inadequate height or length, extrusion, infection, and patient dissatisfaction.10-12 Jackson et al13 observed that the number of complications of alloplastic augmentation rhinoplasty in Asians is lower compared with that of whites. In our series analyzing 355 patients over a mean follow-up of 160 days, in which surgeries were performed by

Chapter 36 

Primary Closed Rhinoplasty

26 different surgeons using varying techniques, there was a 7.9% rate of major complications that required implant removal or revision. Most complications were related to the selection of an inappropriately large implant, resulting in deviation and extrusion.12 It is essential to instruct the patient to monitor the implant continually for changes, because early infection may be treated with antibiotics, and early extrusion with tissue thinning may be circumvented by early removal of the implant. In the event that the implant is removed, it is prudent to wait at least 6 months before performing revision rhinoplasty using autologous material.

Fig. 36-11  Th s 45-year-old woman presented 1 year after augmentation rhinoplasty with an L-shaped silicone pros-

thesis, which was performed by another surgeon at an outside clinic. She had developed an ulcer with granulation over the exposed prosthesis at her nasal tip. The exposed nasal prosthesis was removed at our clinic with minimal debridement and without primary closure. The wound healed in 2 weeks, and the patient considered the scar acceptable at her 17-month follow-up. She is seen preoperatively and 17 months postoperatively.

565

566

Part V 

Primary or Secondary Rhinoplasty

Pearls for Success • For patient selection, surgeons should consider primary closed rhinoplasty for a patient whose skin is loose and thick. • The layers of dissection are as follows: fi st, the loose connective tissue layer above the septal cartilage; second, the subperiosteal layer above the nasal bone. • It is important to choose the proper size and type of implant. • It is essential to allow ample space for a properly sized prosthesis. • Surgeons should avoid using this technique on a patient with a short nose or with thin nose skin.

Refer ences 1. Quatela VC, Chow J. Synthetic facial implants. Facial Plast Surg Clin North Am 16:1-10, 2008. 2. Peled ZM, Warren AG, Johnston P, et al. The use of alloplastic materials in rhinoplasty surgery: a meta-analysis. Plast Reconstr Surg 121:85e-92e, 2008. 3. Toriumi DM, Pero CD. Asian rhinoplasty. Clin Plast Surg 37:335-352, 2010. 4. Letourneau A, Daniel RK. The superfic al musculoaponeurotic system of the nose. Plast Reconstr Surg 82:48-57, 1988. 5. Wu WT. The Oriental nose: an anatomical basis for surgery. Ann Acad Med Singapore 21:176-189, 1992. 6. McCurdy JA Jr. Augmentation rhinoplasty with silicone prostheses. Oper Tech Otolaryngol Head Neck Surg 19:72-78, 2008. 7. Khoo BC. Augmentation rhinoplasty in the Orientals. Plast Reconstr Surg 34:81-88, 1964. 8. Toriumi DM, Swartout B. Asian rhinoplasty. Facial Plast Surg Clin North Am 15:293-307, 2007. 9. Lam SM. Asian rhinoplasty. Semin Plast Surg 23:215-222, 2009. 10. Jung DH, Kim BR, Choi JY, et al. Gross and pathologic analysis of long-term silicone implants inserted into the human body for augmentation rhinoplasty: 221 revision cases. Plast Reconstr Surg 120:1997-2003, 2007. 11. Graham BS, Thi inger JK, Barrett TL. Nasal tip ulceration from infection and extrusion of a nasal alloplastic implant. J Am Acad Dermatol 44(2 Suppl):362-364, 2001. 12. Tham C, Lai YL, Weng CJ, Chen YR. Silicone augmentation rhinoplasty in an Oriental population. Ann Plast Surg 54:1-5; discussion 6-7, 2005. 13. Jackson IT, Choi HY, Clay R, et al. Long-term follow-up of cranial bone graft in dorsal nasal augmentation. Plast Reconstr Surg 102:1869-1873, 1998.

K23345_Pu_c36_Prim Closed Rhino_r4_cl_555-566.indd 566

4/3/2015 9:57:41 AM

37 Primary and Secondary Open Rhinoplasty

T

Hyunsoo Kim, Moohyun Paik, Lee L.Q. Pu

he   world is becoming increasingly smaller as a result of progress in transportation, communication, and information technologies. Despite racial, religious, and cultural differences, people’s aesthetic views are continuously converging. However, the nasal shape requested by patients whom we have encountered in our practice does not typically deviate from their ethnic identities. Compared with a decade ago, Asian patients now want a lower dorsal height and higher tip projection. They are interested in ideal proportions and contours of the forehead and chin, and they want a young and attractive Asian face, not a Westernized look. Asian rhinoplasty must start with an understanding of patient preferences based on the individual’s ethnic identity.

Anatomic Characteristics of an Asian Nose Compared with the noses of most people of European descent, a typical Asian’s nose generally has a thicker nasal skin–soft tissue envelope, higher tension, weaker lower lateral cartilage, and greater interdomal width. Mesorrhine and platyrrhine nasal characteristics are common1 (Fig. 37-1), and a low dorsum and thick sebaceous skin are often noted (Fig. 37-2).

Leptorrhine

Mesorrhine

Platyrrhine

Fig. 37-1  The nasal base may be classifi d as leptorrhine, mesorrhine, or platyrrhine.

567

568

Part V 

Primary or Secondary Rhinoplasty

Fig. 37-2  Fresh cadaver section of the nasal skin–soft tissue envelope of a Korean man in his late fi ies.

Type I: Interaxial angle of .41 degrees

Type IV: Round nostrils

Type III: 71-100 degrees

Type II: 41-70 degrees

Type V: 101-130 degrees

Type VI: 131-180 degrees

Type VII: .180 degrees

Fig. 37-3  Farkas classifi ation of nostril shape.

Typically, patients seek augmentation of these existing structures rather than reductive procedures.2 More Asians than white individuals have an anterior nasal spine with an acute columellar-labial angle resulting from hypoplastic development and a short, retracted columella.3 According to the classifi ation system of nostril types of Farkas et al,4 the nostril shape can be categorized based on the interaxial angle formed by the long axes of the nostrils (Fig. 37-3). By this classifi ation, as identifi d by Bae et al,5 the majority of Koreans have type II and III nostrils, which account for 29.4% and 38.8%, respectively. Thus, in 68.2% of Koreans, the angle between both long axes of the nostril is greater than 100 degrees. To address the various complex issues that originate from the characteristics of the Asian nose, surgical approaches should be selected that provide the surgeon with a fi ld of vision and convenient manipula-

Chapter 37 

Primary and Secondary Open Rhinoplasty

tion. Although columellar scarring after open rhinoplasty is a disadvantage in the Asian compared with the white European nose, the scar becomes so minimal 6 months after surgery that it is almost not visible.6-8 However, the surgical approach should be based on the patient’s concerns and not his or her ethnicity. The surgeon should consider whether these concerns can be resolved with a closed versus an open approach and whether the patient can tolerate any surgical scars. Few patients want only to raise their nasal dorsum or remove a dorsal hump; patients are increasingly interested in a harmonious relationship between the forehead, nasal dorsum, nasal tip, and alar columella. These patient complaints cannot be resolved by a closed approach. Furthermore, surgeons prefer open rhinoplasty because they can easily access the nasal tip and manipulate the nasal framework with an unobstructed view. In most Asian patients, the skin–soft tissue envelope, which consists of thick dermal and fat layers, tends to soften the contour of a relatively small skeletal framework. A thick skin–soft issue envelope is rarely found in white patients who visit our clinic.

NASAL TIP SURGERY IN ASIAN PATIENTS Many Asian noses have weak or small cartilages that make up the nasal tip and septum, and thick, inelastic skin–soft issue envelopes covering them. Although the lateral and medial crura of the lower lateral cartilage are fi mly attached to the piriform aperture and upper lateral cartilage, caudal nasal septum, and suspensory ligament by many ligamentous structures, the nasal tip cannot be aesthetically pleasing if the lower lateral cartilage is weak and the skin–soft issue envelope covering it is thick and heavy. Thus the surgical plan must include creation of the appropriate projection and implementation of rotation, defin tion, and position in the nasal tip. Because projection and caudal rotation are often insuffici t in an Asian nasal tip, the surgeon must use a procedure that can maintain the anterior projection and caudal rotation postoperatively. To achieve both of these goals, we prefer to use a fi ed-type strut rather than a fl atingtype strut. We have often observed that unless fl ating struts are used selectively, the nasal tip returns to its original position over time because of the movement of the nasal muscles and the effect of gravity on the skin–soft tissue envelope.9 Th s relapse occurs more often when an open approach is used, because it is more likely to damage the supporting structure of the nasal tip. When an open approach is used in Asian rhinoplasty, fi ed struts are advantageous because they maintain the nasal tip continuously in the desired position. Thus the most frequently selected procedure is the septal extension graft 10 Regardless of the patient’s ethnicity, if the lower lateral cartilage is of average strength and the caudal nasal septum, particularly the anterior septal angle, is sufficiently caudal, the projection can be satisfactorily increased with various suture techniques, including the crural septal suture (projection control suture), without the use of fi ed struts. However, in an Asian nose, because of the limited extensibility of the skin– soft tissue envelope, the projection of the nasal tip inevitably causes cephalic rotation of the nasal tip. Paik 11 solved this problem with an interposition graft of the conchal cartilage between the upper and lower lateral cartilages and a caudal rotation of the nasal tip (caudal rotation graft). To implement appropriate projection and defin tion, additional suture techniques, a tip graft, and an intercrural strut graft are necessary.

Surgical Technique for Nasal Tip Surgery Sutur e Techniq ues

Suture technique can adjust cartilage shape by strengthening its intensity without damaging it. Suture retention of cartilage shape is probably essential only during the fi st 6 to 8 postoperative weeks. After this initial period, the draped, reshaped skin–soft issue envelope acts as a “biologic cast” over the reshaped

569

570

Part V 

Primary or Secondary Rhinoplasty

framework, stabilizing the adherence and wound maturation process.12 Thus, because cartilage shape can be maintained even without sutures for up to 2 months, some surgeons recommend the use of an absorbable suture such as PDS to reduce the chances of knot exposure. Other surgeons recommend the use of a nonabsorbable suture to maintain the shape, because of the small possibility of knot exposure if the knot is placed in a safe position. Tapered, round-bodied suture needles are recommended to reduce damage to the cartilage. To obtain satisfactory results from Asian open rhinoplasty, surgeons should use suture techniques in a certain sequence. In an Asian nose, it is frequently not easy to use medial crural fix tion sutures, such as dome equalization and interdomal sutures, to establish a standard for initial dome projection symmetry. Because the medial crus is often narrow in an Asian nose, if medial crural fix tion sutures are used in advance, the space for the columellar strut becomes narrow, which presents another challenge. The standard point of the middle and medial crura is replaced by a gentian violet stain at the border between the lobular segment (middle crus) and columellar segment (medial crus) at both sides. The columellar-septal and medial crural–septal sutures between the lower lateral cartilage and septal cartilage are called the projection control sutures or tip rotation sutures, depending on their function. The suture point at the anterior border of the caudal septum is higher than the suture point of the medial crus, which increases the projection of the nasal tip complex. Th s is called an advancement projection control suture. In the opposite case, the lower lateral cartilage moves posterior, reducing the projection of the nasal tip complex. Th s is called the recession projection control suture. Th s suture can also correct a hanging columella. The fi st step of the columellar-septal suture technique is to anchor the 5-0 or 4-0 monofilament suture material at the dorsal septum (usually the anterior septal angle) (Fig. 37-4, A) and to pass it through both medial crura to the sites of the columellar segment of the medial crus, which is slightly posterior to the junction with the middle crus (Fig. 37-4, B and C). After appropriate tension is applied to the suture connecting the two points, the surgeon should press the nasal tip from above to ensure that the appropriate strength and height can be maintained. A knot is then made. After suture placement, care must be taken, because excessive pulling and knotting may cause a retracted columella. When correcting a hanging columella, the surgeon should suture only the cephalic portion of the medial crus of the site undergoing correction and apply appropriate tension to it. When also using a columellar strut, the surgeon should hook the sutures to an appropriate site of the caudal septal border, pull out the sutures at both sides from below, and insert the columellar strut between the two sutures. The surgeon must ensure that the sutures are positioned between the columellar strut and medial crus and that the sutures cover the columellar strut (Fig. 37-4, D). The surgeon should then make a knot (Fig. 37-4, E), apply tension, and adequately adjust the projection of the tip complex. Because all the steps of the suture technique must be completed before applying tension and knotting, the surgeon should pull and stretch out the ends of the suture threads that have passed through the medial crus and caudal septal border and fix the ends with tape on the operation fi ld.13 For additional projection and structural stability, bilateral spreading of the anterior portion of the strut graft nd shield graft may be helpful (Fig. 37-4, F). In most primary cases, these sutures can advance the tip complex anteriorly or posteriorly up to 3 mm without compression of the membranous septum (Figs. 37-4, G and H and 37-5, A through H).

Chapter 37 

Primary and Secondary Open Rhinoplasty

A

B

C

D

E

F

G

571

H

Fig. 37-4  Suture technique. A, Adequate exposure of the cartilaginous framework is a prerequisite for the suture tech-

niques. B, A 4-0 monofilament is usually anchored to the anterior septal angle. A dissection between the medial crura is not always necessary, because the membranous septum acts as a stop against the columellar base when the columellar-septal suture is placed under tension and creates a vector of cephalic retraction. C, From the anterior septal angle, both suture ends are passed through the membranous septum and out below the columellar segment of the medial crus. D, The strut graft is nestled between the suture ends. A separate suture is used to fix the strut graft to the medial crura, just anterior to the free ends of the long suture. Th s new crural strut construct provides an axis along which the anchoring point can be adjusted to control the degree of rotation and/or projection. E, The free suture ends are tied once over the caudal surface of the strut graft, and its tension is adjusted to control the projection and rotation of the nasal tip element. Th s new tip point is fi alized with a set of square knots. F, In this case, the anterior portion of the strut graft was flared over the middle crus, which provides a wide base for a shield graft G and H, The sutures provide 3 mm freedom of movement in either the posterior or anterior direction without compression of the membranous septum. Additional tip projection requires adjuvant skeletal remodeling with the use of various grafts

K23345_Pu_c37_Prim Sec Open Rhino_r5_dc_567-594.indd 571

4/3/2015 10:01:58 AM

572

Part V 

Primary or Secondary Rhinoplasty

Results

A

B

C

D

E

F

G

H

Fig. 37-5 Th s 34-year-old woman presented with a dorsal hump, drooping tip, vertical columellar groove, and hanging columella. She underwent a primary rhinoplasty, including septoplasty and suture technique (columellar-septal suture). Note the cephalic rotation of the nasal tip from the columellar-septal suture.13

Chapter 37 

573

Primary and Secondary Open Rhinoplasty

Caudal Rot atio n Graft

To correct the cephalically rotated dome to the caudal position, a piece of conchal cartilage is fashioned into an elliptical or rhomboid shape between the distal anterior septal border and lateral crus for use as a supporting structure. If there is a signifi antly retracted ala or any possibility of a pinched tip deformity when a weak lateral crus may turn to the medial side with a lateral crural–spanning suture, a cartilage graft is inserted between the lateral crus and dorsal septum or between the lateral crus and upper lateral cartilage to push the alar rim caudally. Graft aterials for a caudal rotation graft, i tercrural strut graft, nd shield graft are usually harvested from the cymba and/or cavum concha (Fig. 37-6), but cartilages from the septum are also effective. A caudal rotation graft is simple and effective and offers many advantages when septal cartilage cannot be used. However, because caudal rotation of the nasal tip decreases tip projection, an intercrural strut and a shield graft ith a projection control suture (columellar-septal suture) must be used together to maintain tip projection. For a short nose with a retracted ala, the alar rim that is supported by the lateral crus must be moved along with the dome in the caudal direction so that the retracted ala can be corrected. If a simple septal extension technique or caudal rotation graft is used in this case, the nasal tip will be extended in the caudal direction, and the nose will become longer, but the alar retraction will worsen. Instead, a wider caudal rotation graft can be designed and inserted between the lateral crus and upper lateral cartilage (Fig. 37-7). As a result, the alar rim will move in the caudal direction along with the dome, which simultaneously corrects the length and alar retraction.

A

B

C

D

Fig. 37-6  Caudal rotation graft A, The columellar-septal suture was used to obtain the desired amount of nasal tip

projection at the cost of cephalic rotation. B, The lower lateral cartilages are secured in a caudally rotated position with the cavum conchal or caudal rotation graft C, Anterior view of the caudal rotation graft; he graft s placed securely between the cartilaginous vault and cephalic margin of the lower lateral cartilages. D, One ear can provide three separate grafts i needed for total nasal tip remodeling. In this intraoperative photo the cymba and cavum concha were harvested from the same ear. The cymba concha was used as the intercrural strut graft (middle graft). The cavum concha was divided into the caudal rotation graft (top graft and shield graft (bottom graft (different patients).

574

Part V 

Primary or Secondary Rhinoplasty

Results

A

B

C

D

E

F

G

H

Fig. 37-7 Th s 36-year-old man who had an alloplastic implant had intermittent episodes of inflammation, with gradual contraction of the skin–soft issue envelope that led to secondary columellar retraction and cephalic rotation. During secondary rhinoplasty, the implant and surrounding capsule were completely removed. The ligamentous structures, including those in the scroll area, were dissected, which allowed the lower lateral cartilage to move freely in the caudal direction. A columellar-septal suture was used to maintain the amount of nasal tip projection. The nasal tip was fi ed caudally with a caudal rotation graft.

K23345_Pu_c37_Prim Sec Open Rhino_r5_dc_567-594.indd 574

4/3/2015 10:02:06 AM

Chapter 37 

575

Primary and Secondary Open Rhinoplasty

Sept al Extens io n Graft

When restructuring the lower lateral cartilage to create an aesthetically pleasing Asian nasal tip, the fi ed strut gives a more predictable result because it is less affected by the ligamentous structure, skin–soft issue envelope, gravity, and elastic recoil of the lower lateral cartilage. Th s strut also produces a stronger long-term result. The fi ed strut that we most frequently use in Asian rhinoplasty is a septal extension graft (batten type). The ideal septal extension graft aterial is septal cartilage (Fig. 37-8), but autologous rib cartilage is also used when a suffici t volume of nasal septal cartilage cannot be harvested.14 Irradiated homograft co tal cartilage is also used in primary rhinoplasty. However, the most important step of the septal extension technique is freeing the lower lateral cartilage from the ligamentous attaching structures around the caudal upper lateral cartilage (scroll area), piriform aperture, interdomal area, and membranous and caudal septa (Fig. 37-9). The key elements for successful nasal tip surgery are the complete dissection of the lower lateral cartilage from any adhesions in those areas and an adequate extension of the skin–soft tissue envelope.

A

B

Fig. 37-8  Septal cartilage extension graft A, A robust sep-

tal extension graft. Usually the cartilaginous septum is less than generous in Asian patients. Preservation of a structurally sound L-strut is the most important deterrent of stress-induced postoperative septal deviation. B, Septal extension techniques are effective in lengthening the columella and repositioning the nasal tip, especially in patients with a thick (that is, resistant) skin–soft tissue envelope.

A

Fig. 37-9  Septal extension in a patient with inadequate lower

lateral cartilage. A, The lower lateral cartilage is often significantly attenuated in patients undergoing revision. Despite this, the cartilages must be fully dissected to reduce the retractile force that transfers to and eventually deforms the remaining Lstrut and contributes to cephalic rotation of the tip. B, With adequate release, the lower lateral cartilages are free to signifi antly shift in the caudal and anterior directions. The tensionless movement allows simultaneous dorsal lengthening and caudal repositioning. Complete release of the lower lateral cartilages and skin– soft tissue envelope is a more signifi ant determinant of success than the choice or execution of various fix tion methods.

B

576

Part V 

Primary or Secondary Rhinoplasty

When a lower lateral cartilage is fixed to a septal extension graft that is attached to the septum, the surgeon should be attentive to the nasal tip contour after the skin–soft tissue envelope is covered. In particular, the alar-columellar relationship, columellar-lobular angle, columellolabial angle, philtral length, and nasal length must be carefully considered before deciding on the fixi g point (Fig. 37-10). • In the alar-columellar relationship, the vertical distance between the columellar-lobular angle and tipdefini g points is divided in half by a horizontal line at the highest point of the alar rim (Fig. 37-10, A). The columella should be 1 to 2 mm below the virtual line, connecting the anterior and posterior apex of the nostril to the caudal side (Fig. 37-10, B). • In the lateral view, the location of the columellar-lobular angle should be at the same level as the anterior apex of the nostril. A 35-degree angle or less is appropriate. Procedures that use fi ed struts should not emphasize the protrusion of the columellar-lobular angle. Compared with the effects from fl ating struts, the alar rim is pulled in the cephalic direction when smiling, whereas the columellarlobular angle does not move and the columella may appear to sag. Th s phenomenon may be more noticeable in patients of short stature (Fig. 37-10, C). • The appropriate nasolabial angle is 100 degrees for women and 95 degrees for men. Undercorrection is more tolerable than overcorrection in Asian patients. The nasolabial angle becomes larger during surgery but will become smaller once the swelling disappears after surgery (Fig. 37-10, D). • The philtral length, the distance between the subnasale and stomion, should be half that between the stomion and menton. Compared with the face of a young, average-looking Korean woman, the typical face of a more attractive Korean woman has a longer midface than lower face and a shorter distance between the stomion and menton in particular.15 • Assuming that the nasal length is the distance between the nasion and tip point, the ideal length is 0.67 times the midfacial length. The average nasal length of Koreans is 42.6 mm for men and 39.1 mm for women, but more attractive women have 5% more length than this15 (Fig. 37-10, E). • Based on the alar crease base and nasal tip from the lateral view, the ideal tip projection is 0.67 times the nasal length. The average tip projection of Koreans is 26.5 mm for men and 23.5 mm for women16 (see Fig. 37-10, E). A well-balanced lobular unit requires at least three points of fix tion in the lower lateral cartilages and a septal extension graft. First, to appropriately adjust the alar-columellar relationship, columellolabial angle, and philtral length, the suture should start from the inferior portion of the columellar segment of the medial crus near the footplate segment and reach the anterior end of the columellar segment. Second, to configu e the nasal tip point, the suture that starts from the inferior portion of the lobular segment of the middle crus and reaches the domal segment follows. In this step the columellar-lobular angle and the projection, rotation, and position of the nasal tip must be suffici tly considered. Finally, to adjust nasal tip defin tion by flaring or spanning the lateral crus of the lower lateral cartilage, the septal extension graft and lower lateral cartilages are sutured in the domal segment and the lateral crus in the direction of the width. In Asian patients undergoing secondary rhinoplasty, particularly for contracted short noses, both lower lateral cartilages are often weakened or partially lost because of multiple repeated surgeries (Fig. 37-11)and because other autologous cartilages, soft tissues, homografts, xenografts, or alloplastic materials have been grafted. Thus the surgeon must pay special attention to these situations. If both lower lateral cartilages with destroyed innate symmetry are not restored, the surgeon may encounter many unexpected postoperative problems. In addition, the symmetry of the alar rim and nostril may be broken.

Chapter 37 

Primary and Secondary Open Rhinoplasty

577

A

B

D

C

E

Fig. 37-10  The ideal in Asian rhinoplasty. A, In frontal view a tangential line drawn through the highest points of the

alar rims should divide the distance between the tip defini g point and columellar-lobular angle. B, In lateral profile the line connecting the anterior and posterior apex of the nostril should be equidistant between the nostril margin and columella. Th s off et distance is ideally 2 mm. C, The columellar-lobular angle should be at the same level as the anterior apex of the nostril. Angles of 35 degrees or less are ideal in Asian female patients. D, The ideal nasolabial angle is 100 degrees for women and 95 degrees for men. Asian patients tolerate undercorrection rather than overcorrection. E, The average tip projection is 23.5 mm for Korean women and 26.5 mm for Korean men. (From Kim SH, Whang E, Choi HG, et al. Analysis of the midface, focusing on the nose: an anthropometric study in young Koreans. J Craniofac Surg 21:1941-1944, 2010.)

K23345_Pu_c37_Prim Sec Open Rhino_r5_dc_567-594.indd 577

4/3/2015 10:02:09 AM

578

Part V 

Primary or Secondary Rhinoplasty

Results

A

B

C

D

E

F

G

H

Fig. 37-11 Th s 24-year-old woman with a history of alloplastic dorsal augmentation through endonasal access complained of implant margin demarcation, narrow middle vault width, supratip fullness, a high dorsum, and a drooping tip. These problems were addressed by implant removal, dorsal augmentation with a dermis fat graft, and a septal extension graft to control tip rotation and position.

K23345_Pu_c37_Prim Sec Open Rhino_r5_dc_567-594.indd 578

4/3/2015 10:02:13 AM

Chapter 37 

579

Primary and Secondary Open Rhinoplasty

A

B

C

D

E

F

G

H

Fig. 37-12 Th s young woman, who had a previous rhinoplasty operation, had a thick skin–soft issue envelope, a short and retracted columella, and a wide nostril angle. She wanted a more defi ed contour of the lobule while maintaining a soft overall image. A septal extension graft was used to achieve a nasal silhouette that closely approached the aesthetic guidelines. No dorsal augmentation was performed. She is shown 7 years after surgery.

K23345_Pu_c37_Prim Sec Open Rhino_r5_dc_567-594.indd 579

4/3/2015 10:02:17 AM

580

Part V 

Primary or Secondary Rhinoplasty

ALAR-COLUMELLAR DISCREPANCIES In the frontal view, the lobule, alar rim, and columella create a “gull-wing” shape at the caudal margin of the nasal tip in accordance with their respective anatomic characteristics (see Fig. 37-10, A). The position and angle of the columellar breakpoint created by the lobule and columella are also very important in the lateral and quarter views. The anterior margin of the nostril begins at the same level as the columellar breakpoint, namely, the columellar-lobular angle. The maximum distance from the long axis of the nostril to either the alar rim or columella should be 1 to 2 mm17 (see Fig. 37-10, B). The caudal edge of the lateral crus normally runs parallel to the alar rim for up to half the distance from the center of the nasal tip to the piriform aperture. The lateral half of the alar rim, which does not have cartilage, is supported by thick skin and fibrofatty areolar tissue with the anterior and posterior dilator naris muscle.18 As previously mentioned, many Asians have weak or small lower lateral cartilages and thick inelastic skin–soft issue envelopes covering them. Moreover, the cephalocaudal width of the lateral crus of Koreans is narrower than that of black or white individuals, and the distance from the caudal end of the lateral crus and nostril rim margin is longer in Korean nasal tips compared with those of black or white individuals.19 These data suggest that the anatomic characteristics of an Asian nose, in particular a Korean nose, are susceptible to alar retraction. Our personal clinical experiences with Asian alar retraction concur with these anatomic characteristics. Alar and columellar retraction are the most common alar-columellar discrepancies in Korean noses.

Surgical Technique for Alar-Columellar Discrepancies Al ar Extens io n Graft fo r a Retra cted Al a

The causes of alar retraction are divided into congenital and acquired factors (Box 37-1). An analysis of these factors largely reveals two types of developmental mechanisms. First, when the position or shape (convex or concave) of the lateral crus is changed and cannot support the alar rim, notching may occur, which can cause a retraction. Th s mechanism corresponds to overexcision, hypoplasia of the lateral crus, malposition in the medial cephalic direction, and a concave shape in the cephalocaudal direction. Second, the middle and medial crura are dragged too far in the posterocaudal direction, and the flex ble part of the alar rim is buckled from the lateral view, which also causes notching. Th s corresponds to septal overgrowth and overcorrection of the short nose deformity. The technique to correct retraction differs, depending on the cause, but a graft r a flap is needed to fill the gap between the retracted lateral crus and alar rim, except if there is malposition of the lateral crus and septal overgrowth. In general, a vestibular incision is performed parallel to the alar rim, the alar rim is moved caudally, and composite tissue is grafted to the resulting defect. The composite graft s approximately 10 to 20 mm by 5 to 10 mm, and the graft hould ideally consist of elliptical conchal cartilage and overlying skin. Furthermore, the cartilage thickness must be thinned to about 1 mm. Alar retraction may also be corrected with the use of an alar spreader graft, alar contour graft, or a lateral crural strut graft. e alar spreader graft an push down the alar rim from the cephalic direction to the caudal direction. By grafting cartilage between the upper and lower lateral cartilages and widening the gap between these two cartilages, the alar cartilage can move to the caudal direction (interposition graft)

Chapter 37 

581

Primary and Secondary Open Rhinoplasty

Kim and Roh20 exposed the lower lateral cartilage with an open rhinoplasty incision and made an alar extension graft c mposed of triangular cartilage. They then used an onlay graft in ront of the lower lateral cartilage to fix he medial end to the middle crus (Fig. 37-13, A and B). The lateral end was inserted and fi ed into the subcutaneous pocket that had been prepared in advance in the shape of a fi ger-in-groove (Fig. 37-13, C and D). Finally, they made a U-flap out of vestibular skin and used it as an advancement flap to correct the alar retraction (Fig. 37-13, E and F).

Box 37-1  Causes of Alar Retraction Congenital Factors • Lower lateral hypoplasia • Concave-shaped crus in the cephalocaudal direction • Cephalic malposition of the lateral crus • Overgrowth of the anterior septal angle

A

B

Acquired Factors • Excessive cephalic trim of the lateral crus • Overcorrection of short nose deformity

C

E

D

F

Fig. 37-13  Alar extension graft A and B, Conchal cartilage is harvested and divided into two triangular grafts, hich

are laid on top of the lower lateral cartilages. They are fi ed medially to the medial crus. Laterally, the ends are inserted into a subcutaneous pocket in the vestibular skin. C and D, The standard open rhinoplasty incision is modified bilaterally. Each limb of the incision incorporates a U-shaped flap and subcutaneous pocket. E and F, The lateral ends of the grafts are secured posteriorly within the subcutaneous pocket with button sutures. The lateral ends of the alar extension grafts insert into the subcutaneous pocket of this incision. Alar retraction is corrected by advancement of the U-shaped flap over the cartilaginous foil.

582

Part V 

Primary or Secondary Rhinoplasty

Results An alar extension graft s the procedure of choice when secondary rhinoplasty is performed on an Asian nose that has congenitally weak lateral crura or damaged or lost lateral crura, and the alar extension graft can give structural reinforcement to the lower lateral cartilage (Fig. 37-14). Furthermore, a lower lateral cartilage that has been structurally reinforced by a triangular cartilage graft cosmetically improves the shape of the nasal lobule in an Asian nose.

A

B

C

D

E

F

G

H

Fig. 37-14 Th s 38-year-old woman had severe alar deformities before and after her alar extension graft w s placed. She had an extensive history of rhinoplasties, with resultant destruction of the lower lateral cartilages. The preoperative anterior photo reveals notable nostril show and rim notching with a concomitant decrease in the vertical distance between the alar groove and rim. Alar-columellar retraction is shown from the lateral and oblique views. The alar extension graft eturned a signifi ant amount of biologic heft o the alar sidewall, and the septal extension graft plays a role in extending the columella.

Chapter 37 

Sept al Lengthening

Primary and Secondary Open Rhinoplasty

fo r Advancing the Col umell a

Columellar retraction in an Asian nose frequently creates an acute columellar-labial angle. When midface development is insuffici t, this phenomenon may resemble a dentoalveolar protrusion. Columellar retraction may be caused by congenital factors, including an insufficient caudal portion of the septal cartilage, underdevelopment of the premaxilla, and an anterior nasal spine in nasomaxillary hypoplasia (Binder syndrome) or the loss of the columella, membranous septum, and anterior nasal spine resulting from trauma, a scar contracture of the vestibular fl or, and an excessive septal resection. The most popular corrective maneuver for columellar retraction is to push the columellar base in the caudal direction with septal cartilage, conchal cartilage, or irradiated homograft co tal cartilage. In other words, the part between the middle and medial crura is dissected to expose the caudal border of the septal cartilage. A batten-type cartilage graft is inserted between the caudal septum and lower lateral cartilages and is fi ed by a mattress suture at the level of the middle septal angle; the columella is pushed in the caudal direction. At this point, the posterior edge of the batten graft is placed on the anterior nasal spine and fi ed with a figu e-of-eight suture or advanced more in the caudal direction to make the columellar-labial angle blunt. In severe caudal septal hypoplasia with a short, weak cartilaginous vault, which results in a high degree of columellar retraction, we fi d it optimal to apply a two-segment cantilever graft (Figs 37-15 and 13-16).

A

B

Fig. 37-15  A two-segment cantilever graft A, Costal cartilage is fashioned into dorsal (D) and lobular (L) components. The components are assembled in either a dovetail or dado joint. B, A cantilever graft in situ. The graft offers an excellent solution for patients who have both severe caudal septal hypoplasia and a diminutive cartilaginous vault.

583

584

Part V 

Primary or Secondary Rhinoplasty

Results

A

B

C

D

E

F

G

H

Fig. 37-16 Th s 22-year-old man with a congenital nasal deformity had congenital midfacial retrusion, hypoplasia of the hyaline cartilages, a low radix, a severely retracted columella, and hanging alae. The alar rim was reduced to redefi e the outermost nasal elements before the central features could be addressed. The twosegment cantilever graft i creased the overall height of the nose and provided a more defin tive contour of the lobular subunit. The lobular component provided the skeletal framework needed to reconstruct the lobular shape and caudally extend the columella. The postoperative photos show the columella in a much more caudal location, even 5 years after surgery.

K23345_Pu_c37_Prim Sec Open Rhino_r5_dc_567-594.indd 584

4/3/2015 10:02:26 AM

Chapter 37 

Primary and Secondary Open Rhinoplasty

Ma xill ar y Spine Impl ant fo r Col umell ar Retra ctio n

When the position, defin tion, and rotation of the nasal tip complex satisfy cosmetic standards but a retrusive columellar base with a slightly underprojected tip exists, it can be effectively corrected with a welltrimmed, triangular silicone block of an appropriate size as a maxillary spine implant (Fig. 37-17). In this case an intraoral approach is recommended. The caudal septum can be accessed by applying a 1.5 cm vertical incision 5 mm away from the upper mucolabial sulcus. The surgeon should position a triangular silicone implant at the posterior septal angle in the caudal margin of the anterior nasal spine and fix t to the caudal posterior border of the septal cartilage with a nylon 5-0 suture.18 The maxillary spine implant improves not only the columellar-labial angle but also slightly projects the nasal tip (Fig. 37-18). However, an L-type silicone implant, which is a dorsal implant connected to a long columellar leg at the distal end for columellar advancement and tip projection, is not recommended. Th s is because infections, extrusions, capsular contractures, and displacements, which are known as major complications of Asian augmentation rhinoplasty from an alloplastic dorsal implant, are caused by an overly large volume implant, which is stretched over the fi ed upper and middle vaults and flex ble lower third. However, these complications can be reduced by separating the alloplastic materials from the flex ble nasal tip and fixi g them to a fi ed unit.20-22

A

B

Fig. 37-17  A maxillary spine implant. A, Maxillary spine implants are supplied in 2 cm triangular blocks with a concave side. The silicone block is fashioned so that the concavity abuts the anterocaudal margin of the cartilaginous septum, and the remaining portion is trimmed to fit within the skin envelope of the columella. B, A mockup demonstration of implant location over the maxillary spine. The implant is introduced through the mucolabial sulcus and fi ed to the cartilaginous septum. Usually the depressor septi nasi muscle is detached from its origin, and a strip of this muscle is resected. The anterior spine is exposed on which the implant can be shaped, fitted, and secured with 5-0 nylon to the septum.

585

586

Part V 

Primary or Secondary Rhinoplasty

Results

A

B

C

D

E

F

G

H

Fig. 37-18 Before the implant, this patient was unhappy with the way her droopy nose drooped even more when she smiled. To address this concern, a cephalic rotation suture was used to add a cephalic vector to the resting position of the nasal tip. The maxillary spine implant was placed as described previously. Postoperatively, the patient’s nasal tip no longer droops when she smiles.

Discussion Suture techniques with a caudal rotation graft are very useful tools when performing Asian nasal tip plasties, but with some important caveats. As mentioned previously, when nasal tip position is changed to the caudal direction to correct a cephalic-rotated nasal tip, the projection of the nasal tip will inevitably be reduced because the skin–soft issue envelopes have limited extensibility. In this situation an additional

K23345_Pu_c37_Prim Sec Open Rhino_r5_dc_567-594.indd 586

4/3/2015 10:02:31 AM

Chapter 37 

Primary and Secondary Open Rhinoplasty

procedure may be necessary to augment tip projection, and suture techniques (projection control suture and crural-septal suture) are very useful maneuvers. In the Asian nose, however, because of deficient cephalic-positioned septal cartilage, projection control sutures are used to induce columellar base retraction. Patients with mild columellar retraction, who usually have a relatively well-developed middle septal angle, can be managed with a narrow and thick conchal cartilage onlay graft etween both medial crura at the level of the middle septal angle. In patients with an underdeveloped cephalic-positioned middle septal angle, a septal lengthening procedure is necessary to position the middle and anterior septal angles more caudally (Fig. 37-19). The septal extension graft s useful in extending the anterior and middle septal angles in a more antero­ caudal direction. Unfortunately, the size of the harvested graft may not be adequate in many patients (Fig. 37-19, A through C). In conjunction with the septal extension graft, uture techniques are helpful to augment projection. However, this additional projection may result in an increase in cephalic rotation (Fig. 37-19, D and E). The caudal rotation graft s the fi al piece of the puzzle that brings the nasal tip to the desired location and rotation (Fig. 37-19, F). The most frequent complication of suture techniques with a caudal rotation graft is the sagging of tip projection caused by loosening of suture tension or a stress rupture in the suture material over time. It is simple and easy to connect the anterior septal angle and posterior portion of the lower lateral cartilage by using a straight needle after an open rhinoplasty incision before the projection control suture is attempted again.

A

F

B

C

E

D

Fig. 37-19  A solution to the nasal tip problem in Asian patients. For some Asian patients with low projection, undesirable rotation, and an inadequate amount of septal cartilage, no single technique allows a surgeon to simultaneously control projection and rotation. An outcome that is aesthetically desirable and durable requires the use of multiple techniques.

587

588

Part V 

Primary or Secondary Rhinoplasty

During the past two decades, rhinoplasty surgeons in Korea have found that the septal extension graft is not as straightforward as previously believed. Complications on complications have helped us realize that the problem was not in the surgical technique. Rather, we failed to recognize the extreme differences between Asian and white cartilaginous septum. We have seen 10 mm plus L-struts gradually buckle under the weight of a thick skin–soft tissue envelope in several patients. Currently we think there are patients in whom we should never open the septal mucosa, no matter how small the proposed graft is. When the caudal portion of the septal cartilage is dislodged to one side of the maxillary crest, the cau­ dal septum between the anterior and posterior septal angles assumes an inclined I shape (septal tilt) (Fig. 37-20, A). When the caudal portion of the septal cartilage is accurately located on the maxillary crest, the septal cartilage may be overharvested, and the remaining L-struts might not have suffici t weight-bearing capacity and could be bent in a C or S shape (C or S, anteroposterior) (Fig. 37-20, C and E). In the former case the dislodged overlapped, caudal posterior portion of the cartilage is excised obliquely to shorten and restore its proper position. A nonabsorbable suture is then hooked to the periosteum or soft tissue of the anterior nasal spine, passed through the nasal septal cartilage, and pulled and fi ed with a figu e-of-eight suture. The fixi g method does not have to be a figu e-of-eight; the key is to shorten the vertical septal strut and stretch it to be straight (Fig. 37-20, B).

A

B

E

F

C

D

Fig. 37-20  Septoplasty before extension graft in patients with a preexisting deviation. A, A signifi ant amount of the caudal septal tilt does not allow straight and upright septal extension. B, Repositioning of the posterior caudal septum with a figu eof-eight suture provides a straighter base for the septal extension graft C, C-shaped anteroposterior deviation. D, C-shaped anteroposterior deviation was corrected with scoring and/or a batten graft E, S-shaped anteroposterior deviation. F, S-shaped anteroposterior deviation was corrected with scoring and a reinforcing strut graft

Chapter 37 

Primary and Secondary Open Rhinoplasty

In the latter case, multiple shallow scoring incisions are applied to the concave surface of the bent cartilaginous vertical strut and reinforced with a batten graft (Fig. 37-20, D and F). Our alar extension graft is designed to reasonably correct the alar notching that often occurs in the weak lower lateral cartilage of Asian patients. When a small cartilage graft is transplanted to the superfic al surface of the lateral crus, it is possible to have a visible step-off at the anterior end of the graft. We rarely have visible step-offs with our alar extension grafts because the graft is large enough to cover the entire medial half of the lateral crus. Also, the distance between the graft and skin is maintained by a shield graft in the anterior rim area, where visible step-offs are often noted. Another factor that conceals visible step-offs is the comparatively thick skin covering this area. In all patients the blood supply of the vestibular U-flap was not compromised, even though flap base dissection was extended to the dermal level of the caudal rim, and the use of the U-flap resulted in successful healing without any complications. The framework of the lobule that was reinforced by the grafted cartilage changed the concave ala to an equilateral triangle in worm’s-eye view. A maxillary spine implant is an effective way to correct the retracted columella and has the additional advantage that tip complex augmentation can be performed at the same time. Because the depressor septi nasi muscle is also accessible through the operative fi ld, it can more assertively correct tip drooping. However, this procedure attaches the implant to the caudal nasal septum, and the results are inevitably affected by the status of the anterior nasal spine and posterior septal angle. Thus this procedure is not recommended if the septum is dislocated and/or deviated. Because a voluminous maxillary spine implant can result in a bulging mass at the membranous septum and an unnatural smile by pushing down the orbicularis oris muscle, the implant should be about 5 to 7 mm thick. Infection or extrusion of the implant is a rare complication.

Pearls for Success • A suture technique is effective only when the lower lateral cartilage is strong enough to withstand the tension from the suture materials. Thus it works when the proper indications are present. • To achieve a successful result, it is important to position the anterior septal angle properly; the angle should be suffici tly anterior and caudal. • It will take trial and error during surgery to obtain the appropriate projection and rotation. • The scroll area should be completely released between the upper and lower lateral cartilages. • The thick portion of the conchal caudal rotation graft is fixed to the lower lateral cartilage, and the opposite thin portion of the caudal rotation graft is fi ed with a 6-0 or 5-0 nylon suture to the transverse portion of the upper lateral cartilage at the level of the midvault. • Oversized septal harvesting is extremely dangerous in an Asian nose because of its limitation of septal stiffness compared with a white nose. Preserving an adequate amount of the L-strut is essential. • Caudal septal deviation influences the fi al result of a septal extension technique. Specifi ally, the caudal septal tilt makes the columella slant. Thus a preoperative caudal septal examination is also essential. • Overcorrection, which occurs more frequently, is less tolerable than undercorrection after the septal extension technique. • Dissection to create the vestibular subcutaneous pocket needs to extend as far caudal as possible. • The lateral end of the alar extension graft s inserted deeply into the subcutaneous pocket and secured with a pull-out suture. • When the septal extension graft s set up in advance, the alar extension graft an fix he alar retraction more effectively.

589

590

Part V 

Primary or Secondary Rhinoplasty

Expert Commentary Susumu Takayanagi Rhinoplasty is a popular cosmetic procedure in Asia. To successfully perform rhinoplasty on Asians, the surgeon must know the features of Asian noses and the desires and expectations of the Asian patient. For example, most Asian noses are wide; in addition, Asian noses may be short, have low projection, and have fi m and thick nasal skin. Various techniques can be used to create the beauty of Asian noses, including augmentation rhinoplasty, the correction of broad tips, elongation of the nose, and alar base reduction.

Closed Versus Open Rhinoplasty Most Asian rhinoplasties, especially for dorsal augmentation, can be performed through a closed approach. However, if additional corrections of the nose are planned, many surgeons prefer an open rhinoplasty approach, because a more precise procedure can be accomplished through an open method. If open rhinoplasty is selected, it is important for the surgeon to evaluate the quality of the skin before surgery. Patients who have white, red, or oily skin are good candidates for open rhinoplasty, because the scar will not be visible. When the patient has atopic dermatitis, asthma, or dark and dry skin, the scar often tends to be hypertrophic or have pigmentation. Care should be taken if open rhinoplasty is used in these patients. There are several types of incisions used in open rhinoplasty. For most open rhinoplasty surgeries, I prefer to use the flying-bird incision (Fig. 37-21, A). When pinching the nasal tips with fi gers shows the bulging skin anterior to the nostril, such as a small dog-ear deformity, a small amount of that skin should be removed after open rhinoplasty to create a smooth skin surface (Fig. 37-21, B). When this type of incision is used, however, the scar sometimes shrinks and the notch of the scar may eventually become visible.

A

B

Fig. 37-21  A, The flying-bird incision, my preferred open rhinoplasty incision. B, When pinching the nasal tip shows the bulging of the skin anterior to the nostril, a small amount of that skin should be removed to create a smooth surface.

Augmentation Rhinoplasty One of the most popular techniques that surgeons use for Asian noses is augmentation rhinoplasty. The procedure for augmentation rhinoplasty alone is usually performed through a closed approach. However, open rhinoplasty may be required if other techniques are combined. An I-shaped or L-shaped silicone prosthesis is most commonly used for augmentation rhinoplasty. However, when an L-shaped prosthesis is used in some patients, infection and pressure necrosis may occur at the nasal tip (Fig. 37-22).

Chapter 37 

Primary and Secondary Open Rhinoplasty

Fig. 37-22  When an L-shaped prosthesis is used, pressure necrosis at the nasal tip may occur.

When performing augmentation rhinoplasty, I prefer to use an I-shaped prosthesis. However, I will use a scar tissue graft or augmentations of less than 2 mm or diced ear cartilage wrapped with fascia for augmentations of more than 3 mm. The width of the undermining of the nose can be exactly the same as the width of the prosthesis, which is as narrow as possible, and the subcutaneous tunnel should be stretched only in a vertical direction for placement of the graft. lso, it is important that the superior part of the prosthesis be placed beneath the periosteum. To avoid upper or lower movement of the prosthesis, tape should remain affixed for 5 days after surgery. Patients should be instructed to look for early signs of infection, such as redness or erythema of the whole nose or part of it. If the patient notices infection, he or she should immediately consult his or her surgeon.

Correction of Broad Nasal Tips To correct broad nasal tips, I prefer to use open rhinoplasty. Although there are several techniques used for nasal tip surgery in Asians, I prefer to sever the cartilage in the nose to achieve an effective result. When the patient prefers a slight nasal tip projection, a 2 to 3 mm wide portion of cartilage should be removed in the dome area (Fig. 37-23, A). When the patient desires a greater nasal tip projection, lateral crura should be cut laterally and combined in the midline (Fig. 37-23, A through C).

A

B

C

Fig. 37-23  A, When the nasal tip projection requires a slight correction, a 2 to 3 mm wide section of cartilage should be removed in the dome. B, When the technique requires a greater nasal tip projection, the lateral crura should be severed and the medial parts sutured in the midline. C, By combining the cartilage in the midline, the surgeon can create more projection in the nasal tip.

591

592

Part V 

Primary or Secondary Rhinoplasty

After the surgery, the surgeon can create a narrow nasal tip by starting sponge fixation between 3 and 6 days after surgery. The patient should be instructed to use sponge compression for 3 months after surgery (Fig. 37-24).

A

B

Fig. 37-24  A, After the surgery, sponge fix tion is used to create a narrow and smooth nasal tip. B, If slight supratip bulging becomes visible, another small sponge is used to create a smooth supratip.

Correction of Short Nose Deformity Some Asian patients have a short nose, so sometimes it is necessary to perform surgery to elongate the nose. When the change is less than 2 to 3 mm, then the nasal tip can be elongated by using the curved cartilage covered with dermis, or diced cartilage wrapped with fascia or an absorbable suture. Th s technique can be performed through closed rhinoplasty. The round-shaped graft r curved cartilage covered with dermis should be sutured by absorbable 6-0 sutures, and one or two stitches should penetrate the nasal tip skin and be fix ted by skin closure. Th s suture should be cut at the surface level of the skin 4 or 5 days after surgery. To create the desired shape of the nasal tip, the surgeon must advise the patient to use tape fix tion or sponge fix tion for 3 weeks when they are at home. If the patient needs more than 2 to 3 mm elongation of the nose, I prefer to perform open rhinoplasty. Two ear cartilage grafts should be harvested from both ears and then be sutured together. After suturing the ear cartilage, the surgeon overlaps the superior part of these cartilages with the lower part of the septal cartilage to elongate the nasal tip downward (Fig. 37-25).

A

B

Fig. 37-25  A, Harvested ear cartilage from both ears. B, Combined ear cartilage grafts are fix ted to the lower edge of the septal cartilage.

Chapter 37 

Primary and Secondary Open Rhinoplasty

Alar Base Reduction Some Asian patients have a wide alar base, which is best corrected through reduction. When the lobule itself is very round and curved, only a part of the lobule can be removed to make it smaller, in which case the shape and size of the nostril are not changed (Fig. 37-26, A). If the alar base is too wide, the skin of the nostril fl or should be removed together with the lobule so that the alar base width can be reduced. It is important to undermine the lateral side of the skin incision to allow easy movement of this area toward the midline. I also use a 4-0 nylon straight suture to fix te both sides of the alar base (Fig. 37-26, B).

A

B

Fig. 37-26  A, When the lobule is large, only a part of it can be removed (shaded area). Th shape

and size of the nostril are not changed. B, When the alar base is too wide, the skin of the nostril fl or should be removed together with the lobule (shaded area).

Management of Complications Infection of the prosthesis may occur after surgery. The infection rate among my patients is 0.7%. The first sign of infection is redness of the skin surface. When the redness is visible, antibiotics should be given for 2 to 3 weeks. If the redness becomes more notable and swelling and/or pain occurs, the prosthesis may have to be removed. After the prosthesis is removed, it is important to slightly compress the nose with tape for 1 week to prevent the nose from shortening, because inflammation of the wound in the nose causes the nose to shrink. The prosthesis can be inserted again 3 months after it is removed. When asymmetry of the prosthesis position occurs, the position of the prosthesis can be corrected when the swelling of the nose is no longer visible, which is usually several weeks after the surgery. To fix te the prosthesis in the midline, tape should be fix ted for 5 or 6 days after the surgery; in addition, for 1 month, patients should be instructed to apply the tape with sponge or gauze to keep the nose straight when they are at home. When deformity of the grafted ear cartilage for the elongation of the nose occurs, the correction should wait at least 2 to 3 months. To correct the deformity, open rhinoplasty should be performed and part of the grafted cartilage should be cut; if necessary, this small piece of cartilage can be grafted to create a straight nasal tip.

593

594

Part V 

Primary or Secondary Rhinoplasty

Refer ences 1. Aung SC, Foo CL, Lee ST. Th ee dimensional laser scan assessment of the Oriental nose with a new classification of Oriental nasal types. Br J Plast Surg 53:109-116, 2000. 2. Toriumi DM, Pero CD. Asian rhinoplasty. Clin Plast Surg 37:335-352, 2010. 3. Song IC. Changing concepts in cosmetic rhinoplasty in Orientals. Probl Plast Reconstr Surg 1:572-581, 1991. 4. Farkas LG, Kolar JC, Munro IR. Geography of the nose: a morphometric study. Aesthetic Plast Surg 10:191-223, 1986. 5. Bae TH, Yu YG, Kim WS, et al. Anthropometry of nose in Korean twenties. J Korean Craniofacial Surg 10:61-66, 2009. 6. Taylor SC. Skin of color: biology, structure, function, and implications of dermatologic disease. J Am Acad Dermatol 46(2 Suppl Understanding):S41-S62, 2002. 7. Fitzpatrick TB. The validity and practicality of sun-reactive skin type I through VI. Arch Dermatol 124:869-871, 1988. 8. Park CY, Kim YB, Hong SP. Corrective rhinoplasty through open rhinoplasty technique. J Korean Soc Plast Reconstr Surg 14:573-581, 1987. 9. Westreich RW, Courtland HW, Nasser P, et al. Defini g nasal cartilage elasticity: biomechanical testing of the tripod theory based on a cantilevered model. Arch Facial Plast Surg 9:264-270, 2007. 10. Byrd HS, Andochick S, Copit S, et al. Septal extension grafts: a method of controlling tip projection shape. Plast Reconstr Surg 100:999-1010, 1997. 11. Paik MH, Chu LS. Correction of the short nose using derotation graft. Arch Aesthetic Plast Surg 18:35-44, 2012. 12. Tebbetts JP. Shaping and positioning the nasal tip without structural disruption: a new, systemic approach. Plast Reconstr Surg 94:61-77, 1994. 13. Paik MH. Suture techniques in Asian rhinoplasty. Unpublished manuscript, 2006. 14. Kim HS. Contracted nose. In Korean Society of Rhinoplastic Surgeons. Current Trends in Asian Rhinoplasty: Operation Guide. Seoul: Koonja Publishing, 2011. 15. Lee JS, Kim KH, Kim YW. Anthropometric analysis of the attractive and normal faces in Korean female. J Korean Soc Plast Reconstr Surg 31:526-531, 2004. 16. Kim SH, Whang E, Choi HG, et al. Analysis of the midface, focusing on the nose: an anthropometric study in young Koreans. J Craniofac Surg 21:1941-1944, 2010. 17. Gunter JP, Rohrich RJ, Friedman RM. Classification and correction of alar-columellar discrepancies in rhinoplasty. Plast Reconstr Surg 97:643-648, 1996. 18. Rohrich RJ, Raniere J, Ha RY. The alar contour graft: correction and prevention of alar rim deformities in rhinoplasty. Plast Reconstr Surg 109:2495-2505, 2002. 19. Dhong ES, Han SK, Lee CH, et al. Anthropometric study of alar cartilage in Asians. Ann Plast Surg 48:386-391, 2002. 20. Kim HS, Roh SG. The alar extension graft for retracted ala. J Korean Soc Plast Reconstr Surg 36:66-74, 2009. 21. Flowers RS. Augmentation maxilloplasty. In Terino EO, Flowers RS, eds. The Art of Alloplastic Facial Contouring. St Louis: Mosby–Year Book, 2000. 22. Kim HS. Dorsal augmentation in secondary rhinoplasty. J Korean Soc Aesthetic Plast Surg 14:79-98, 2008.

K23345_Pu_c37_Prim Sec Open Rhino_r5_dc_567-594.indd 594

4/3/2015 10:02:37 AM

38 Secondary Cleft Rhinoplasty

C

Philip Kuo-Ting Chen

left rhinoplasty remains a challenging task for plastic surgeons. However, primary correction of cleft lip nasal deformities has improved signifi antly over the past two decades; today presurgical nasoalveolar molding provides surgeons with a more favorable condition at the time of primary repair. Treatment results have improved as surgeons have gained a better understanding of the pathologic factors of the cleft nose and refi ements in surgical techniques.1-7 In contrast to cosmetic rhinoplasty, which mainly involves changing height, width, and contour of the central portion of a symmetrical nose, the difficulty in cleft hinoplasty is the asymmetry resulting from tissue deficie cy and tissue distortion between the two sides of the nose. Th s tissue deficie cy and distortion involve all components of the nose: the tissue coverage, support, and lining. The deficie cy and distortion of tissue not only make correction difficult, but also cause a signifi ant rate of relapse after surgery. Nevertheless, because of the improvements in modern cosmetic rhinoplasty, patients and their families expect a good result from cleft hinoplasty. Th s expectation has compelled surgeons to operate on some relatively minor deformities that were deemed acceptable 20 years ago. In my opinion, the typical minor deformities include mild asymmetry in nostril shape and size, mild deviation of the columella, and mild irregularity in the nasal dorsum.

Pathology The pathology of secondary unilateral cleft nasal deformity has been well documented. The problems that still need to be addressed are as follows8-11: • Depressed alar rim and alar dome • Kinking of the alar rim with a classic groove (Fig. 38-1, A and B) • Laterally and downwardly displaced alar base with a flared alar-facial groove • Deficie t nasal fl or • Deviated columella • Webbing on the soft triangle • Deviated or crooked nasal dorsum • Deviated nasal septum • Hypertrophic turbinate • Sagittally deficie t maxilla under the alar base

595

596

Part V 

Primary or Secondary Rhinoplasty

A

B

Fig. 38-1  Classic cleft asal deformity. Preoperative assessment of a patient with left econdary cleft l p and nasal deformity. The left ala and alar base are vertically and sagittally depressed, and the nasal dorsum is deviated.

Indications The primary indications for nasal revision are to address the cosmetic, structural, and psychological concerns of the patient and his or her family. In my surgery center, presurgical nasoalveolar molding and primary nasal correction are routinely used at the time of primary cleft lip repair. With improved results, secondary nasal revisions are seldom required in preschool-age children, because most of these patients can go to kindergarten or primary school without being teased by their peers. The second factor to be considered for nasal revision is the cooperation of the patient. The youngest age at which a patient can be cooperative with his or her postoperative care is approximately 4 to 5 years of age. The third factor for nasal revision is the residual skeletal imbalance between the alar bases. Nasal revision should be delayed until after alveolar bone grafting and orthodontic alignment of the dental arch have been performed. If maxillary retrusion is present, a nasal revision alone will not achieve the best possible result because of the poor facial profile. To achieve the optimal result in these patients, nasal revision should be postponed until after orthognathic surgery when the patient reaches skeletal maturity. However, if peer group pressure and teasing surpass these considerations, this guideline must remain flex ble, and revision can be considered at any time before skeletal maturity. The last factor to consider is the expectations of the patient and his or her family. As with other cosmetic surgeries, an unrealistic expectation is a contraindication for surgery.

Preoperative Assessment The cooperation of the patient and his or her caregivers is a key factor in the success of a nasal revision and must be secured at each step. Preoperatively, the surgeon must carefully evaluate the patient to determine the pathology of his or her secondary deformity, and the corrective technique chosen should ideally address this deformity anatomically. Secondary cleft lip and nasal deformities are closely related to the skeletal base. Their revision should logically occur at the conclusion of the whole treatment protocol or at least after the correction of the skeletal base. The only exception should be when there are psychological considerations in preschool-age or school-age children.

K23345_Pu_c38_Sec Cleft Rhino_r5_cl_595-610.indd 596

4/3/2015 10:09:27 AM

Chapter 38 

597

Secondary Cleft Rhinoplasty

The surgeon must also assess the relationship between the lip and the nose. The position of the alar base is determined by the position and direction of the orbicularis oris muscle after the initial repair. A laterally and downwardly displaced alar base can only be repositioned by a “re-repair” of the lip rather than any minor revision on the alar base. The surgeon should determine whether the patient has a deviated nasal septum and a hypertrophic inferior turbinate. Although the main goal for cleft hinoplasty is to improve the patient’s appearance, producing a functional improvement should also be considered whenever possible.

Surgical Technique Lip Revis io n

As previously mentioned, a laterally and downwardly displaced alar base can only be repositioned through a re-repair of the lip. The key factor for a favorable outcome with lip revision is that the previous lip scar should be excised to mobilize and reposition the displaced alar base through reorientation of the orbicularis oris muscle. The alar bases must be symmetrical in their vertical, horizontal, and even sagittal positions before proceeding to formal rhinoplasty12 (Fig. 38-2).

Na sal Revis io n

Although descriptions of numerous revision procedures have been published, few of them are focused on the restoration of normal nasal anatomy, and the minor revision procedures will only be effective for some minor deformities. For all but the most minor deformities, I prefer an open rhinoplasty approach.12-15 Th advantages of open rhinoplasty have been advocated in many articles and include the excellent exposure, good hemostasis, and flex bility of this procedure in combining many corrective procedures.

The Incision The columellar incision should be placed at the midcolumella to avoid any potential tissue necrosis in the lower columella. Th s is a more signifi ant issue in whites than in Asians, because the columellar length is shorter in Asians. The columellar incision can be designed in many ways: as a transverse incision, a stepped incision, a V-shaped incision, or an inverted V-shaped incision. The resulting scar for each incision is

A

B

C

Fig. 38-2  Lip revision. A, Preoperative assessment of this patient showed a right secondary cleft l p and nasal deformity. The right ala and alar base are vertically and sagittally depressed, and the nasal dorsum is deviated. B, Basal view of the same patient. C, The alar base was repositioned through a lip revision with adequate mobilization of the alar base.

598

Part V 

A

Primary or Secondary Rhinoplasty

B

Fig. 38-3  The incision lines of the open rhinoplasty. A, The cleft-side incision is a reverse-U incision matching the alar

rim on the noncleft side. The incision line on the noncleft side nostril is for an infracartilaginous or rim incision. B, Basal view of the incision lines for an open rhinoplasty.

Fig. 38-4  The extent of dissection: symmetrical exposure of the LLCs, ULCs, and nasal bones.

similar if the incision is fresh. However, for secondary or tertiary open rhinoplasty, a purely transverse incision should be avoided, because a transverse scar tends to be depressed and more visible. The columellar incision is then extended behind the columella and upward. It continues as an infracartilaginous incision or rim incision on the noncleft side. On the cleft side, a reverse-U incision is made on the dome area if there is webbing on the soft riangle, or an infracartilaginous or rim incision is made if the position and shape of the alar rim are similar to that of the noncleft side. The incision continues into the vestibulum. The reverse-U should be made to match the alar rim on the noncleft side, and it continues into an infracartilaginous or rim incision in the nasal vestibulum (Fig. 38-3).

The Dissection The dissection should begin at the columella, where it is easier to achieve a clear dissection and to fi d the loose areolar space between the medial crura in the columella. Once the intercrural space is found, dissection can easily progress through this space upward along the lower lateral cartilages (LLCs) to separate the tip of the fibrofatty tissue from the LLCs. The extent of the dissection must be symmetrical to ensure symmetrical scar contracture postoperatively. The dissection should reach the piriform rim laterally and the nasal bones superiorly. The dissection plane is above the perichondrium on the LLCs and the upper lateral cartilages (ULCs) and under the periosteum on the nasal bones and the frontal process of the maxilla. Any asymmetry of the LLCs and ULCs or deviation of the dorsum can be clearly seen after this dissection (Fig. 38-4).

Chapter 38 

Secondary Cleft Rhinoplasty

Fig. 38-5  Any lining deficiency should be checked on the cleft side using a single hook placed on the dome of the cleftside alar dome.

Fig. 38-6  Release of the lining deficie cy by further dissection laterally to release the fascia of the nasalis muscle.

Correction of a Lining Deficiency Any lining deficie cy is evaluated by placing a hook on the dome of the cleft-side LLC. By pulling the hook upward, the tightness on the vestibulum can be assessed (Fig. 38-5). With my technique in primary nasal correction, mucosal flaps—the inferior turbinate flap and the L-flap—are used for nasal reconstruction; thus a lining deficie cy is seldom a problem in secondary cleft hinoplasty. However, if the primary lip repair failed to solve the lining defi iency on the floor and lateral wall of the cleft-side nostril, the tightness of the vestibular skin and mucosa will prevent adequate repositioning of the LLC on the cleft side. The fi st step to correct the tightness of the vestibular skin and mucosa is to release the fascia of the nasalis muscle laterally in the piriform area. Th s can often correct a mild tissue deficie cy or a mild scar contracture in this area (Fig. 38-6). For moderate tissue deficie cy, an unequal Z-plasty or a Potter’s VY-plasty can be considered. In an unequal Z-plasty a triangular skin flap from the nasal vestibulum between the alar rim and infracartilaginous incision is used. The triangular flap is then transposed 90 degrees inward to a backcut at the lateral end of the lateral crura parallel to the piriform rim. The Potter’s VY-plasty advances the LLC medially by making a V-incision at the lateral end of the lateral crura and advancing it medially to close as a Y. The Potter’s VY-plasty can provide a better correction of the lining deficie cy than the unequal Z-plasty; however, Potter’s VY-plasty tends to pull the lateral alar rim more cephalically after wound closure, because a VY closure narrows the depth of the nasal vestibulum. For severe tissue deficiency in this area, the best solution is to use tissue from the inferior turbinate, which is easy to access by reopening the lip. The cleft-side in erior turbinate is usually hypertrophic and can provide ample tissue for the

599

600

Part V 

Primary or Secondary Rhinoplasty

release of severe lining deficie cy in this area. Reduction of the hypertrophic turbinate is also helpful for correcting a nasal obstruction.

Correction of the Nasal Framework After correction of the soft tissue deficiency, the cleft-side LLC can be easily advanced to match that of the noncleft side. An interdomal suture can be placed to maintain the cleft-side LLC in its new position. However, a columellar strut can better maintain the cleft side LLC in its corrected position and prevent relapse (Fig. 38-7). The cartilage used for this internal splinting must be of suffici t strength to counteract the deforming forces in the cleft nose. Conchal cartilage is usually not strong enough for internal splinting in cleft rhinoplasty. Septal cartilage can be used in white patients, but rib cartilage should be considered in Asian patients, because the size of the septal cartilage is usually not adequate for a columellar strut (Fig. 38-8). The symmetry of the alar domes should be reevaluated after insertion of a columellar strut and repositioning of the LLC on the cleft side. Some residual depression on the cleft side can be further corrected through insertion of an onlay cartilage graft A nasal osteotomy should be considered if there is any signifi ant deviation of the nasal bone. The osteotomy can be easily done in combination with an open rhinoplasty. Because the soft tissue is already separated from the nasal bone in an open rhinoplasty, I prefer to keep the central part of the nasal dorsum intact and only perform a lateral nasal osteotomy (Fig. 38-9). Th s approach generally requires an infracture on the noncleft side and an outfracture on the cleft side to straighten the dorsum. A signifi antly de-

Fig. 38-7  Repositioning of the cleft-side LLC with insertion of a columellar strut.

A

B

Fig. 38-8  A, A rib cartilage graft arvested from either the seventh or eighth rib. B, From left o right: alar rim graft batten graft, and columellar strut.

Chapter 38 

Secondary Cleft Rhinoplasty

A

B

C

D

Fig. 38-9  A, Markings for a nasal osteotomy. B, Osteotomy lines on the left sid . C, The osteotomy lines on the right side. Note the intact central strut on the central dorsum. D, The result after the nasal osteotomy.

Fig. 38-10  The alar rim graft and the columellar strut.

viated nasal septum must be straightened through a submucous resection and scoring of the remaining dorsal portion of the septum to correct the nasal airway.

Reshaping the Tip and Ala Defatting of the excess fibrofatty tissue in the tip is often necessary in Asians. Cartilage grafts can then be used to reshape the tip, which is also done in cosmetic rhinoplasty for a noncleft patient. Various tip grafts, such as a shield graft nd an umbrella graft, an be used to improve the shape of the nasal tip. Whenever the dorsum is short with excessive nostril show, a septal extension graft or batten graft is used to push the nasal tip caudally for lengthening of the nose. A piece of cartilage graft laced along the cleft-side lar rim—not on top of the cleft-side LLC—is very important to eliminate the residual kinking or notching of the cleft-side alar rim and to better correct the shape of the alar rim (Fig. 38-10).

601

602

Part V 

Primary or Secondary Rhinoplasty

Dorsal Augmentation Dorsal augmentation is a very useful adjunctive procedure in cleft rhinoplasty to improve the shape of the dorsum and to provide a camouflage effect for the residual tip and nasal deformity. Autologous tissue is always the preferred choice of material for augmentation, because I have found that silicone implants have an unacceptably high extrusion rate. Calvarial bone has been recommended by several surgeons for augmentation, based on its low resorption rate when rigidly fixed. However, even when rigidly fixed, calvarial bone still has the risk of asymmetrical resorption on its two sides. Graft d viation is also difficult to correct in the presence of rigid fix tion. Rib cartilage graft, although less problematic in terms of resorption, has the disadvantage of having a high rate of graft w rping. Several ideas have been proposed to prevent warping using internal K-wires or differential carving of the cartilage graft nd then waiting for a period of time before putting the graft i to the nose; however, none of these techniques truly eliminates the unpredictable warping phenomenon. The use of the Turkish delight technique has increased, and I have adopted it with diced cartilage graft for augmentation. The diced cartilage graft an achieve a much higher rate of stable and pleasing results in dorsal augmentation compared with the whole-piece cartilage graft; herefore the diced cartilage graft s more useful in correcting mild asymmetry and irregularity of the nasal dorsum. 14,15 The original Turkish delight technique has been modifi d to use pure diced cartilage, which is inserted into a 1 cc syringe through a suction device (Fig. 38-11).The diced cartilage can be easily injected into the subperiosteal pocket through these 1 cc syringes (Fig. 38-12). The diced cartilage can be manually reshaped to the desired height

Fig. 38-11  Diced cartilage graft in 1 cc syringes.

A

B

Fig. 38-12  A, Dorsal augmentation through a diced cartilage graft in a ubperiosteal pocket above the intact central dorsal strut after a nasal osteotomy. B, Injection of the diced cartilage graft into the subperiosteal pocket.

Chapter 38 

Secondary Cleft Rhinoplasty

Fig. 38-13  The shape of the nasal dorsum can be changed with manual molding.

and width and even the desired curvature (Fig. 38-13). The shape of the graft can still be manually molded after surgery for approximately 1 to 3 months, enabling the surgeon to have better control of the fi al appearance. The main disadvantage of a diced cartilage graft is the prolonged swelling of the nasal tip, which can last for 2 to 3 months after surgery.

Redraping of Soft Tissue After correction of the lining and framework, the skin is carefully redraped. Usually the soft tissues will adequately stretch and redrape over the rib or septal cartilage columellar strut, which is robust enough to maintain the tip projection. The webbing at the soft riangle should be accurately trimmed to avoid any residual deformity in this area.

Balancing the Nostrils The nostril width should be reevaluated after the previous procedures have been performed. It is not uncommon for a patient to have a wider nostril on the cleft side, even after a lip revision. The alar base on the cleft side must be advanced medially to balance the width of the nostrils. Th s can be achieved by a simple YV-plasty with cinch sutures anchoring to the nasal septum. A more difficult problem is a small nostril on the cleft sid . Th s complex problem should ideally be corrected according to the location of the tissue deficiency. A small nostril can be the result of tissue deficiency in the nasal fl or, the columella, or the alar rim. When the tissue deficie cy is located in the nasal fl or, using a Z-plasty on the nasal floor can effectively correct the problem by moving a perialar flap into the nasal fl or and bringing the alar base outward. A wedge-shaped skin-fat composite graft from the earlobe is suggested if the tissue deficie cy is on the cleft-side columella. A tissue deficie cy in the alar rim is the most difficult problem to address, because there is no similar tissue that can be used for replacement. A composite graft from the noncleft-side alar rim creates the problems of a visible scar and color mismatching. I prefer to use a composite earlobe graft for the columella and to shift the columellar tissue into the alar rim.

603

604

Part V 

Primary or Secondary Rhinoplasty

Prominent Alar Dome on the Noncleft Side Despite medial advancement of the cleft-side L C and the addition of cartilage grafts, he noncleft-sid alar dome occasionally remains prominent, maintaining the asymmetry. To narrow or lower the alar dome on the noncleft sid , a cephalad resection of the LLC or even a Goldman tip procedure with transection of the intermediate crura on the noncleft side is helpful.

Higher Alar Rim on the Noncleft Side Sometimes it is necessary to lower the noncleft-side alar rim to achieve symmetry when the noncleft-sid alar rim is too high or the cleft-side alar rim is still low despite the use of the previous corrective procedures. A higher alar rim on the noncleft side can be corrected relatively easily through the use of a composite graft (cartilage-skin graft) from the conchal area of the ear. The composite graft is placed on the intercartilaginous incision on the noncleft side to separate the LLC and ULC to lower the alar rim.

Weir Excision on the Noncleft Side It is not uncommon for a patient to have persistent asymmetry despite having undergone all of these procedures. For the larger nostril on the noncleft side, the final solution is to reduce the size of that nostril. A Weir excision is a general term for the procedure of reducing the larger nostril on the noncleft side; however, the exact part of the noncleft-side nostril to be excised should be carefully evaluated. In a typical Weir incision, the lower part of the alar rim must be reduced if the alar rim on the noncleft side is too prominent. The incision should be placed slightly above the alar-facial groove—but not right within the alar-facial groove—because the incision will destroy this natural groove and flatten the alarfacial junction. If the nasal fl or is too wide, the reduction should include part of the nasal fl or tissue.

Tissue Deficiency on the Nasal Sill The nasal sill is the most difficult area of the nose to reconstruct. A nasal sill deficie cy occurs as a result of excessive excision of this tissue during primary repair. There is no similar tissue elsewhere on the body to replace this unique sill tissue; hence no simple reconstructive techniques exist. The surgeon should carefully examine the tissue inside the nasal fl or to see whether any nasal sill remnants are available. If remnants are available, a Z-plasty can be performed to reposition this tissue out into the nasal sill area.

Bony Deficiency on the Nasal Floor Despite the widespread practice of alveolar bone grafting, it is still common to have a deficie cy on the bony base of the nasal fl or. Th s bony deficie cy must be differentiated from a soft tissue deficie cy in this area. A soft issue deficie cy can be corrected through rearrangement of local tissue, such as through rerepair of the orbicularis oris muscle and advancement of the alar base medially, or through a YV-plasty or a Z-plasty on the nasal fl or. Bony deficie cy can seldom be corrected by soft tissue overcorrection alone and should preferably be managed by bone grafting to the nasal fl or. I commonly use rib as the preferred

K23345_Pu_c38_Sec Cleft Rhino_r5_cl_595-610.indd 604

4/3/2015 10:09:32 AM

Chapter 38 

Secondary Cleft Rhinoplasty

donor site for cleft- ose revisions, because rib can provide not only cartilage for the framework and tip reshaping, but also bone for augmentation of the nasal fl or. Diced cartilage graft s also a good choice, because resorption after surgery will be less, and the symmetry can be manually molded.

Postoperative Care Postoperative care for a secondary cleft rhinoplasty patient is similar to that for cosmetic rhinoplasty. The suture lines should be cleansed with normal saline solution and covered with antibiotic ointment. The sutures on the columellas should be removed 5 to 7 days after surgery. Micropore tape is used to hold the cheek tissue to prevent relapse of the position of the alar base. The tape should be used for at least 6 months. Starting 1 week after surgery, a silicone nasal conformer is used for splinting to prevent distortion of the alar rim from scar contracture. I have found that using the conformer in primary rhinoplasty in cleft patients has shown the significant efficacy of this device in achieving more consistent results. The conformer is used for at least 6 months, but only at night, to ensure better patient compliance. The plaster splint is removed when sutures are removed. The patient is instructed to manually massage the dorsum of the nose at least 10 times a day, for at least 3 to 5 minutes each time. The patient should put more pressure on the nasal tip, because it tends to remain swollen longer. A nasal clip is also helpful to reduce the swelling of the nasal tip.

Suction Drains and Compression Dressing Whenever a defatting procedure is performed, suction drains and compression dressing must be used to prevent hematoma and reduce swelling. Both hematoma and prolonged swelling will lead to the recurrence of a thick, bulbous nasal tip. A 19-gauge butterfly needle can be used as a suction drain, and plaster splints can be used for a pressure dressing (Fig. 38-14).

Fig. 38-14  A plaster splint is used for external compression.

605

606

Part V 

Primary or Secondary Rhinoplasty

Results More than 80% of patients are satisfi d after undergoing a secondary cleft rhinoplasty procedure. The common, persistent nasal deformities among Asians are as follows: • Residual nostril hooding in the soft triangle area • Asymmetry of the alar domes as a result of some relapse on the cleft side or a prominent alar dome on the noncleft side

E

A

B

C

D

F

Fig. 38-15 Th s 18-year-old girl presented with midface retrusion and a secondary cleft-l p deformity on the left side. She had orthognathic surgery to correct her skeletal discrepancy and then a lip and nose revision. The results are stable 4 years after surgery

K23345_Pu_c38_Sec Cleft Rhino_r5_cl_595-610.indd 606

4/3/2015 10:09:34 AM

Chapter 38 

Secondary Cleft Rhinoplasty

607

• Asymmetrical alar rims from a lack of support lateral to the LLC on the cleft side • Asymmetrical nostrils from the laterally displaced alar base on the cleft side • Nasal fl or discrepancy resulting from bony deficie cy on the cleft side • Inadequate muscle approximation on the nasal fl or or tissue deficie cy in the nasal sill • A crooked nasal dorsum caused by an uncorrected nasal bony deviation • A thick nasal tip (in Asians)

E

A

B

C

D

F

Fig. 38-16 Th s 18-year-old girl presented with midface retrusion and a secondary cleft-l p deformity on the left side. She had orthognathic surgery to correct her skeletal discrepancy and then a lip and nose revision. The results are stable 3 years postoperatively.

K23345_Pu_c38_Sec Cleft Rhino_r5_cl_595-610.indd 607

4/3/2015 10:09:35 AM

608

Part V 

Primary or Secondary Rhinoplasty

Management of Complications Like any other surgical procedure, cleft hinoplasty carries a certain risk of complications. The possible complications in cleft rhinoplasty include hematoma, infection, and skin necrosis. Hematoma can be avoided by careful hemostasis throughout the procedure and during postoperative drainage. Infection is rare, because all of the grafts re autologous tissue. Infection usually can be controlled by oral antibiotics and local drainage. Surgical debridement is seldom needed. Skin necrosis is very uncommon, even in the columellar area, because the columella is much shorter in the Asian nose.

Revis io n Sur ger y of Unsa tis f a ct or y Res ul t s

The technique for revision for tertiary nasal deformities should be based on each individual’s condition. For residual alar depression on the cleft side, another Tajima incision and another piece of cartilage graft are usually needed. A laterally displaced alar base on the cleft side an be corrected through a YV-plasty on the nasal fl or to move the alar base medially. A nasal-fl or deficie cy on the cleft side can be improved through additional bone grafting on the nasal fl or or additional soft issue revision such as muscle approximation on the nasal fl or. Shaving of the uneven cartilage graft n the nasal dorsum or a nasal osteotomy is necessary to correct a crooked nasal dorsum. A larger nostril on the noncleft side can be corrected through a Weir excision.

Discussion There are no absolute criteria for indications and contraindications in the secondary revision of cleft l p nasal deformities. The need for surgery is mainly based on patients’ request and surgeon’s ability. Careful preoperative evaluation, meticulous surgical technique, and cooperative postoperative care are key factors in achieving a more consistent and pleasing result.

Pearls for Success • The surgeon must conduct a thorough preoperative assessment. • Ensuring the cooperation of the patient and/or his or her caregiver is a key factor for success. • When performing open rhinoplasty, the surgeon should focus on restoration of normal nasal anatomy. • Symmetrical dissection on both sides of the nose is essential to ensure symmetrical scar contracture after surgery. • The surgeon should release the lining deficie cy by using mucosal flaps—the inferior turbinate flap and L-flap—for nasal reconstruction. • The displaced cartilaginous framework should be repositioned. • Asymmetrical bony framework should be corrected. • An onlay cartilage graft can correct any residual depression on the cleft side. • Redraping the soft tissue requires adequate debulking of the nasal tip. • Good postoperative care is critical to successful secondary cleft rhinoplasty.

K23345_Pu_c38_Sec Cleft Rhino_r5_cl_595-610.indd 608

4/3/2015 10:09:35 AM

Chapter 38 

Secondary Cleft Rhinoplasty

609

Refer ences 1. Grayson BH, Cutting CB. Presurgical nasoalveolar orthopedic molding in primary correction of the nose, lip, and alveolus of infants born with unilateral and bilateral clefts. Cleft Palate Craniofac J 38:193-198, 2001. 2. Li AQ, Sun YG, Wang GH, et al. Anatomy of the nasal cartilages of the unilateral complete cleft l p nose. Plast Reconstr Surg 109:1835-1838, 2002. 3. Chen PK, Noordhoff MS, ane A. Repair of unilateral cleft l p. In Neligan P, ed. Plastic Surgery, ed 3. Philadelphia: Elsevier, 2013. 4. Chen PK, Noordhoff MS. Bilateral cleft lip and nose repair. In Losee JE, Kirschner RE, eds. Comprehensive Cleft Care. New York: McGraw-Hill, 2008. 5. Salyer KE, Genecov ER, Genecov DG. Unilateral cleft lip-nose repair—long-term outcome. Clin Plast Surg 31:191208, 2004. 6. Chang CS, Por YC, Liou EJ, Chang CJ, Chen PK, Noordhoff MS. Long-term comparison of four techniques for obtaining nasal symmetry in unilateral complete cleft l p patients: a single surgeon’s experience. Plast Reconstr Surg 126:1276-1284, 2010. 7. Lu TC, Lam WL, Chang CS, Chen PK. Primary correction of nasal deformity in unilateral incomplete cleft l p: a comparative study between three techniques. J Plast Reconstr Aesthet Surg 65:456-463, 2012. 8. Millard DR Jr. Cleft Cr ft. e Evolution of Its Surgery, vol 1: The Unilateral Deformity. Boston: Little Brown, 1976. 9. Stal S, Hollier L. Secondary deformities of the cleft l p, nose, and palate. In Mathes SJ, ed. Plastic Surgery, ed 2. Philadelphia: Elsevier, 2006. 10. Byrd HS, El-Musa KA, Yazdani A. Correction of secondary unilateral cleft l p and nose deformity. In Losee JE, Kirschner RE, eds. Comprehensive Cleft Care. New York: McGraw-Hill, 2009. 11. Feldman EM, Koshy JC, Hollier LH, et al. Secondary deformities of the cleft lip, nose, and palate. In Neligan P, ed. Plastic Surgery, ed 3. London: Elsevier, 2013. 12. Chen PK, Noordhoff MS. Secondary cleft lip and cleft nasal deformity. In Guyuron B, Eriksson E, Persing JA, et al, eds. Plastic Surgery: Indications and Practice. Philadelphia: Elsevier, 2009. 13. Chen K, Noordhoff MS. Open tip rhinoplasty. Ann Plast Surg 28:119-130, 1992. 14. Bergeron L, Chen PK. Asian rhinoplasty techniques. Semin Plast Surg 23:16-21, 2009. 15. Chang CS, Bergeron L, Chen PK. Diced cartilage rhinoplasty technique for cleft l p patients. Cleft alate Craniofac J 48:663-669, 2011.

K23345_Pu_c38_Sec Cleft Rhino_r5_cl_595-610.indd 609

4/3/2015 10:09:35 AM

K23345_Pu_c38_Sec Cleft Rhino_r5_cl_595-610.indd 610

4/3/2015 10:09:35 AM

Part VI

Cosmetic Surgery of the Ear

K23345_Pu_c39p_Spec Asian Ear_r4_dc_611-626.indd 611

4/3/2015 10:13:13 AM

K23345_Pu_c39p_Spec Asian Ear_r4_dc_611-626.indd 612

4/3/2015 10:13:13 AM

39 Special Considerations in Cosmetic Surgery of the Asian Ear

A

Akira Yamada

sians are more sensitive to the roundness of the ear, compared with other ethnic groups. A redundant, round lobule is considered a sign of wellness, luck, and wealth in Asian society. On the other hand, Asians are less sensitive to prominent ear than Western society. One of the basic foundations of Asian philosophy is a strong belief in fate, destiny, and the importance of luck, both good and bad, in daily aff irs. 1 Asians generally do not mind big ears; they see them as lucky ears. The facial anatomic structure that most people focus on is the facial triangle, composed of eye-nose-eye. The external ear is located away from the facial triangle; therefore most people usually do not pay attention to it. However, people notice ears that do not look natural because of excessive protrusion, a disrupted helical curve, missing parts, and asymmetry. The main function of the external ear is to look normal. Therefore the goal of cosmetic surgery of the external ear is to make the ear look as natural as possible. The nose differs signifi antly between ethnic groups. Farkas et al2 reported signifi ant differences specifically of the columellar width, nasal tip projection, and angulation of the nares. Contrary to the signifi ant variations in the eyes and nose among different ethnic groups, the external ear (auricle) is probably the least anatomically variable structure. Knowledge of normal anatomy, proportion, and dimensions of the external ear is paramount when planning surgery for Asian patients.

Anatomy and Special Considerations of the Normal Ear The external ear is a delicate anatomic structure located behind the face mask.3 It is composed of complex convolutions, prominences, depressions, and curves. Surgeons fi st need to determine whether an ear has all anatomic parts, including the helix, antihelix, tragus, antitragus, intertragal notch, lobule, and conchal cavity (Fig. 39-1). These anatomic parts are in good balance and harmony in a normal ear. Any destruction or disruption can be noticeable by others.

613

614

Part VI 

Cosmetic Surgery of the Ear

Helix Fossa triangularis Inferior crus Crus helicis Tragus

Superior crus Otobasion superioris Scapha Cymbum concha Antitragus Cavum concha Intertragal notch Lobule

Otobasion inferioris

Fig. 39-1  Normal anatomy of the external ear. Surgeons should assess all of these parts of the ear.

Fig. 39-2  Normal ratio of the external ear. The ear is about 55% to 60% as wide as it is long.

Pr opor tio ns of the Ear

Tolleth4 has described the normal proportions of the auricle. The ear is about 55% to 60% as wide as it is long, and its axis inclines posteriorly (Fig. 39-2). Its protrusion from head to edge is normally 1.5 to 2 cm. Tolleth carried out his study in the United States. Nagata5 in Japan actually uses this norm for his framework template. I do not see a difference in proportion between different ethnic groups. When a tumor is excised (wedge resection), the proportion to the rest of the ear should be maintained to prevent disharmony of the ear shape.

Chapter 39 

Special Considerations in Cosmetic Surgery of the Asian Ear

Fig. 39-3  The normal location of the external ear is one length posterior to the orbital rim on a level with the brow, and it is posteriorly inclined.

Fig. 39-4  Two centimeters should be maintained between the posterior margin of the sideburn and the tragus. Violation of this rectangle can cause an anterior inclination of the ear, which is unattractive.

Lo ca tio n of the Ear

Tolleth4 stated that an exquisitely modeled but badly positioned ear is less attractive than a lesser production correctly placed. Assessment of the location of the external ear comprises three factors: axis, level, and distance. The external ear is located approximately one length posterior to the orbital rim, on the brow level, and it is posteriorly inclined (Fig. 39-3). The rectangular area of skin in front of the external ear should not be violated. The posterior margin of the side burn is 2 cm from the tragus.6 Violation of this rectangle can cause anterior inclination of the ear, making it less attractive (Fig. 39-4). Harvesting too much skin from the preauricular area can cause an unnatural-looking ear.

615

616

Part VI 

Cosmetic Surgery of the Ear

Ear Shap e

Variation of the ear shape among different ethnic groups is not as significant as variation of the eyes and nose. Harada et al7 analyzed ear shape with a curve ratio analysis method to identify the ear shape difference.8 They applied the key line concept to the ear shape analysis. Key line is a term that describes characterdefini g lines in industrial design. Harada et al7 defi ed two key lines in the external ear: the helix-lobule curve and the conchal outline curve. The helix-lobule curve is classifi d into three types: type A (30%), type B (46%), and type C (24%) (Fig. 39-5). The conchal outline has type 1 and 2 curves (Fig. 39-6). They classifi d the ear shape into six types (3 3 2) based on this analysis. My observation shows that many people think type A-1 (Fig. 39-7) is probably the most aesthetically pleasing. Based on the authors’ curve analysis, expert earmakers (Brent9 in the United States and Nagata5 in Japan) use a cartilage framework that is similar to type A-110 (Fig. 39-8), which supports my observation.

Type A (30%)

Type B (46%)

Type C (24%)

Fig. 39-5  Classifi ation of a helix-lobule curve.

Type 1

Conchal outline

Type 2

Fig. 39-6  Classifi ation of a conchal outline curve.

Chapter 39 

Special Considerations in Cosmetic Surgery of the Asian Ear

617

Fig. 39-7  Schema of a type A-1 ear. Th s is probably the most attractive ear shape of the six types.

A

B

Fig. 39-8  A, Curve analysis of a Brent-type ear framework. B, A Nagata-type framework. Both expert earmakers use a

curve that is similar to that of a type A-1 ear. (Adapted from Brent B. Technical advances in ear reconstruction with autogenous rib cartilage grafts: personal experience with 1200 cases. Plast Reconstr Surg 104:319-334, 1999.)

K23345_Pu_c39p_Spec Asian Ear_r4_dc_611-626.indd 617

4/3/2015 10:13:16 AM

618

Part VI 

Cosmetic Surgery of the Ear

Fig. 39-9  Acquired pixie ear after face-lift procedure.

Lobul ar Shap e

A round, smooth lobule is the preferred shape, especially for Asians and members of Western society. In Western society, a linear lobule, which occurs with a pixie ear or as a complication of face-lift procedures, may not be acceptable. With regard to curve analysis, the external ear is composed of multiple, complex curve surfaces; a straight line usually does not exist except in a pixie-ear lobule. Therefore transformation of a straight lobular line (Fig. 39-9) to a curved line will create more balance and harmony to the external ear. Creation of a type A helix-lobule curve (see Fig. 39-5) yields the best aesthetic outcome.

Abnormal Conditions of the Ear Lobul ar Defo rmit y Caus ed by Pier cing

Piercing of the ear can cause a variety of deformities that result from trauma, gravity, or keloid/hypertrophic scar formation. Because lobule is a pure soft tissue structure without skeletal support, surgeons should pay attention to the free margin. Tumor excision perpendicular to the margin will deform and disrupt a round curve. Fig. 39-10, A, shows a square-looking lobule caused by piercing. It probably resulted from wound healing perpendicular to the lobular margin. Based on the curve analysis, the patient had a type A helixlobule curve on both ears. I used a type A template as a guide for surgery to transform a square lobule to a smooth, round lobule (Fig. 39-10).

Chapter 39 

Special Considerations in Cosmetic Surgery of the Asian Ear

A

B

C

D

E

F

Fig. 39-10  A, Preoperative view of a square right lobule caused by piercing. B, Postoperative view. C, Postoperative

evaluation with a type A-2 template. D, Preoperative view of the left ear. E, Postoperative outcome. F, Postoperative evaluation with a type A-1 template.

Cleft Ear

Cleft ear can be either congenital or acquired, for example, from trauma. A continuous, smooth curve transition should be created at the ear cleft. Once the type of ear shape is identifi d, the optimal type of lobular curve becomes evident. Fig. 39-11 shows a congenital cleft ar with a wide cleft. ompared with the contralateral smooth curve of the lobule, the right lobule has a triangular shape that looks unnatural. Because the rest of the helix-lobule curve was type A, I used a type A template to determine the location for attachment of the lobule. The postoperative view shows a smooth lobular curve in continuation with the helix.

619

620

Part VI 

B

A

C

Cosmetic Surgery of the Ear

D

E

Fig. 39-11  A, Preoperative view of a congenital cleft ear. B, A normal ear. C, The skin incision design is marked. D, Intraoperative confi mation of the ear curve with a type A template. E, The immediate outcome.

Pr ominent Ear

Most Western textbooks defi e a prominent ear as one that protrudes more than 20 mm or more than 30 degrees from the temporal/temporomastoid surface of the head. The defin tion in most Asian texts is less strict: protrusion of more than 25 mm or more than 40 degrees from the temporal/temporomastoid surface of the head. Knowledge of the difference between these two standards is critical for discussing the needs of the patient and family. Such a discussion includes their cultural background, where the patient currently lives, and where the patient will live in the future. In Asia, otoplasty is generally considered a cosmetic procedure.

Subtle Defo rmit y of the Ear

When evaluating a patient’s external ear, a surgeon needs to know the cause of subtle deformities such as helix-antihelix adhesion. If you know the detailed structure of the external ear, it is easy to diagnose its deformities. It is uncommon for a patient to ask a surgeon to correct this deformity. Often patients do not notice it. Knowledge of this subtle deformity is important for total ear reconstruction, because an ear with

K23345_Pu_c39p_Spec Asian Ear_r4_dc_611-626.indd 620

4/3/2015 10:13:20 AM

Chapter 39 

Special Considerations in Cosmetic Surgery of the Asian Ear

helix-antihelix adhesion does not have an optimal shape, as on a template. We should not create deformity by trying to exactly match a normal shape to the contralateral side, which has a minor deformity. We should set a goal of construction of a normal-looking external ear. Stahl ear is a minor deformity that is surgically correctable (Fig. 39-12). The upper ear has an extra fold of cartilage, resulting in a pointed appearance. Many patients and family are unaware of the deformity until the child is older. Various techniques have been described to eliminate the extra crus, but none is perfect. Cryptotia means hidden ear. It describes an ear in which the upper portion of the auricle is buried underneath the mastoid skin (Fig. 39-13). It is relatively common in the Asian population. Ear cartilage is normal

Fig. 39-12  Stahl ear is a congenital deformity, more commonly known today as Spock ear or Vulcan ear. The third crus (the cartilage fold that bridges the helix and superior crus) causes pointing of the ear.

Fig. 39-13  Cryptotia is a congenital condition that causes the upper third of the external ear to be buried. It is frequently associated with a helix-antihelix adhesion deformity.

621

622

Part VI 

A

C

Cosmetic Surgery of the Ear

B

D

E

Fig. 39-14  A, Constricted ear is a congenital ear deformity with various degrees of skin/cartilage deficie cies in the up-

per half of the ear. B, A simple otoplasty (Mustardé) signifi antly corrects the hooding/folding of the ear, but it does not reconstruct the deformed parts, such as the inferior crus. C and D, More reconstructive procedures are necessary to expand the helix with a local skin flap and cartilage graft from the cavum concha. E, A type A-1 template is overlapped to evaluate the surgical outcome. Helical expansion is nicely achieved, with some deviation of the conchal outline.

in many cases, but it may have a defect or deformity such as a helix-antihelix adhesion. On the other hand, a constricted ear always has a deformity and defect of skin and cartilage. Lop ear and cup ear describe a condition that is similar to constricted ear. Because of a tissue defect and constriction, a simple otoplasty approach does not always work perfectly (Fig. 39-14, A and B). A skin flap and cartilage may be needed in a reconstructive procedure to release and expand the helix (Fig. 39-14, C through E).

Tumor Res ectio n Near the Helix-L obule

The helix-lobule curve has a free margin. Therefore, to prevent a noticeable result, the curve should not be disrupted during removal of a tumor or nevi. The skin incision should never be designed with the long axis of elliptical skin resection perpendicular to the free margin. Th s axis should be parallel or oblique to the free margin (Fig. 39-15). Scar that is perpendicular to the free margin can disrupt the lobular curve (see Fig. 39-10).

Chapter 39 

A

Special Considerations in Cosmetic Surgery of the Asian Ear

B

E

C

623

D

F

Fig. 39-15  Design of an elliptical tumor excision at the helix-lobule curve. A, Th s excision is designed in the wrong

orientation (perpendicular to the helix curve). B, The outcome. C, Proper orientation is parallel to the helix curve. D, Th outcome. E, Proper orientation of elliptical tumor markings and excision. F, The outcome.

Expected Outcome After Cosmetic Ear Surgery in Asians The goal of ear surgery in Asians is to restore the harmony and balance of the external ear, with special emphasis on the smooth roundness of the ear curve. To achieve this goal, surgeons must carefully assess patients preoperatively, including the shape of the overall external ear, the existing deformity, the tendency of hypertrophic scar/keloid formation, the history of allergy, and current medications that can cause perioperative bleeding. Any complication can jeopardize a surgeon’s goal to achieve a beautiful ear. Careful follow-up is essential to prevent unsightly scar formation. Patients should be informed preoperatively of all possible complications. The expected outcome varies based on the deformities. In general, a relatively good outcome can be expected for patients with acquired deformities such as lobular deformities from piercing, pixie ear, and facelift rocedures. Alternatively, an optimal outcome is more difficult to achieve for congenital deformities because of the complexity of the morphology.

K23345_Pu_c39p_Spec Asian Ear_r4_dc_611-626.indd 623

4/3/2015 10:13:25 AM

624

Part VI 

Cosmetic Surgery of the Ear

Common Problems After Cosmetic Ear Surgery in Asians Kel oid and Hyper tr ophic Scars of the Ear The occurrence of keloid/hypertrophic formation in the auricle is higher in Asians than in whites. Th s is discussed in detail in Chapter 4. As I described previously, if a keloid is located near the helix-lobule free margin, it should be resected parallel to the helix-lobule curve to prevent deformity (Figs. 39-16 and 39-17). The true cause of keloid/hypertrophic scarring is not understood. Based on my observation, patients with allergic disease such as asthma, nasal allergy, and atopic dermatitis or patients with a family history of allergic disease are more likely to develop hypertrophic scars. Tranilast, an antiallergic medicine, has been approved for the treatment for keloid/hypertrophic scar in Japan and has become part of the standard regimen of care. The most frequent complication after keloid/hypertrophic scar resection is recurrence of the original condition. Therefore patients should be well informed preoperatively about possible recurrence, and the discussion should be documented. Surgeons need to know all available medical treatment options for keloid/

A

B

C

D

Fig. 39-16  A, Preoperative view of a keloid formation. B and C, An elliptical excision should be oriented parallel to the helix curve. D, Immediate postoperative view after bolster suture fix tion.

A

B

Fig. 39-17  A, Th s patient’s ear is marked for removal of a keloid in the helix. B, An immediate postoperative view shows smooth continuation of the helix.

Chapter 39 

Special Considerations in Cosmetic Surgery of the Asian Ear

hypertrophic scar recurrence, for example, occlusive dressings, compression therapy, intralesional corticosteroid injections, cryosurgery, radiotherapy, laser therapy, interferon therapy, 5-fluorouracil, doxorubicin, bleomycin, verapamil, retinoic acid, imiquimod 5% cream, tamoxifen, tacrolimus, botulinum toxin, vascular endothelial growth factor inhibitors (bevacizumab), and tumor necrosis factor–alpha inhibitors (etanercept). Among these numerous options, compression therapy and intralesional corticosteroid injections are readily available options for surgeons. Because keloid/hypertrophic scar normally develops several weeks to months after surgery, follow-up visits need to be emphasized to patients.

Infectio n

The postoperative infection rate after external ear surgery is no higher than with other facial surgery, but the presence of nasal MRSA should be determined preoperatively in patients with atopic dermatitis. I usually give prophylactic antibiotics for 2 to 5 days. If infection occurs, topical iodine gel plus petroleum-based ointment and a systemic antibiotic is my choice of treatment. If infection persists despite broad-spectrum antibiotics, my index of suspicion of MRSA infection is high.

Iss ues fo r Revis io n

Revision is always a possibility. Because the goal is to restore the balance and harmony of the external ear, revision may be necessary. The other important principle in revision surgery is that more revisions cause more skin and cartilage deficiency. Therefore a thorough preoperative discussion of benefits and risks of revision surgery is imperative.

Discussion Because the external ear is away from the facial triangle, the ear is not the center of attention. However, asymmetry, disruption of helix-lobule curve, too much protrusion, and keloid formation will be noticed by others. Surgeons need to be aware that Asians are more sensitive to roundness of the external ear, and they should avoid surgical manipulation that could disrupt the smooth curve and proportion of the ear. Of the six types of external ear shapes, type A-1 (Harada et al7) is probably the most attractive. Keloid/hypertrophic scar is likely the most frequent reason to see doctors, along with complications after ear surgery. Therefore knowledge of the prevention and treatment strategy for this problem is critical.

Pearls for Success • The external ear must have all of the important anatomic parts to have balance and harmony. Therefore surgeons should know all parts. • The location, dimension, and proportion of the external ear should be assessed. An external ear that is in a normal location and has good dimensions and proportions usually looks normal or attractive. • Surgeons need to be aware that the helix is the key line of the external ear. • Type A-1 is probably the most attractive external ear shape of the six types of normal variation in any ethnic group. • A round lobule is the preferred shape, especially in the Asian population. • Asians have a relatively high incidence of hypertrophic scar/keloid formation.

625

626

Part VI 

Cosmetic Surgery of the Ear

Refer ences 1. McCurdy JA. Facial surgery in Asian patients. In Mataroy WE Jr, ed. Ethnic Considerations in Facial Aesthetic Surgery. Philadelphia: Lippincott-Raven, 1998. 2. Farkas LG, Hreczko TA, Deutsch CA. Objective assessment of standard nostril types: a morphometric study. Ann Plast Surg 11:381-389, 1983. 3. Yamada A, Ueda K, Yorozuya-Shibazaki R. External ear reconstruction in hemifacial microsomia. J Craniofac Surg 20 Suppl 2:S1787-S1793, 2009. 4. Tolleth H. Artistic anatomy, dimensions, and proportions of the external ear. Clin Plast Surg 5:337-345, 1978. 5. Nagata S. A new method of total reconstruction of the auricle for microtia. Plast Reconstr Surg 92:187-201, 1993. 6. Yamada A. Anthropometric study of ear position and its clinical application to the total external ear reconstruction. Bull Osaka Med Coll 55:81-89, 2009. 7. Harada T, Yamada A, Sato A, et al. Analysis of the characteristics of external ears’ curves and the development of the templates. Bull Jap Soc Sci Design 57:21-26, 2011. 8. Harada T, Yoshimoto F. An aesthetic curve in the fi ld of industrial design. In Proceedings of the IEEE Symposium on Visual Language. Tokyo, Japan: The Institute of Electrical and Electronics Engineers, Inc, Sept 1999. 9. Brent B. Microtia repair with rib cartilage grafts: a review of personal experience with 1000 cases. Clin Plast Surg 29:257-271, 2002. 10. Brent B. Technical advances in ear reconstruction with autogenous rib cartilage grafts: personal experience with 1200 cases. Plast Reconstr Surg 104:319-334, 1999.

K23345_Pu_c39p_Spec Asian Ear_r4_dc_611-626.indd 626

4/3/2015 10:13:28 AM

40 Otoplasty for Prominent Ear

O

Ruhong Zhang, Qun Zhang

toplasty for prominent ears is one of the most frequently performed aesthetic surgical procedures in children and adolescents.1 Prominent ears are relatively common, with an incidence of approximately 5% in white populations. However, in Asians no exact statistical data are available.2 Although the physiologic consequences are negligible, the aesthetic and psychological effects on the patient can be substantial.3

Anatomy A thorough understanding of the anatomy of normal and prominent ears is essential to accurately assess and surgically correct the defect. The normal ear has a convoluted sheet of cartilage with a thin cutaneous cover. The ear is a complex composite of cartilage and skin with many intricate involutions and folds and is composed of the following five critical elements: 1. Concha 2. Helix 3. Antihelix 4. Tragus 5. Lobule Less important parts of the normal ear include the antitragus, intertragic notch, and Darwin’s tubercle. 4 The normal ear has several proportions that are common in the normal, nonprominent, aesthetic ear5-8 (Box 40-1). The main causes of the prominent ear are as follows: • Conchal hypertrophy or excess (upper pole, lower pole, or both) • Inadequate formation of the antihelical fold (the root, superior crus, inferior crus, or all) • A conchoscaphal angle greater than 90 degrees in severe cases; conchoscaphal angle as much as 150 degrees or more9 (Fig. 40-1) • A combination of conchal hypertrophy and an underdeveloped antihelical fold4 Other causes of a prominent ear include cranial abnormalities that influence the base on which the ear rests, lobular protrusion, and anterolateral displacement of the tail of the helix.4 Occasionally, conchal excess can be difficult to see.

627

628

Part VI 

Cosmetic Surgery of the Ear

Box 40-1  Proportions of the Aesthetic Ear • The long axis of the ear inclines posteriorly at approximately a 20-degree angle from the vertical. • The ear axis does not normally parallel the bridge of the nose (the angle differential is approximately 15 degrees). • The ear is positioned at approximately one ear length (5.5 to 7 cm) posterior to the lateral orbital rim between the horizontal planes that intersect the eyebrow and columella. • The width is approximately 50% to 60% of the length (width 3 to 4.5 cm; length 5.5 to 7 cm). • The anterolateral aspect of the helix protrudes at a 21- to 30-degree angle from the scalp. • The anterolateral aspect of the helix measures approximately 1.5 to 2 cm from the scalp (although there is a large amount of racial and gender variation). • The lobule and antihelical fold lie in a parallel plane at an acute angle to the mastoid process. • The helix should project 2 to 5 mm more laterally than the antihelix on a frontal view. From Janis JE, Rohrich RJ, Gutowski KA. Otoplasty. Plast Reconstr Surg 115:60e-72e, 2005.

A

B

Fig. 40-1  A, Cross-section of a normal ear. B, A prominent ear resulting from an increased conchoscaphal angle. (Redrawn from Mathes SJ. Plastic Surgery, ed 2. Philadelphia: Saunders Elsevier, 2006.)

Usually the prominent ear deformity is bilateral; however, Spira et al10 indicated that the cause of the defect may be different on each side. Therefore any procedure to correct a prominent ear should also address the underlying anatomic defect and attempt to correct it.4

Indications The broad spectrum of ear projection makes it difficult to defi e what is normal based on absolute parameters. Although quantitative means can be defi ed for almost any dimension of the external ear, prominence must always be viewed based on an individual’s facial structure. Projection beyond an objective, average value is often considered abnormal, but much of the fi al opinion should be based on the patient’s or family’s perception rather than a societal standard. In most Asian countries, it is desirable to have ears with fi e projection. For the Chinese, a large ear is a symbol of good fortune. People have traditionally thought that it is beautiful to have well-projected ears beside their faces, but this perception has changed in recent years. Increasingly, people realize that a prominent ear is an abnormality of the external ear and want to correct it.

Chapter 40 

Otoplasty for Prominent Ear

Preoperative Assessment The preoperative or pretreatment assessment should focus on the following four areas: 1. Analysis of the physical attributes of the ear or ears 2. Emotional and mental preparation of the patient and family 3. Selection of the appropriate surgical technique to address the deformity 4. Determination of the optimal anesthetic and patient position During a meticulous preoperative evaluation of the anatomy, the surgeon should assess the following in the patient with prominent ears11,12: • Degree of antihelical folding • Depth of the conchal bowl • Plane of the lobule and deformity if present • Angle between the helical rim and mastoid plane • Quality and spring of the auricular cartilage4 These features can be subtle or quite exaggerated. It is common for patients to have different combinations of these abnormalities on either ear. Frequently a patient will have a different deformity on each side, and these may be equally severe. However, the surgeon must be aware of the potentially different combinations of deformities on either side if symmetry is to be achieved. Photos are often helpful. A basic series should include full frontal and lateral views of both ears. Frontal closeups, oblique views, and posterior images of each ear are also helpful. The expectations of the patient and family are just as important as the anatomic irregularities of the auricle. It is important to discuss the potential outcomes and complications and to ensure that the patient has realistic expectations. Parents of children may have very rigid views regarding their expectations of the surgery, and these expectations need to be openly discussed. Diligent postoperative care to avoid unwanted complications must be established with the family before surgery. During counseling of younger patients and their families, the surgeon should address the ability of the younger patient undergoing otoplasty to participate appropriately in the postoperative care and protection of the dressing. To select the proper surgical technique, the anatomic factors that led to the prominent ear were previously discussed. The surgeon should develop a complete plan that will correct each observed anatomic irregularity. Anesthesia and positioning are integral parts of the surgical planning. General anesthesia is preferred in children and is supplemented with local anesthesia. It is important to determine any complications from or contraindications to general anesthesia. In adults otoplasty is often performed under local anesthesia, which uses 1% to 2% lidocaine with adrenaline 1:200,000. Regarding positioning, the supine position has been the position of choice simply out of convention. In contrast, Manushakian et al13 described the use of the prone position in more than 100 patients. They stated that this position is advantageous because it allows constant comparison with the contralateral ear without the need for repositioning. In this study patients reported that the prone position was comfortable and noted overall excellent surgical results.

Surgical Techniques Nonsurgical correction of prominent ears usually yields poor results. In the repair of the prominent ear, the goal is to achieve symmetry. McDowell’s basic goals of otoplasty5 (Box 40-2) should be applied to correct prominent ears.

629

630

Part VI 

Cosmetic Surgery of the Ear

Box 40-2  McDowell’s Goals of Otoplasty 1. All upper-third ear protrusion must be corrected. 2. The helix of both ears should be seen beyond the antihelix from the frontal view. 3. The helix should have a smooth and regular line throughout. 4. The postauricular sulcus should not be markedly decreased or distorted. 5. The helix to mastoid distance should fall in the normal range of 1.0 to 1.2 cm at the top, 1.6 to 1.8 cm in the midportion, and 2.0 to 2.2 cm in the lower third. 6. The position of the lateral ear border to the head should match within 3 mm at any point between the two ears. In addition, any procedure should provide symmetrical and reproducible results and avoid unnecessary costs and complexity, scars, complications, and recurrence. Adapted from McDowell AJ. Goals in otoplasty for protruding ears. Plast Reconstr Surg 41:17-27, 1968.

To achieve these goals, numerous techniques have been described, many of which produce acceptable results. Before the prominent ears are corrected, it is necessary to assess the physical attributes of the ear or ears. If the upper third of the ear protrudes because of an absent or weak antihelix, the surgeon must create the antihelical fold. If the middle third is too prominent, the surgeon must recess the cartilage excision or suture fix tion. If the lobule protrudes, the protrusion must be corrected by resecting or retropositioning the cartilaginous tail of the cauda helicis or excising the retrolobular skin.

Cr ea tio n of the Antihelical

Fold

Many techniques have been reported to correct the antihelical fold.4 However, there are two major schools of thought. The fi st is that a cartilage incision is required, which is the cartilage-cutting technique. Th second is the cartilage-sparing technique, which relies on horizontal mattress sutures. Of course, there are also combinations of these two techniques.

Car til a ge-Cu t ting Techniq ues

The fi st aesthetic otoplasties reported by Ely in 1881 and Luckett in 1910 were examples of the cartilagecutting techniques.9,14 Becker, Converse, Farrior, and Pitanguy advanced the cartilage-cutting techniques in the 1950s and 1960s9 (Figs. 40-2 and 40-3). It is preferable to use the cartilage-cutting techniques for stiff, thick cartilage requiring a break in its inherent elastic spring to maintain results. Cartilage may be incised either partial thickness or full thickness and from either the anterior or posterior aspect. Portions of the cartilage may also be excised, scored, or abraded to help reshape the auricle. With any cartilage-cutting technique, the surgeon runs the risk of creating visible contour irregularities and sharp edges, which may limit the aesthetic acceptability of the results.14

Car til a ge-S par ing Techniq ues

Cartilage-sparing techniques were developed to address the potential contour irregularities that may arise with the cartilage-cutting techniques.14 The suture techniques should be used for thin or pliable cartilage. No contour irregularities are created, because the cartilage is not incised. However, in patients with stiffer cartilage, these techniques may not achieve adequate correction, because the elastic spring of the cartilage remains intact. In 1963 Mustardé fi st introduced the use of multiple horizontal mattress sutures to re-create the new antihelical fold4 (Fig. 40-4). Th s technique avoided the sharp visible margins that resulted from any of the techniques that incised or excised cartilage from the antihelical fold. Mustardé’s eponymous technique used the placement of permanent sutures on the posterior surface of the ear cartilage to create

Chapter 40 

A

631

Otoplasty for Prominent Ear

B

C

Fig. 40-2  Evolution of the tube principle for correction of prominent ears. A, Luckett technique. B, Barsky technique. C, Becker technique. (Redrawn from Mathes SJ. Plastic Surgery, ed 2. Philadelphia: Saunders Elsevier, 2006.)

Fig. 40-3  Complete correction otoplasty. (Tanzer modifi ation of the Converse procedure). (Redrawn from Mathes SJ. Plastic Surgery, ed 2. Philadelphia: Saunders Elsevier, 2006.)

K23345_Pu_c40 42_Otoplasty Prom Ear_r4_dc_627-640.indd 631

4/3/2015 9:29:09 AM

632

Part VI 

Cosmetic Surgery of the Ear

Fig. 40-4  Mustardé mattress suture technique to create the antihelical fold. (Redrawn from Janis JE, Rohrich RJ, Gutowski KA. Otoplasty. Plast Reconstr Surg 115:60e-72e, 2005.)

Fig. 40-5  Conchal mastoid sutures to correct conchal excess. (Redrawn from Janis JE, Rohrich RJ, Gutowski KA. Otoplasty. Plast Reconstr Surg 115:60e-72e, 2005.)

a soft, entle antihelical fold. These scaphoconchal sutures must be placed precisely. Suture management during knot setting must be done gently to avoid suture “fatigue.” One drawback to this technique is the high tension under which the sutures may be placed, which can lead to suture failure. The technique is also not easily used in the heavy cartilage of the ears of adult men. In 1968 Furnas introduced the use of conchal mastoid mattress sutures to reduce the projection of a deep conchal bowl4,14 (Fig. 40-5). Although the cartilage-scoring techniques are injurious to the cartilage, they will be discussed with the cartilage-sparing techniques, because no full-thickness cartilaginous incisions are performed. Scoring techniques are based on the observations of Gibson and Davis that cartilage tends to warp away from an injured surface.4 Stenström and Chongchet applied this theory to otoplasty. Stenström’s initial technique consisted of anterior scaphal scoring to produce an antihelical fold. He later modifi d his technique with the addition of a posterior approach. The desired amount of cartilage warping can be adjusted by the extent of the scratching or scoring.

Chapter 40 

Otoplasty for Prominent Ear

Combined Appr oa ches

Today many surgeons combine the cartilage-cutting and cartilage-sparing techniques to achieve the desired results. In 1967 Kaye combined the anterior scoring technique of Stenström with the posterior suture placement technique of Mustardé.4 This procedure, which was the first of several composite techniques, used the vertical curvilinear striations of the anterior perichondrium to weaken the cartilaginous “spring,” followed by the creation and securing of the new antihelical fold with the placement of posterior mattress sutures.

Cor r ectio n of the Conch al Defect

The conchal bowl can be corrected in a manner similar to that of the antihelix. Several methods, including suturing techniques, excisional techniques, and scoring, can be used to correct the conchal deformity.15 Conchal mastoid sutures can be used to correct the conchal excess or prominence of the superior two thirds of the ear. 15 Th s suture technique was fi st described by Owens and Delgado in 1955.4 Their method was subsequently modifi d and popularized by Furnas, who used nonabsorbable, full-thickness mattress sutures that were placed in the conchal cartilage (piercing the anterior perichondrium) and sutured them to the mastoid fascia, thus reducing auricular protrusion (see Fig. 40-5). Spira et al10 modifi d this technique to include a laterally based conchal cartilage flap that is subsequently sutured to the mastoid periosteum. This maneuver brings the concha closer to the scalp and thus reduces the protrusion. This particular technique has the advantage of a thick cartilaginous flap that can be more permanently and precisely anchored to the periosteum while decreasing the tendency to obstruct the external auditory canal. In addition, excisional techniques can be used to reduce conchal hypertrophy. Th s technique separates the cartilage where the concha meets the tail of the helix and removes an adequate portion along the conchal rim through a posterior approach. Skin and cartilage techniques are usually performed through an anterior approach. The cartilage must then be reapproximated. Th s cartilage incision is well hidden in the natural convexity of the junction of the conchal bowl and antihelical complex.

Lobule Pos itio ning

Wood-Smith used a modifi d fishtail correction to correct the prominent lobule4 (Fig. 40-6). The posterior skin and subcutaneous tissue of the lobule may be excised in a V, heart, or elliptical pattern and reapproximated for size reduction.

Fig. 40-6  A modifi d fishtail technique to correct a prominent lobule. (Redrawn from Janis JE, Rohrich RJ, Gutowski KA. Otoplasty. Plast Reconstr Surg 115:60e-72e, 2005.)

633

634

Part VI 

Cosmetic Surgery of the Ear

Postoperative Care After complete hemostasis is reached and observed for 10 minutes postoperatively with no signs of bleeding, the posterior skin incision is closed layer by layer. The postauricular suture line is covered with antibiotic ointment or a single layer of Vaseline gauze. The curve of the new antihelix folds and the concha and concavities of the anterior surface may be stabilized with a fluffed, wet, all-cotton gauze dressing placed on the anterior surface of the ear. The gauzes are held in place with plastic wrap and an Ace bandage. Care of the new ear contours during the early postoperative period is very important. The dressing is removed after 2 days. The elastic bandage should be worn for the next 3 postoperative days and while sleeping at night for the next month to prevent accidental stresses on the ear and to ensure that the patient does not make any unintentional movements during sleep that could jeopardize the surgical results. The skin sutures are gradually removed 7 to 10 days after surgery. Vigorous activities such as sports and dancing are allowed 1 month from the day of surgery. After the dressing is removed, showering and hair washing can be resumed.

Results Patient follow-up ranged from 6 months to more than 10 years. Because there was good communication with patients before surgery and favorable surgical outcomes, almost all of the patients were satisfi d with their results. Only one patient was unhappy with her result; she felt that the distance between the helix and mastoid skin exceeded her expectation. In fact, after surgery, the distance between the helix and mastoid skin was reduced and was no more than 2 cm. However, she was satisfi d with her result after reoperation. No major complications, such as hematomas, cartilage infection, wound infection, suture granulomas, or necrosis, occurred in these patients. The postoperative scars were hidden on the posterior surface of the auricle, and there were no keloids.

K23345_Pu_c40 42_Otoplasty Prom Ear_r4_dc_627-640.indd 634

4/3/2015 9:29:10 AM

Chapter 40 

Otoplasty for Prominent Ear

635

Fig. 40-7 Th s 27-year-old man presented with a prominent ear on the right side. A physical examination revealed that the right ear lacked a helical fold. The operative plan started with induction of local anesthesia. The preoperative marking of the antihelix was done with methylene blue dye, and a posterior skin incision was made. Two long linear surgical incisions were designed on the posterior surface of the cartilage along the marks. The incisions were made through the cartilage, and several horizontal mattress sutures were inserted into the edges of the separated incision with 3-0 silk. The sutures were not drawn tight until all the sutures were inserted; the surgeon determined the exact tightness of the sutures so the desired contour was obtained. Six months after surgery, the ears had good symmetry with a natural profile. No major complications, such as hematomas, cartilage infection, wound infection, or necrosis, occurred. The postoperative scars were hidden on the posterior surface of the auricle. There were no keloids and no recurrence of the deformity.

K23345_Pu_c40 42_Otoplasty Prom Ear_r4_dc_627-640.indd 635

4/3/2015 9:29:11 AM

636

Part VI 

Cosmetic Surgery of the Ear

Fig. 40-8 Th s 22-year-old woman presented with bilateral prominent ears, an absent helical fold, and conchal hypertrophy. The operative plan began with the induction of local anesthesia. The preoperative marking of the antihelix was done with methylene blue dye, and a posterior skin incision was made. Two long linear surgical incisions were made on the posterior surface of the cartilage along the marks, and the incisions were made through the cartilage. Several horizontal mattress sutures were inserted into the edges of the separated incision with 3-0 silk. The excess cartilage where the concha meets the tail of the helix was removed along the conchal rim, and the remaining cartilaginous tissues were sutured with 3-0 silk. One year after surgery, the ears have good symmetry with a natural profile. The distance between the helix and mastoid skin was reduced and did not exceed 2 cm.

K23345_Pu_c40 42_Otoplasty Prom Ear_r4_dc_627-640.indd 636

4/3/2015 9:29:12 AM

Chapter 40 

Otoplasty for Prominent Ear

Management of Complications Bleed ing and Hemat oma

Hematoma is one of the most feared immediate postoperative complications.4 Bleeding and hematomas are the result of incomplete hemostasis at the time of surgery. It starts with the acute onset of severe, persistent, and often unilateral pain. When bleeding and hematomas occur, the collection of blood should be evacuated as soon as possible to prevent fl oding of the blood supply to the skin and subsequent necrosis. If hematoma occurs, the head dressing should be removed and the sutures released to drain the hematoma. If bleeding continues, reoperation and exploration are essential.

Infectio n and Cho nd r itis

Infection is another potentially devastating complication of otoplasty, particularly because it can lead to the development of chondritis and residual deformity. Infection can be caused by a lapse in proper sterile surgical technique or dehiscence resulting from excessive tension during closure, or it can be an untoward sequela of prior hematoma evacuation. If redness, swelling, and drainage are found, treatment with intravenous antibiotics and the use of topical mafenide acetate cream are recommended. Chondritis requires emergency surgery. If left untreated, it can result in deformity. Therefore prompt debridement of devitalized tissue is necessary.4

Skin Necr os is and Loss

The profuse blood supply also protects the skin cover of the ear and maintains its vitality through the subdermal circulation. The skin can be widely undermined to provide the necessary access to underlying structures. However, if applied too tightly, conforming dressings can obstruct the venous circulation in the subdermal plexus and result in the loss of skin in the involved area. Th s complication can be avoided with the use of appropriate dressings.

Hyper tr ophic Scar Forma tio n

In about 2% of patients, scar tissue hypertrophy of the postauricular suture line occurs. The use of serial intralesional steroid injections will usually control the overgrowth of scar tissue. Keloid formation can occur in Asians. Management is more difficult and often includes intralesional excision and steroid injections, followed by cutaneous irradiation in dermal doses. Recurrence of keloid scars, even after treatment, is not uncommon.

Sutur e Line Granul omas

Conchal setback sutures may occasionally be visible because of “bow-stringing” of the sutures under the thin skin cover. Th s buried suture will accrete a granulomatous formation around it. If the offending suture is close enough to the skin, extrusion occurs, and removal of the suture is sufficient. The typical late occurrence of suture line granulomas allows local treatment, including removal and topical wound care, without a change in the surgical contours.

637

638

Part VI 

Cosmetic Surgery of the Ear

Hypes thes ia and Dyses thes ia

Disturbances of fi e sensation are not uncommon after incisions in the postauricular groove. The nerve disturbance is caused by the incisions, abrasions, and undermining, but not by direct sectioning of a named nerve branch. Although the gradual spontaneous return of acceptable sensation is the typical course of events, occasionally a patient will need supportive care—psychological guidance and neurotrophic drugs— in the postoperative period.

Recur r ence

Most often the deformity recurs because the Mustardé postauricular suture or knot fails. In rare cases the suture may weaken and break under stress, but more commonly, the knot loosens and becomes untied. The latter situation can be prevented with the technique previously described—a surgeon’s knot with two visualized square knots. In adults recurrence of the flat scapha is caused by a too shallow abrasion of the anterior cartilage or posterior suture failure. Reoperation is usually required to correct the problem.

Telep ho ne Ear Defo rmit y

Telephone ear deformity is caused by an overaggressive setback of the middle third of the helical rims. Th s occurs as a result of the creation of a severe antihelical fold without correction of the position of the lobule and with or without incomplete correction of the uppermost pole of the helix. If a conchal reduction has been done, overaggressive resection of the conchal bowl may be the causative factor. Reoperation and replacement of the Mustardé sutures are usually needed to establish the desired antihelical fold and conchal position.

Revers e Telep ho ne Ear Defo rmit y With Nar r owing of the Exter nal Aud it or y Can al

Reverse telephone ear deformity occurs when the conchal bowl setback is performed too aggressively and the conchal bowl rolls in the sagittal plane, pushing the tragus laterally and narrowing the outer eighth of the external auditory canal. Surgical replacement of the setback sutures is required to correct the deformity.

Other Und es irable Appearances

Any undesirable appearance is usually apparent by 6 months after surgery and manifests as one or more of the following: a sharply ridged antihelical fold, a lack of normal curvature of the superior crus, irregular contouring, a malpositioned or poorly constructed antihelical roll, an excessively large scapha, and a narrow ear.4 Several of these problems need a separate discussion on ways to prevent their occurrence.

Discussion In preoperative assessment of the patient with prominent ears, the surgeon should focus on the following areas: the physical attributes of the ear or ears, the emotional and mental preparation of the patient and family, selection of the appropriate surgical technique to address the deformity, and selection of the optimal anesthetic and patient position during surgery. The surgeon should also discuss the potential surgical outcomes and complications and ensure that the patient has realistic expectations. When deciding on the proper surgical technique, the surgeon should develop a complete plan that can correct each observed anatomic irregularity.

Chapter 40 

Otoplasty for Prominent Ear

Although the physiologic consequences are negligible, the aesthetic and psychological effects on a patient with prominent ears can be substantial.4 Decreased self-esteem, increased anxiety, behavioral problems, and social avoidance may result from disfigu ement. Otoplasty is an appropriate therapy for these patients. After surgery, patients are more self-confide t, they can face people, and their general happiness is increased.

Pearls for Success • It is recommended that at least 1 cm be left on either side of the skin incision to avoid the ear having a glued-on appearance because otherwise the scar will lie too close to the crease. • Tension-free closure may reduce the incidence of hypertrophic scars. • Complete hemostasis must be achieved during surgery. • The sutures are not drawn tight until all of the sutures are inserted and the surgeon determines the appropriate tightness of the sutures to obtain the desired contour. • Conchal hypertrophy and a prominent earlobe should be corrected.

Refer ences 1. Burnstein FD. Cartilage-sparing complete otoplasty technique: a 10-year experience in 100 patients. J Craniofac Surg 14:521-525, 2003. 2. Adamson PA, Strecker HD. Otoplasty techniques. Facial Plast Surg 11:284-300, 1995. 3. Bradbury ET, Hewison J, Timmons MJ. Psychological and social outcome of prominent ear correction in children. Br J Plast Surg 45:97-100, 1992. 4. Janis JE, Rohrich RJ, Gutowski KA. Otoplasty. Plast Reconstr Surg 115:60e-72e, 2005. 5. McDowell AJ. Goals in otoplasty for protruding ears. Plast Reconstr Surg 41:17-27, 1968. 6. Skiles MS, Randall P. The anesthetics of ear placement: an experimental study. Plast Reconstr Surg 72:133-140, 1983. 7. Farkas LG. Anthropometry of the normal and defective ear. Clin Plast Surg 17:213-221, 1990. 8. Tolleth H. A hierarchy of values in the design and construction of the ear. Clin Plast Surg 17:193-207, 1990. 9. Mathes SJ. Plastic Surgery, ed 2. Philadelphia: Saunders Elsevier, 2006. 10. Spira M, McCrea R, Gerow FJ, et al. Correction of the principal deformities causing protruding ears. Plast Reconstr Surg 44:150-154, 1969. 11. Ellis DA, Keohane JD. A simplifi d approach to otoplasty. J Otolaryngol 21:66-69, 1992. 12. Nuara MJ, Mobley SR. Nuances of otoplasty: a comprehensive review of the past 20 years. Facial Plast Surg Clin North Am 14:89-102, 2006. 13. Manushakian HS, Wilson PA, De Souza BA, et al. The prone position in otoplasty. Plast Reconstr Surg 115:963964, 2005. 14. Petersson RS. Current trends in otoplasty. In Shiffman MA, ed. Advanced Cosmetic Otoplasty: Art, Science, and New Clinical Techniques. Berlin: Springer-Verlag, 2013. 15. Hathiram BT, Khattar VS, eds. Atlas of Operative Otorhinolaryngology and Head and Neck Surgery. New Delhi: Jaypee Brothers Medical Publishers, 2013.

639

K23345_Pu_c40 42_Otoplasty Prom Ear_r4_dc_627-640.indd 640

4/3/2015 9:29:12 AM

41 Correction of Other Congenital Ear Deformities Ruhong Zhang, Feng Xu

CONSTRICTED EAR The constricted ear, also known as a cup ear or lop ear, is a congenital auricle deformity that falls between the protruding ear and microtia deformity in severity. The incidence of the constricted ear deformity is about 10%. Th s is a deformity of the superior third of the auricle in which the helical rim appears tightened as by a purse-string, pulling the broad helix over the scapha like a hood.1

Anatomy The anatomic features of the constricted ear deformity include the following three aspects2: 1. The superior helical cartilage is usually acutely folded on itself. In mild cases, the helix merely folds on itself (Fig. 41-1,A); in severe cases, the upper auricular cartilage sags (Fig. 41-1,B). 2. The ear may be tilted forward, similar to a protruding ear, and the entire structure may be lowset. 3. The auricle is smaller than in a normal ear, and height may be decreased.

A

B

Fig. 41-1  A, A mildly constricted ear. The superior helical rim folds on itself acutely. The tight contour of the helix covers part of the scapha and superior crus of the antihelix. B, A severely constricted ear.

641

642

Part VI 

Cosmetic Surgery of the Ear

Table 41-1  Tanzer Classifi ation of the Constricted Ear Type

Description

I

Involvement of the helix only

II

Involvement of the helix and scapha

IIA

No supplemental skin needed at the margin of the auricle

IIB

Supplemental skin needed at the margin of the auricle

III

Extreme cupping deformity; often associated with incomplete migration, forward tilt, stenosis of the external auditory canal, and deafness

From Tanzer R. The constricted (cup and lop) ear. Plast Reconstr Surg 55:406-415, 1975.

Preoperative Assessment Various terms have been applied to this deformity, including lop, cup, or lidding ears, but the broader term constricted ear, originated by Tanzer,3 minimizes confusion about the nature of the defect. The constricted ear deformity combines the features of an overhanging upper pole with a degree of prominence as a single abnormality with a spectrum of severity. The malformation ranges from mild to severe (bordering on true microtia), depending on the severity of developmental failure and the extent of developmental abnormality in the branchial arch (or hillocks). Surgeons can use the Tanzer method to assess the severity of the ear deformity. The Tanzer method classifies this group of ear abnormalities into the types listed in Table 41-1.Surgically, types I and II are defi ed as mild and moderate deformities. Type III is considered severe and requires reconstruction of a new ear with the addition of rib cartilage grafts. For patients with a type III deformity, the correction is essentially the same as for a microtia repair if the deficie cy is severe enough to produce a height difference of 1.5 cm.

Surgical Technique Type I

It is easy to release the slightly folded helical rim to achieve favorable results, because there is sufficient skin relative to the slightly folded cartilage.4

Type IIA

Management of the auricular cartilage with or without supplementation involves adjusting the anterior helix, filleting the deformed helix and scapha, and reconstructing the upper pole of the ear. No supplemental skin is needed to manage the soft tissue. The surgical steps are outlined in Fig. 41-2.

Type IIB

To supplement and expand the auricular cartilage, conchal cartilage grafts rom the ipsilateral or contralateral side are often used as supporting cartilage. The harvested costal cartilage is used to construct the auricular defect in severe cases. The description and surgical steps for correction are outlined in Fig. 41-3. The skin flap from the back surface of the ear is used to cover the reconstructed superior pole of the auricle.

Chapter 41 

A

B

D

643

Correction of Other Congenital Ear Deformities

C

E

F

Fig. 41-2  Surgical steps to repair a type IIA classifi ation of the constricted ear. A, The surgeon identifies he defect

area and outlines a normal helical rim. B, The soft issue is elevated and degloved from the back of the ear to the anterior antihelix level on the upper two thirds of the ear. C, The folded helical rim is released with several incisions. D and E, Th unfolded helical rim is then attached and expanded with a piece of auricular cartilage harvested from the conchal cavity. F, A bolster suture is necessary to make this result stable and permanent.

A

B

C

D

Fig. 41-3  Type IIB classification of the constricted ear deformity. A and B, The outline of the skin incision and skin flap

incision. C, The appearance of the banner flap elevation and auricular defect after release of the constricted superior pole of the auricular cartilage. D, The fabricated costal cartilage grafted to the defect of the superior pole of the auricular cartilage.

K23345_Pu_c41 43_Cx Congen Ear Deform_r3_cl_641-654.indd 643

4/3/2015 10:22:52 AM

644

Part VI 

Cosmetic Surgery of the Ear

Results

Type IIA A

B

Fig. 41-4 Th s 12-year-old girl had a type IIA constricted right ear. The helix of the right ear was curled and folded inward, the scapha was significantly narrow, the upper half of the width of the ear was relatively shorter than that of her contralateral ear, and the auriculocephalic angle was relatively larger (Fig. 41-4, A). Only adequate release and reshaping of the cartilage were performed during surgery; no skin flaps were transferred or transplanted. Ten days after surgery, the helix fold had disappeared, the scapha was evident, the upper half of the width of the auricle was significantly increased, and the auriculocephalic angle had obviously decreased (Fig. 41-4, B). The patient, family, and surgeons were satisfi d with the results.

Chapter 41 

Correction of Other Congenital Ear Deformities

Type IIB A

B

Fig. 41-5 Th s 10-year-old boy had a type IIB constricted right ear. Preoperatively, the cartilage at the upper pole of his left ear was extremely curled and collapsed downward, the superior crus of the antihelix was not visible, the length and width of the auricle were reduced, and the auriculocephalic angle was relatively larger (Fig. 41-5, A). To correct this type of deformity, the surgeon must not only reshape and support the cartilage, but also properly design the skin flaps to cover the cartilage framework. Six months after surgery, all of the patient’s deformities were well corrected with a satisfactory and stable shape (Fig. 41-5, B).

Management of Complications Early postoperative complications, including hematoma, infection, skin necrosis, and wound dehiscence, are not common.5 The most common late-phase sequela is the recurrence of helical downfolding. Th s unsatisfactory aesthetic outcome may occur because of a failure to prevent helical collapse. Because cartilage has “memory,” it has a tendency to return to its original shape.6 Therefore a cartilage flap should be harvested at the helical rim to avoid a recurrence of the deformity. If this step is neglected, the helix is bound to refold. A recurrent helical downfolding can undergo revision with a radial incision on the refolded helical rim; a conchal cartilage graft can be taken from the same ear or the contralateral ear. Another complication is that a smooth curvature of the superior helical rim is not obtained, because the folded helical rim does not completely release and the conchal cartilage graft is easily deformed. To correct this complication, reoperation and reliable fix tion of the conchal cartilage graft are needed.

645

646

Part VI 

Cosmetic Surgery of the Ear

Fig. 41-6  Th s 7-year-old boy with cryptotia of the right ear had an embedded upper auricle without significant cartilage adhesion.

CRYPTOTIA Cryptotia (from crypto “buried or hidden,” oto “ear”) is a congenital deformity in which the upper third of the auricle is buried beneath the temporal skin (Fig. 41-6). The superior auriculocephalic sulcus is not evident but can be seen when gentle fi ger pressure is applied. Th s deformity is more prevalent in Asians than in the white population. The incidence in Japanese children is reported to be as high as 1 in 400 cases.7 Treatment of this condition includes releasing the cartilage from under the skin, recontouring the cartilage, and covering the released ear cartilage with either local skin flaps or skin grafts 8

Anatomy The anatomic structures of cryptotia most often present as one of the following two deformities: 1. Embedded upper auricle: Patients complain about the asymmetry of their ears, because the superior half of the auricle is not visible. As a result, patients have a difficult time wearing glasses because the auriculocephalic sulcus is not visible. 2. Adhesion of the upper auricular cartilage: Th s anatomic deformity is frequently neglected by inexperienced plastic surgeons. The three types of cartilage adhesion are helical adhesion, antihelical adhesion, and adhesion of both structures. Th s malformation is recognized when the surgeon manually pulls out the upper pole of the ear. Early splinting can be successful, but later correction requires surgical division of the abnormal muscle or muscles.9 Skin is added to the deficie t retroauricular sulcus, and cartilaginous reconstruction may also be required. The traditional view is that some patients with mild cryptotia do not have abnormal cartilage development, but currently most surgeons believe that any patient with cryptotia has cartilage dysplasia.10 Therefore the consensus is that a successful cryptotia procedure should correct both deformities.

Surgical Technique V-Y Advancement Fl ap Techniq ue

The most important step of the preoperative assessment to correct cryptotia is to stretch the upper pole of the auricle upward and outward with external force until the whole auricular structure is visible. Next, the surgeon must carefully observe the difference between the affected side and the normal side and pay close attention to the type and severity of the auricular cartilage adhesion and the consistency in height between the highest point of the auricle and that of the normal side.

Chapter 41 

Correction of Other Congenital Ear Deformities

Usually the auricle of the affected side will be slightly lower than that of the normal side. In addition, with repeated stretching, the surgeon can also see and feel the elasticity of the skin and thus have a reference point for the design of the flap. The steps for performing the V-Y advancement flap technique to correct cryptotia are as follows (Fig. 41-7): 1. A reversed V incision is made in the supraauricular region (Fig. 41-7, A). The anterior margin of the reversed V incision ends at the level of the inferior crus of the antihelix. The posterior margin of the flap extends along the hairline of the retroauricular region and ends at the level of the helical crus. 2. The skin is incised. The triangular flap is freed and elevated from the temporal scalp above the superfic al temporal fascia level, and the posterior surface of the upper half of the cartilage is exposed (Fig. 41-7, B). 3. The superior auricular muscle is dissected and placed in the normal position. In addition, the fibrous tissue and intrinsic transverse muscle causing the contracture of the antihelix are dissected. 4. The adhesion between the anterior scapha and helical cartilages is separated. The helical cartilage is cut radially. The cartilage strip from the concha cavity is taken and transplanted to the stretched helix to strengthen the support of the helix cartilage (Fig. 41- 7, C). 5. The flap is inferiorly advanced in a V-Y fashion toward the newly constructed supraauricular sulcus. Finally, the incision is closed (Fig. 41-7, D and E). 6. The new scapha and concha are packed and shaped with petrolatum gauze. Th s gauze is also placed on the posterior incision. Several cotton wool pieces cover the anterior and posterior surfaces of the ear. Loose gauze and a gauze pad are placed around the ear to serve as a pressure bandage. 7. The dressing is changed 48 hours after surgery. The flap is examined for hematoma development and adequate blood supply. The sutures can be removed 10 days after surgery if no complications occur. A

B

D

E

C

Fig. 41-7  The steps for performing the

V-Y advancement flap technique to correct cryptotia.

647

648

Part VI 

Cosmetic Surgery of the Ear

Autho rs’ Modifica tio n

The V-Y advancement flap technique is one of the conventional ways to surgically correct cryptotia. Th s technique has several advantages, including simple and easy design, suffici t skin to the upper and posterior portions of the auricle, suffici t depth of the auriculocephalic sulcus, and no additional requirements for skin grafting. Its main disadvantages are scarring on the temporal scalp, a lowered temporal hairline from the inferior advancement of the flap, and a pronounced lowset upper auricle with narrow cymba conchae. As a result of our increasing experience with the correction of cryptotia, we have modifi d the previously described techniques to obtain optimal results. Our modifi ation of the V-Y advancement flap technique is as follows (Fig. 41-8): 1. The upper pole of the auricle is pulled upward and outward to show a relatively normal structure, and the incision is marked along the auriculocephalic sulcus. 2. The skin is incised, and careful dissection is done between the cartilage and skin of the anterior and posterior ear to completely expose the upper third of the ear cartilage. 3. The adhesion between the anterior scapha cartilage and helical cartilage is separated. The helical cartilage is cut radially. 4. The cartilage strip from the conchal bowl is taken and transplanted to the stretched helix to strengthen the support of the helix cartilage. 5. We produce a normal auricular contour by expanding the constricted ear cartilage. To accomplish this, we place our fi gers at the junction of the inferior crus of the antihelix and the crus of the helix and push the entire cartilage framework backward and upward to the mastoid area. The contact point is marked with methylene blue. Reshaped auricular cartilage is penetrated and sutured with 3-0 nonabsorbable sutures at the marked point to the mastoid area. Th s manipulation is intended to prevent a recurrence and can greatly reduce the tension on the skin incision. 6. A running 6-0 nylon permanent suture is used to close the incision. The new scapha and concha are packed and shaped with petrolatum gauze. Th s gauze is also placed on the posterior incision. Several cotton wool pieces cover the anterior and posterior surfaces of the ear. Loose gauze and pad are placed around the ear to serve as a pressure bandage. 7. The dressing is changed 48 hours after surgery. Hematoma development and blood supply to the flap are observed. The stitches can be removed 10 days after surgery if no complications occur. A

B

Stay sutures

Flap elevated Mastoid periosteum

Reshaped auricular cartilage

Fig. 41-8  Our modifi ation of the V-Y advancement flap technique.

Chapter 41 

Correction of Other Congenital Ear Deformities

Our modifi ation has two advantages over conventional techniques. First, it was thought that cryptotia made the upper skin of the auricle insuffici t and that a skin defect may exist after cartilage restoration. Thus a free skin graft or local flap approach was used to repair the wound. We found that the skin and scalp of the mastoid area had good elasticity and that the skin incision can be sutured directly with our improved method, which decreases skin tension. Second, we fi ed the auricular cartilage framework to the mastoid periosteum, which can effectively resist the retraction of the cartilage framework and avoid recurrence of the deformity. The disadvantage is that our modifi ation makes the auriculocephalic sulcus of the upper quarter of the auricle shallow.

Results

A

B

Fig. 41-9 Th s 7-year-old boy presented with cryptotia on the right side. The primary complaint was asymmetry of the ears. Preoperatively, the auriculocephalic sulcus at the upper pole of the right ear had disappeared, although a local helical adhesion had formed and there was an angular deformity in the antihelix (Fig. 41-9, A). A complete release of the soft issues, such as muscles and fascias, was required, which created traction of the upper pole during surgery to reshape the external helix. At 6-month follow-up, there was no difference between the shape and structure of the right ear compared with that of the normal ear, and there was no recurrence of the deformity (Fig. 41-9, B).

649

650

Part VI 

Cosmetic Surgery of the Ear

Management of Complications The most common early postoperative complication is rebound bleeding, which causes hematoma. Drainage and pressure dressings are effective treatments. The most common sequela in the late phase is the recurrence of the embedded upper auricle. Failure to dissect the abnormal muscles and fibrous tissues contributes to this poor result. Therefore the key to a successful revision of this deformity is the complete release of the abnormal auricular muscle insertion. Another unsatisfactory result is a failure to correct the cartilaginous deformity. The surgeon must recognize the anatomic irregularity of the cartilage before the revision to determine the appropriate strategy for correcting the deformity.

STAHL’S EAR Stahl’s ear is a relatively rare congenital partial auricular deformity. The deformity mainly manifests as an excess third crus, which is frequently accompanied by the angulation deformity of the helix.11

Anatomy Stahl’s ear has a unique shape characterized by a third crus extending from the antihelix across the scaphoid fossa. Th s gives the ear an odd pointed shape that resembles a baboon’s ear. Other features that might be present include a narrowing of the helix, an absence of the superior crus, and a broadening of the scaphoid (Fig. 41-10). The deformity is rare and more commonly seen in Asians.

Fig. 41-10  Stahl’s ear deformity of the right ear. Stahl’s ear consists of an accessory third crus in the ear cartilage, with

an inconspicuous superior crus of the antihelix. The helix shows unfurling, which results in an abrupt contour and a broad scaphoid.

Chapter 41 

651

Correction of Other Congenital Ear Deformities

Preoperative Assessment The focus of assessment for Stahl’s ear is identifi ation of the deformity, including an excess third crus, angulation of the helix, and absence of the superior crus. Each of these deformities should be corrected during surgery.

Surgical Technique In neonates and infants, various congenital ear deformities, including Stahl’s ear, can be corrected with the use of thermoplastic splints. In older children and adults, surgical correction of Stahl’s ear is difficult, which explains the large number of different procedures described in the literature for this relatively rare deformity12-14 (Fig. 41-11).Corrections include the following: • Elimination of the third crus • Creation of a natural helix • Creation of the superior crus • Reduction in the abnormal widened scaphoid

B

A

Abnormal third crus cartilage

Helical rim cartilage

Excised third crus cartilage

C

Third crus cartilage Conchal cartilage graft

Fig. 41-11  A, The abnormal third crus cartilage is exposed. B, The third crus cartilage is excised, including the pointy

area of the helical rim. C, The excised third crus cartilage is used to reconstruct the helical rim and superior crus, and a conchal cartilage graft is used to reconstruct the antihelical defect.

652

Part VI 

Cosmetic Surgery of the Ear

Results

A

B

Fig. 41-12 Th s 50-year-old man with Stahl’s ear is shown before and after correction. An excess third crus extended from the antihelix across the scaphoid fossa. There was no superior crus and broadening of the scaphoid (Fig. 41-12, A). At 6-month follow-up, it is evident that these problems have been corrected (Fig. 41-12, B).

Management of Complications Surgical correction of Stahl’s ear is difficult. Common complications include a helical contour that is not smooth on part of the third crus and an unnatural appearance of the superior crus.

Pearls for Success • In a constricted ear deformity, understanding the degree of malformation is the key to treatment. • Accurate preoperative assessment of the anatomic abnormalities is crucial for surgeons to develop an effective surgical plan. • Various individual techniques are frequently necessary to address each malformation. • The most common complication of cryptotia is recurrence of the deformity, including the disappearance of the superior auriculocephalic sulcus and/or the helical deformity. • Although Stahl’s ear is rare, different techniques are described in the literature, with varying results. To achieve a satisfactory outcome, several techniques must be combined.

Chapter 41 

Correction of Other Congenital Ear Deformities

653

Refer ences 1. Pham TV, Early SV, Park SS. Surgery of the auricle. Facial Plast Surg 19:53-74, 2003. 2. Nagata S. Alternative surgical methods of treatment for the constricted ear. Clin Plast Surg 29:301-315, 2002. 3. Tanzer R. The constricted (cup and lop) ear. Plast Reconstr Surg 73:38-58, 1984. 4. Horlock N, Grobbelaar AO, Gault DT. 5-year series of constricted (lop and cup) ear corrections: development of the mastoid hitch as an adjunctive technique. Plast Reconstr Surg 102:2325-2332; discussion 2333-2335, 1998. 5. Limandjaja GC, Breugem CC, Mink van der Molen AB, et al. Complications of otoplasty: a literature review. J Plast Reconstr Aesthet Surg 62:19-27, 2009. 6. Lentz AK, Plikaitis CM, Bauer BS. Understanding the unfavorable result after otoplasty: an integrated approach to correction. Plast Reconstr Surg 128:536-544, 2011. 7. Cho BC, Han KH. Surgical correction of cryptotia with V-Y advancement of a temporal triangular flap. Plast Reconstr Surg 115:1570-1581, 2005. 8. Hodgson EL, McGregor AD. Correction of cryptotia using full-thickness skin grafts. Ann Plast Surg 47:471-472, 2001. 9. Matsuo K, Hirose T, Tomono T, et al. Nonsurgical correction of congenital auricular deformities in the early neonate: a preliminary report. Plast Reconstr Surg 73:38-50, 1984. 10. Uemura T, Matsumoto N, Tanabe T, et al. Surgical correction of cryptotia combined with intraoperative distention using isotonic saline injection and rotation flap method. J Craniofac Surg 16:473-476, 2005. 11. Ferraro GA, Perrotta A, Rossano F, et al. Stahl syndrome in clinical practice. Aesthetic Plast Surg 30:348-349; dis­ cussion 350, 2006. 12. Weinfeld AB. Stahl’s ear correction: synergistic use of cartilage abrading, strategic Mustarde suture placement, and anterior anticonvexity suture. J Craniofac Surg 23:901-905, 2012. 13. Khan MA, Jose RM, Ali SN, et al. Correction of Stahl ear deformity using a suture technique. J Craniofac Surg 21:1619-1621, 2010. 14. Sugino H, Tsuzuki K, Bandoh Y, et al. Surgical correction of Stahl’s ear using the cartilage turnover and rotation method. Plast Reconstr Surg 83:160-164, 1989.

K23345_Pu_c41 43_Cx Congen Ear Deform_r3_cl_641-654.indd 653

4/3/2015 10:22:55 AM

K23345_Pu_c41 43_Cx Congen Ear Deform_r3_cl_641-654.indd 654

4/3/2015 10:22:55 AM

Part VII

Cosmetic Surgery of the Facial Skeleton

K23345_Pu_c42p_Cosmet Surg Fac Skel_r3_dc_0655-0666.indd 655

4/3/2015 10:28:28 AM

K23345_Pu_c42p_Cosmet Surg Fac Skel_r3_dc_0655-0666.indd 656

4/3/2015 10:28:28 AM

42 Special Considerations in Cosmetic Surgery of the Asian Facial Skeleton

F

Roland T. Minami, Samuel H. Lance, Granger B. Wong

acial aesthetics is a complex, multifactorial subject with anthropologic, cultural, physical, psychological, media, and other influences. Structural components of the face may be the primary factors influencing aesthetic perception, but what constitutes “attractive” depends on the attitudes of the viewer. In this chapter, information from numerous sources has been collected to enhance the understanding of the “aesthetic facial skeleton of Asians,” as viewed by Asian and white observers.

Anthropologic Skeletal Differences Between Asians and Whites Some of the most interesting observations regarding the differences between Asian and white facial bones and skull structure are from the fi lds of anthropology and forensic medicine. Quigley1 studied the Terry collection of skulls at the Smithsonian Institution and came to the following conclusions: • The cranial vault is more globular in shape (Fig. 42-1). • The nasion is more shallow (Fig. 42-2). • The nasal bones are shorter (Fig. 42-3). • The nasal aperture is larger in the vertical direction (this is consistent with short nasal bones) (Fig. 42-4). • The nasal spine is shorter. • Maxillary alveolar flare is present (supporting the fi ding of bimaxillary alveolar protrusion observed in cephalometric studies) (Fig. 42-5). • The characteristic “zygomatic angle” approaching 90 degrees is present (Fig. 42-6). The zygomatic angle, which is the angle of the anterior face of the zygomatic bone as it intersects the Frankfort horizontal plane, is of particular interest. Quigley1 found that this angle is about 65 degrees in most whites. Asians have a much greater angle, and those skulls with zygomatic angles approaching 90 degrees

657

658

Part VII 

Cosmetic Surgery of the Facial Skeleton

are almost certainly Asian. Th s increased zygomatic angle may be responsible for the characteristic “high cheekbone” attributed to Asian faces. It is possible that the cheekbone is not so much higher but fuller. The Asian cheekbone has its own built-in submalar implant, and this bulk, plus a thicker soft tissue pad over the zygoma, may be the reasons for this appearance. Asian infant skulls also have a characteristically broad, blocklike or square zygoma, and this characteristic continues as the skull matures. A

B

Fig. 42-1  Globular Asian cranial vault. A, Caucasoid. B, Mongoloid.

Fig. 42-2  Short Asian nasion.

K23345_Pu_c42p_Cosmet Surg Fac Skel_r3_dc_0655-0666.indd 658

4/3/2015 10:28:29 AM

Chapter 42 

A

Special Considerations in Cosmetic Surgery of the Asian Facial Skeleton

659

B

Fig. 42-3  Short Asian nasal bones and nasal spine. A, White. B, Asian.

A

B

Fig. 42-4  Broad Asian nasal aperture. A, White. B, Asian.

Fig. 42-5  Asian maxillary alveolar flare resulting from bimaxillary alveolar protrusion.

K23345_Pu_c42p_Cosmet Surg Fac Skel_r3_dc_0655-0666.indd 659

4/3/2015 10:28:30 AM

660

Part VII 

Cosmetic Surgery of the Facial Skeleton

Fig. 42-6  Characteristic Asian zygomatic angle approaching 90 degrees.

A

B

A

A

Fig. 42-7  Greater procumbancy and protrusion of the maxillary teeth and the posterior position of cephalometric point A. A, White. B, Asian.

Johnson2 has listed other profile characteristics differentiating white and Asian norms: • Procumbancy or angle or tilt of the teeth is greater in Asians, and the Chinese are very procumbent (Fig. 42-7). • The protrusion of a tooth is its anteroposterior position. Bimaxillary protrusion in Asians is a combination of both procumbancy and protrusion. • Asian groups have a more anterior position of the cephalometric point A, which refl cts the position of the maxillary alveolus. This is the most anterior profile position of the maxillary alveolus and is related more to the alveolar position than to the actual position of the remainder of the maxilla, which may be rather hypoplastic (compared with white norms) or flat in Asians. In this study the soft tissue thickness of Asians and whites was not statistically different. Th s is somewhat surprising in view of the clinical impressions of both surgeons and laypeople. The skeletal framework may be the most important factor in the differences in appearance except for specific anatomic differences, such as in the eyelids and nose.2

Chapter 42 

Special Considerations in Cosmetic Surgery of the Asian Facial Skeleton

A

B

Fig. 42-8  Rounder Asian orbital shape and pinched-appearing nasal bones. A, White. B, Asian.

A

B

Fig. 42-9  Smaller facial index in Asians compared with whites. A, Asian. B, White.

In the frontal view, Asian and white skulls differ in the following ways1: • The orbits are rounder in both sexes (Fig. 42-8). • The maxillary sinus is wider and larger. • The nasal bones are tented or pinched in appearance. • There is a broader flare of the nasal aperture, wider fl or area, and rounder aperture (see Fig. 42-4). Quigley1 and Johnson2 found a signifi ant increase in the width of the Asian face measured between the zygomaticomaxillary junctions. Th s measurement in Mongoloids and the Chinese averages 59 mm in men and 54 mm in women. The distance between the midline and zygomaticomaxillary junction averaged 45 mm in white men and 43 mm in white women. Th s supports the concept of increased facial width in Asians and has been confi med in other studies.

Asian-W hite Pr opor tio ns

An attractive face has lateral cephalometric measurements that are close to the Steiner ideal for whites. 3 Thus the proportions seen in the lateral view of attractive Asians are similar to those of attractive whites in the lateral view, which address the important landmarks in a vertical orientation. In the frontal view, the vertical proportions are again similar between attractive Asians and whites as determined by cephalometric measurements. When comparisons are made between the vertical and transverse facial proportions of attractive white and Asian individuals, both ethnicities have similar vertical proportions. The difference is that the Asian face is wider compared with the white face. Thus if a facial index corresponding to the cephalic index measured the length of the face divided by the width, the facial index in Asians is signifi antly smaller than that in whites (Fig. 42-9).

661

662

Part VII 

Cosmetic Surgery of the Facial Skeleton

Infl uence of Skele t al Frame wor k on Fa ci al Appearance

Fedosyutkin and Nainys4 reported on the relationship between skull morphology and facial features, which is useful in a discussion of the differences in appearance between Asians and whites. For example: • If the frontal edge of the alveolar arch of the mandible is well developed, the projection of the lower lip is pronounced (Fig. 42-10). • Protrusion of the eyeballs is established based on the depth of the orbital cavity. Deep-set eyes in which the upper rim of the orbit is greatly thickened and protrudes relative to the lower rim are found more often in whites (Fig. 42-11). • The cheekbones defi e facial width. • If there is thickening of the outer part of the supraorbital rim and a strong brow ridge (as in whites), the eyebrow is arranged over it, forming an angle as opposed to a more rounded eyebrow contour if the rim is not prominent (as in Asians). This may explain the difference in the eyebrow shape of Asians and whites (Fig. 42-12). • The epicanthal fold near the inner angle of the upper eyelid is characteristic of a high orbit and a lower medium-high nasal bridge, which is found in white and Mongoloid children. In whites this decreases with increasing age, whereas this persists in Asians.

Fig. 42-10  Projection of the lower lip as a refl ction of a pronounced alveolar ridge. (From Fedosyutkin BA, Nainys JV. The relationship of skull morphology to facial features. In Iscan MY, Helmer RP, eds. Forensic Analysis of the Skull. New York: Wiley-Liss, 1993.)

A

B

Fig. 42-11  Characteristics of orbital volume and the upper margin of the orbit. A, Thickened, overhanging rim. B, Narrow rim. (From Fedosyutkin BA, Nainys JV. The relationship of skull morphology to facial features. In Iscan MY, Helmer RP, eds. Forensic Analysis of the Skull. New York: Wiley-Liss, 1993.)

Chapter 42 

Special Considerations in Cosmetic Surgery of the Asian Facial Skeleton

• These authors’ descriptions of the soft tissue differences in skulls with strong and weak characteristics are applicable to the studies of the differences in the white (strong) and Asian (weak) face. For example, the depth of the nasolabial fold depends on the depth of the canine fossa and is more pronounced when the fossa is deep and the profiling of the middle part of the face is strong, such as in whites. Thus whites tend to have deep nasolabial folds, whereas Asians tend to have shallow folds. The figu es in this chapter illustrate the various face shapes and compare them with photos of skulls of Asian and white origin.4

A

B

C

D

E

Fig. 42-12  Skull morphology related to features. A, The direction of the overhang of the fold of the upper eyelid. The

arrangement of the eyebrow is strong. B, Weak eyebrow. C, Pronounced superior orbital margin. D, The form of the upper rim of the eyebrow arched. E, The eyebrow is triangular in shape. (From Fedosyutkin BA, Nainys JV. The relationship of skull morphology to facial features. In Iscan MY, Helmer RP, eds. Forensic Analysis of the Skull. New York: Wiley-Liss, 1993.)

663

664

Part VII 

Cosmetic Surgery of the Facial Skeleton

Table 42-1  Summary of the Differences Between the Asian and White Facial Skeleton Asian

White

Cranial vault

Globular

Ellipsoid

Nasion

Shallow

Deep

Nasal bones

Short

Long

Nasal spine

Short/absent

Moderate

Nasal aperture

Broad, round flare

Narrow, ovoid flare

Zygomatic angle

90 degrees

65 degrees

Maxilla

Hypoplastic

Developed

Alveolus

Bimaxillary alveolar protrusion

Neutral

Cephalometric point A

Anterior

Posterior

Maxillary sinus

Wider and larger

Narrow, shallow

Orbit

Rounder

Ovoid

Facial index

Low

High

Mandible

Developed frontal edge

Recessed frontal edge

Orbital depth

Shallow

Deep

Supraorbital rim

Thi

Thi k

Canine fossa

Shallow

Deep

A summary of the differences between the Asian and white facial skeleton is shown in Table 42-1. Bräuer5 stated that the nose is the most diagnostic area for racial determination and observed the following three types of nasal bridge shapes: 1. Negroid: Quonset hut-shaped, low, and rounded 2. Mongoloid: Tented, low to moderate, with relatively straight sides 3. Caucasoid: Church steeple, high, and pinches

Soft Tiss ue Differ ences

Soft issue thicknesses are population specific, nd therefore all racial and geographic groups should be assessed, because the results from one may not apply to another. Lebedinskaya et al6 found only minor differences in the soft tissue thicknesses in the face while studying Koreans, Buryats, Russians, Lithuanians, and others. Perhaps the geographic proximity of these groups had a greater influence on soft tissue thickness than their race.

Assessment of Facial Beauty The face is the chief component of social perception—how others feel about us and how we feel about them. The social importance of facial appearance has made the enhancement or alteration of the face commonplace as demonstrated by the multibillion cosmetic and cosmetic surgery industries. How we look is important. Attractive individuals are perceived as happier, more intelligent, better educated, wealthier, well adjusted, and nicer people. As we know, any or all of these attributes may be completely untrue.

Chapter 42 

Special Considerations in Cosmetic Surgery of the Asian Facial Skeleton

Box 42-1  Factors Influencing Facial Attractiveness • Morphologic characteristics • Cosmetics and other facial elaboration • Facial expression • Familiarity

Box 42-2  Morphologic Characteristics and Facial Attractiveness in Western Culture • Eyes most frequently mentioned (34%) • Mouth or smile (31%) • Facial proportions or overall facial configur tion (15%) • Hair color (0% to 10%) • Skin color (5%) • Nose shape (5%) Data from Rhodes G, Yoshikawa S, Clark A, et al. Attractiveness of facial averageness and symmetry in non-western cultures: in search of biologically based standards of beauty. Perception 30:611-625, 2001.

Our assessment of beauty is based on consensus, such as the judges of a beauty contest who agree on a winner. Alternatively, we can establish some objective, measurable methods to establish beauty7 (Boxes 42-1 and 42-2).

Objective Standards of Beauty The underlying assumption is that beautiful faces have certain common and measurable morphologic characteristics that are constant despite the wide variations in facial types and patterns. Ricketts8 showed that the golden proportion was present in beautiful faces and other natural items, such as seashells, fl wers, and other human parts. However, proportion alone is not enough. It may be necessary for a given face to fall within the golden proportion to be beautiful, but proportion alone is obviously inadequate to give beauty, because “unattractive” faces may also fall within this proportion. A recent article has shown that the classic canons of beauty are questionable, because many attractive faces fall well outside of their measurements and proportions.9

Common Procedures for Facial Skeletal Surgery in Asians The most common Westernizing procedures include double eyelid formation, dorsal nasal augmentation, malar reduction, buccal fat pad removal, and mandibular angle reduction. The goals of these procedures are to harmonize facial proportions to potentially more Western cephalometric norms and to simply establish facial balance. Eyelid procedures are commonplace and predictable and are done with both incision and incisionless techniques. The same applies to nasal dorsal augmentation. Biocompatibility of silicone and porous polyethylene implants is well tolerated if not excessive to the soft issue envelope. Although not favored in the United States or other Western countries, it is used throughout Asia and perhaps has

665

666

Part VII 

Cosmetic Surgery of the Facial Skeleton

better results with thicker Asian skin. Although zygomatic reduction through a classic open approach is a less common procedure in Western countries and requires a longer postoperative recovery period, it is a popular procedure for young women in Asia, especially in South Korea. However, more recently described, minimally invasive transoral procedures eliminate cutaneous scars and may have faster recovery. Although rarely done in Western countries, surgical reduction of the mandibular angle is also a popular cosmetic procedure for both Asian women and men. Mandibular angle reduction is frought with complications. Furthermore, its use has been diminished by increased usage of botulinum toxin A injections to the masseter muscle to alter surface contours of the mandibular angle. Although the effects are temporary, botulinum toxin A injections to the masseter approximate surgical results but with almost no complications.

Pearls for Success • As surgeons who alter the aesthetic appearance of patients, we must be aware of our own criteria of attractiveness, because these will influence the types of procedures and degree of alterations in a given patient. • We must carefully place ourselves on the hierarchy of traditional to Western criteria for attractiveness just as we do for our patients. • Western-type features are present in Asian populations, such as the “double eyelid,” but they are not as prevalent as in a white population. Therefore these procedures do not necessarily westernize the Asian face. • We must place the procedure in a cultural and anthropologic context to yield an aesthetic result that is still “Asian.” • We need to understand the expectations of these patients to prevent any misunderstanding and disappointment with the surgical results.

Refer ences 1. Quigley C. Skulls and Skeletons: Human Bone Collections and Accumulations. Jefferson, NC: McFarland & Co, 2001. 2. Johnson PF. Racial norms: esthetic and prosthodontic implications. J Prosthet Dent 67:502-508, 1992. 3. Steiner CC. Cephalometric for you and me. Am J Orthod Dentofacial Orthop 30:729-755, 1953. 4. Fedosyutkin BA, Nainys JV. The relationship of skull morphology to facial features. In Iscan MY, Helmer RP, eds. Forensic Analysis of the Skull. New York: Wiley-Liss, 1993. 5. Bräuer G. The origin of modern Asians: by regional evolution or by replacement. In Akazawa T, Aoki K, Kimura T, eds. The Evolution and Dispersal of Modern Humans in Asia. Rotterdam: A.A. Balkema, 1992. 6. Lebedinskaya GV, Balueva TS, Veselovskaya EV. Principles of facial reconstruction. In Iscan MY, Helmer RP, eds. Forensic Analysis of the Skull. New York: Wiley-Liss, 1993. 7. Rhodes G, Yoshikawa S, Clark A, et al. Attractiveness of facial averageness and symmetry in non-western cultures: in search of biologically based standards of beauty. Perception 30:611-625, 2001. 8. Ricketts RM. The biologic significance of the divine proportion and Fibonacci series. Am J Orthod 81:351-370, 1982. 9. Pallett PM, Link S, Lee K. New “golden” ratios for facial beauty. Vision Res 50:149-154, 2010.

K23345_Pu_c42p_Cosmet Surg Fac Skel_r3_dc_0655-0666.indd 666

4/3/2015 10:28:31 AM

43 Aesthetic Corrections of Facial Skeleton: Forehead Contouring Chien-Tzung Chen, Yi-Chieh Chen, Fuan Chiang Chan, Yu-Ray Chen

A

esthetic corrections of the upper facial skeleton involve surgical manipulation of the bony framework of the forehead and the upper orbital rims. The skeletal structure at the temporal region tends to require augmentation rather than surgical correction. Upper face contouring can be generally divided into two types: surgically manipulating the bony framework of the upper face, mainly through formal excision or burring, and adding structure in the form of grafts, which tends to be fat grafts, hydroxyapatite, or polymethylmethacrylate (PMMA) alloplastic material. These two types of manipulations can be performed individually, in combination, or as staged procedures. We usually perform the second type of aesthetic correction (adding structure in the form of grafts) in patients who require fi e adjustment to the fi st type of facial contouring (surgically manipulating the bony framework of the upper face through formal excision or burring).

A

S

Endoscopically assisted surgery has become more widely adopted in recent years as a result of improvements in endoscopic instruments and techniques. Endoscopically assisted surgery provides superior visualization with a less invasive approach and a good aesthetic result with less scarring and a more rapid convalescence. Over the past decade, we have evolved from using the open technique through the coronal incision for achieving good exposure to using an endoscopically assisted technique for exposure of the operative fi ld to correct the upper facial skeleton.

Anatomy The frontal and temporal bones lie anterior to the coronal suture and are responsible for the appearance of the upper face. The frontal bone, which corresponds to the forehead, is convex and usually reveals some remnant of the metopic suture. The skeletal structure of the adult forehead has three distinct layers: the hard internal lamina, the hard external lamina, and the cancellous middle layer or diploë. The average thickness of the skull is 7 mm, but the actual thickness varies among areas and individuals. At the lower part of the frontal bone are the frontal sinuses, which are absent at birth and reach their full size after puberty. In approximately 5% of people the frontal sinuses are absent. The bony contour of the forehead in a young person is relatively flat and smooth, with few irregularities to indicate highlights or shadows when refl cting light. The bony contour of the forehead portrays an expanded and open upper face, which can create the illusion that the lower face is relatively narrow and therefore more youthful and feminine. As

667 K23345_Pu_c43_Aesth Cx Upper Face_r6_cl_667-676.indd 667

4/3/2015 10:30:55 AM

668

Part VII 

Cosmetic Surgery of the Facial Skeleton

Fig. 43-1  Frontal bossing tends to occur bilaterally and symmetrically. There are four distinct locations where frontal

bossing is frequently encountered: two at or just above the medial aspect of the supraorbital rim (solid arrowheads); and two in the midregion of the forehead superior and lateral to the supraorbital prominence (arrows), respectively. These areas of prominence are perceived as visual highlights and have a propensity to dominate and capture the attention of the observing eye, creating the illusion of a narrowed forehead.

individuals age, certain prominent areas or bossing can develop over the frontal bone, disrupting the smooth and expansile forehead contour that once existed. Frontal bossing tends to occur bilaterally and symmetrically. Additionally, we have observed two distinct locations where frontal bossing is frequently encountered (Fig. 43-1): immediately above the medial aspect of the supraorbital rim, and 3 cm above the supraorbital prominence at the frontal eminence. Immediately above the supraorbital rim, a prominence results from the development of the frontal sinus and is present more often in men. The frontal eminence is a rounded elevation refl cting the embryologic origin of the frontal bone from the two bones previously separated by the metopic suture. When light is refl cted off the forehead and frontal bossing is evident, the areas of prominence are perceived as visual highlights set against a background of shadows, which is the rest of the forehead. The highlighted areas tend to dominate and capture the attention of the observing eye, creating the illusion of a narrowed forehead. A narrowed and forward-projecting forehead is aesthetically unappealing, especially in a woman; it conveys an aged visage and presents a stern, angry, or masculine-appearing countenance.

Indications for Upper Face Bony Alteration The indications for upper facial bone alteration are often subjective and must balance both the patient’s desire and the surgeon’s skill. Specific characteristics of a forehead, such as an irregular contour, or a concavity, convexity, narrow width, or raised supraorbital rim, provide a visible target for surgical reconstruction. In other patients, such as those wanting feminization procedures, the surgeon must thoroughly investigate the patient’s desires and expectations. Achieving the desired result in these patients can require simultaneous soft tissue repositioning such as a brow lift, forehead lift, or hair transplantation.

Preoperative Assessment In general, the forehead is not often surgically altered. The two exceptions are patients who have posttraumatic forehead defects and patients who request modest burring of prominent supraorbital rims. We have found that there is another group of patients who present for forehead contouring: transgender individuals who request feminization of the forehead. A good clinical history usually reveals the patient’s aesthetic desires and any potential contraindications for surgery, including the patient’s physical and psychological

Chapter 43 

Aesthetic Corrections of Facial Skeleton: Forehead Contouring

well-being. Patients who present for forehead contouring are usually able to express their aesthetic concerns clearly and are well prepared for the procedure. During the clinical examination, it is critical that the surgeon have a thorough knowledge of cephalometry and its specific measurements. On lateral view, the position and inclination of the forehead, midface, and lower face are noted using soft tissue reference points. Ideally, the forehead and chin should be on the same vertical plane, and the supraorbital rim should project 5 to 10 mm beyond the anterior corneal plane.1,2 Forehead contouring can also be associated with gender reassignment. Because gender reassignment therapy is increasingly being accepted in managing gender identity disorder, patients may increasingly seek facial bone contouring surgery. These patients express a strong desire to live and be accepted as a member of the opposite sex.3 Facial contouring surgery has become an essential part of gender reassignment surgery. It is important to know and appreciate the anatomic differences between a masculine face and a feminine face.4 The distance between the nasion and trichion is greater in men (7 cm) than in women (5 cm). In males the forehead is flat, with prominent supraorbital ridges. In addition, the male forehead has extensive supraorbital bossing, and above this, there is often a flat area before the convex curvature of the upper forehead begins. In females the degree of supraorbital bossing is considerably less or nonexistent, and the area above this is usually less flat and has a more continuous, mild curvature. The female forehead tends to have a smoother and gentler arc. The forehead inclination in females is less posterior than that of males. The impressions gathered during the examination and history taking must be analyzed in conjunction with knowledge of the patient’s desires, the surgeon’s aesthetic sense and surgical limitations, gender considerations, and societal standards. Preoperative photographs are an essential part of preoperative planning. The photographs provide an opportunity for additional analysis, serve as a baseline reference, and are a useful tool for patient communication. In addition, quantitative measurements can be obtained from the use of photographs. For surgical planning in certain patients, the surgeon will request a preoperative CT scan to examine the thickness of the skull bone and to identify contour irregularities, posttraumatic upper face defects, and the dimension of the frontal sinus.

Surgical Technique Open Sur gical Techniq ue

Bone contouring surgery can be performed as a stand-alone procedure or as part of an open brow lift The anesthesia, hair control, incision, and flap elevation in bone contouring surgery are similar to those for an open coronal approach to brow lift. However, we prefer to perform bone contouring surgery with a general anesthetic if possible, because it provides optimal patient comfort. To facilitate postoperative patient comfort, we prefer to use a fi ld block by injecting 10 ml of a long-acting local anesthetic agent such as bupivacaine 0.5% with 1:100,000 epinephrine over the location of the supraorbital and supratrochlear nerves. Then a solution of diluted bupivacaine 0.1% with 1:200,000 epinephrine is injected intradermally over the incision line to promote vasoconstriction at the incision site. Limited infiltration of a local anesthetic to minimize forehead swelling is also advisable so that a precise intraoperative assessment of forehead symmetry is not jeopardized. The frontal periosteum is incised just medial to the superior temporal line on both sides, and superiorly. An inferiorly based periosteal flap is then raised with a periosteal elevator to expose the frontal bone. The locations of frontal bossing that were noted during the clinical examination are confi med. A diamond

669

670

Part VII 

A

Cosmetic Surgery of the Facial Skeleton

B

Fig. 43-2  The open coronal approach to forehead contouring surgery. A, Intraoperative view of bilateral frontal bossing just above the supraorbital rim in a 50-year-old woman. B, A diamond burr was used to carefully shave down the prominent areas; throughout this process, the surgeon must constantly reassess the contour and symmetry of the frontal bone.

burr is used to carefully shave down the prominent areas, the surgeon frequently reassesses the contour and symmetry of the frontal bone (Fig. 43-2). Continuous irrigation while burring prevents excessive heat buildup and thermal bone damage. Once a smooth, symmetrical frontal outline has been attained, the periosteal flap is refl cted back, and elevation and closure of the scalp flap commences. Tension-free closure of the scalp is a vital step in attaining a fi e scar and avoiding alopecia along the incision line; this is particularly important if forehead contouring surgery is performed in conjunction with a brow lift. Drains are rarely required. Antibiotic ointment is applied over the closure site. No other special dressing is needed.

End osc opicall y Ass is ted Sur gical Techniq ue

The patient is given a general anesthetic and placed in the supine position with the head in the neutral position. The entire unshaved scalp and the face are prepared and draped, and methylene blue is used to mark the scalp incisions. Th ee 1.5 cm longitudinally slit incisions are made behind the anterior hairline, in general, if the anterior hairline is 6 cm or more above the eyebrow. The exact position of these incisions depends on the area that will be approached endoscopically. One incision is made to allow endoscopic entrance, and the others are made so that the surgical instruments are able to access to the left nd right forehead, because frontal bossing tends to happen bilaterally and symmetrically. The forehead is then infiltrated with limited normal saline solution containing 1:200,000 epinephrine for both hemostasis and hydrodissection. Infiltration is limited to areas that are to be undermined. The incisions are deepened into the subperiosteal layer. A regular periosteal elevator is inserted to elevate the scalp from the underlying bone and thus to create an optical cavity. To assist the subperiosteal dissection, the surgeon introduces a 4 mm, 30-degree endoscope through the midline incision. To approach the locations of frontal bossing previously noted during clinical examination, the surgeon inserts the endoscopic dissector through the other ports for additional downward subperiosteal dissection. Endoscopic visualization and dissection are also performed to prevent injury to the supraorbital and supratrochlear neurovascular bundles. In the very rare occasion in which the frontal bossing extends beyond the lateral brow region, the periosteal fiber along the superior temporal line is released to increase the optical space laterally. Similarly, an endoscopic diamond burr is used to carefully shave down the prominent areas of the frontal bone (Fig. 43-3). Once the frontal outline is smooth and symmetrical, the subperiosteal space is generously irrigated with normal saline solution and carefully inspected under endoscopic visualization for any bleeders. The scalp wounds are then closed in two layers without any drains.

Chapter 43 

Aesthetic Corrections of Facial Skeleton: Forehead Contouring

Fig. 43-3  Intraoperative view of the frontal bossing at or just above the medial aspect of the upper frontal bone. Under endoscopic visualization, an endoscopic diamond burr was used to carefully shave down the prominent areas of the frontal bone.

For ehead Cont our ing a s Par t of Gend er Rea ss ignment Sur ger y

Facial feminization surgery (FFS) is the general term for a group of surgical procedures that are used to alter the characteristics of the face in male-to-female transsexuals by making them appear more feminine. Facial surgery plays an increasingly important role in the gender reassignment process, particularly in male-tofemale transsexuals with a strong masculine appearance who may benefit from FFS.5

Forehead Reduction and Brow Ridge Contouring One component of FFS is reduction of the prominent supraorbital ridge and glabellar region in males. Th s can be achieved with a coronal incision or through an endoscopically assisted approach for appropriately selected patients. Once fully exposed, the borders of the frontal bossing are marked by perforations with a diamond burr. The burr holes are joined together and the anterior wall of the frontal sinus is mobilized and moved backward on the mucosal pedicle until the planned feminine shape is achieved. The fragment is then stabilized with microplates. The sharp edges are polished with a burr, and the nasofrontal angle is increased from 110 to 130 degrees. For certain patients, the anterior table of the frontal sinus is removed, thinned, and contoured to a more gentle curvature with a series of osteotomies and then fixed into place using microplates. However, in selected patients, contouring the supraorbital rims with a rotary burr to soften the prominent supraorbital ridge is all that is required. These procedures are frequently performed at the same time as a forehead lift. A row lift s also performed, because it helps to create a more feminine appearance. Additional procedures are usually performed only in patients who would likely ask for fi er adjustment after forehead contouring. In our practice, this is the most likely indication for the second type of aesthetic correction, in which a fat graft is commonly used to correct some area of very minor contour irregularity that is evident only to the patients themselves. We routinely perform the fat injection surgery with a local anesthetic so that the patient is able to communicate and be actively involved during the surgical manipulation of the area of concern at the forehead.

Postoperative Care The patient recovers with his or her head in an elevated position. The application of a cold compress can help to reduce postoperative swelling. The patient can shampoo on the second postoperative day. Oral antibiotic therapy is administered for 5 days. For a patient with a coronal incision, scalp staples are removed after 7 to 10 days. A postoperative facial bone CT scan is indicated only in patients who undergo radical bone-contouring procedures.

671

672

Part VII 

Cosmetic Surgery of the Facial Skeleton

Results

Fig. 43-4 Th s 23-year-old transgender woman’s primary complaint was forehead protrusion, which she said she had since birth, and she was concerned about her nasal deviation. During examination, her prominent supraorbital rims and uneven forehead were noted. Her nasal deformity included a prominent dorsal hump and septal deviation. Subsequently, she underwent contouring of her prominent supraorbital rims and frontozygomatic processes through an open bicoronal approach with division of the corrugator muscles. The patient also underwent a dorsal hump resection with a submucosal septal resection through a transcollumelar incision. Septal grafts were used for radix augmentation and columellar support. A right conchal cartilage graft was harvested for a tip shield graft. The patient presented 4 years later with the primary complaint of a “square face,” “wide nose,” and persistent dorsal hump. She then underwent reduction malarplasty and mandibular angle contouring as well as alar narrowing, placement of additional shield grafts, and correction of her nasal bone infractures.

K23345_Pu_c43_Aesth Cx Upper Face_r6_cl_667-676.indd 672

4/3/2015 10:30:56 AM

Chapter 43 

Aesthetic Corrections of Facial Skeleton: Forehead Contouring

673

Fig. 43-5 Th s 23-year-old woman requested upper face contouring. Her chief complaint was of her narrow forehead and prominent brow bone. She reported that she had a head injury during childhood. A preoperative CT image revealed frontal and supraorbital bossing. Endoscopically assisted frontal contouring was performed through three slit incisions, each of which was approximately 1.5 cm long. The dissection was carried out subperiosteally to the lower margin of the supraorbital rim. The bony eminence was shaved down by a diamond burr and rasp. The patient is satisfi d with her postoperative forehead contour, which has a gentle curve and no irregularity.

K23345_Pu_c43_Aesth Cx Upper Face_r6_cl_667-676.indd 673

4/3/2015 10:30:57 AM

674

Part VII 

Cosmetic Surgery of the Facial Skeleton

Fig. 43-6 Th s 21-year-old transgender man presented with the desire to make his face look more feminine. He had previous forehead augmentation with Medpor (7 mm thick), resulting in forehead irregularity and bilateral temporal hollowing. The Medpor forehead implant was removed, and his forehead was recontoured with PMMA to create the convexity and inclination of a female forehead. The total amount of PMMA used was 100 ml, which provided a 13 mm increase in forehead projection. After the recontouring of his forehead, the temporal hollowing improved. He is satisfi d with the result and does not feel that temporal augmentation is necessary.

Discussion In general, the complications of upper face contouring surgery are quite rare. The complications, usually minor, include local hematoma formation, delayed wound healing from a reaction to the underlying absorbable sutures, and scalp alopecia. Adequate hemostasis before scalp wound closure is essential, especially for open coronal flap elevation. Hematomas can be resolved by local aspiration and a compression dressing. Scalp alopecia is managed by direct scar revision with careful preservation of hair follicles after complete maturation of the scalp scar. Revision surgery is largely dependent on the outcome of the previous surgery and patient satisfaction. Minor contour irregularities can usually be managed by fat grafting or hyaluronic acid injection. However, major contour deformity or unsatisfactory results need further reassessment and can be resolved by either coronal flap incision or an endoscopic approach. Although the coronal incision is a widely accepted approach to forehead contouring surgery, it has some notable disadvantages including a long scalp scar, the potential risk for alopecia, and long-term scalp paresthesia.6,7 These disadvantages have signifi ant drawbacks for a patient with simple frontal bossing. With

Chapter 43 

Aesthetic Corrections of Facial Skeleton: Forehead Contouring

the endoscopically assisted technique, only two to three small incisions are required to accomplish the same results that can be achieved through the coronal approach, but without the previously mentioned disadvantages. We have refi ed our surgical skills and adopted the endoscopic technique for less radical upper face contouring surgery. The endoscopically assisted method also provides magnifi d direction visualization with a superior aesthetic outcome, especially for bald patients.8 At the other end of spectrum, the greatest challenges in FFS are managing patients’ expectations and selecting the appropriate procedure for each patient. Patients seeking FFS generally wish to look dramatically different and frequently believe that FFS is their “ticket to a new life.” Th s goal differs from that of patients seeking aesthetic improvement of their facial appearance. Therefore, to reduce any unrealistic expectations from the patient, the surgeon must allocate suffici t time and effort at the outset to explain clearly the risks, benefits, and likely expected surgical outcomes. The patient must be psychologically prepared for the dramatic changes that are intended and have a realistic expectation of the outcome. Before performing FFS, we have the patient assessed by our psychiatrist and proceed with surgery only if there is mutual agreement that the patient is adequately stable and prepared for the procedure. To minimize the risk of failure, we usually carry out facial contouring surgery at the end of gender reassignment therapy.

Pearls for Success • Reduction of frontal bossing can improve the contour of the upper face while simultaneously achieving the desired aesthetic perception of increased forehead width. • For maximum aesthetic results, incorporating frontal bone contouring with soft issue procedures—brow lift, forehead lift, or hair transplantation—is effective and can be performed endoscopically. • Feminization of a male upper face can be achieved by reducing the supraorbital eminence and increasing the convexity of the forehead. A brow lift ay be indicated but the forehead height must be preserved. • For more radical forehead changes, such as those in gender reassignment surgery, the open coronal approach is necessary to adequately achieve the desired results.

Refer ences 1. González-Ulloa M. Quantitative principles in cosmetic surgery of the face (profileplasty). Plast Reconstr Surg Transplant Bull 29:186-198, 1962. 2. Epker BN, Stella JP. Reconstruction of frontal and frontal-nasal deformities with prefabricated custom implants. J Oral Maxillofac Surg 47:1272-1276, 1989. 3. Dempf R, Eckert AW. Contouring the forehead and rhinoplasty in the feminization of the face in male-to-female transsexuals. J Craniomaxillofac Surg 38:416-422, 2010. 4. Farkas LG, Deutsch CK. Two new instruments to identify the standard positions of the head and face during anthropometry. Plast Reconstr Surg 69:879-880, 1982. 5. Becking AG, Tuinzing DB, Hage JJ, et al. Facial corrections in male to female transsexuals: a preliminary report on 16 patients. J Oral Maxillofac Surg 54:413-418; discussion 419, 1996. 6. Riefkohl R, Kosanin R, Georgiade GS. Complications of the forehead-brow lift. esthetic Plast Surg 7:135-138, 1983. 7. Guillot JM, Rousso DE, Replogle W. Forehead and scalp sensation after brow-lift: a comparison between open and endoscopic techniques. Arch Facial Plast Surg 13:109-116, 2011. 8. Chen DJ, Chen CT, Chen YR, et al. Endoscopically assisted repair of frontal sinus fracture. J Trauma 55:378-382, 2003.

675

K23345_Pu_c43_Aesth Cx Upper Face_r6_cl_667-676.indd 676

4/3/2015 10:30:58 AM

44 Aesthetic Corrections of Facial Skeleton: Midface Contouring

W

Rong-Min Baek, Baek-Kyu Kim

ell-defi   ed, high cheekbones are a symbol of youth and beauty. In the medical literature, several techniques for achieving a more attractive midface and malar highlight have been described. Malar augmentation is a common procedure among Westerners who have a dolichocephalic face with a weak malar feature. In contrast with the Western concept of beauty, in which well-defi ed and prominent cheekbones are regarded as integral facial aesthetics, excessive malar prominence is considered unpleasant and undesirable among East Asians. Th s produces a facial appearance that is triangular and possibly emaciated and obstinate.1 Furthermore, in combination with a brachycephalic face and prominent mandibular angles, the overall facial appearance became a square shape. Th s characteristic is undesirable particularly for women in Asia, because it produces an overly aggressive and masculine appearance. For this reason, requests for malar reduction are common in East Asia in contrast to the West, where demands for malar augmentations are predominant. In 1991 Baek et al1 developed a new method of malarplasty that involves lateral orbital and zygomatic arch osteotomy, repositioning of the mobilized malar complex, and bony fix tion. They emphasized that completely mobilized malar complexes can be repositioned three-dimensionally to a more attractive position. When the malar has a lateral prominence, it can be repositioned to the medial side. A drooped malar can be repositioned to the upper side, and an anterior protruding malar can be improved with repositioning to the posterior position. Reposition malarplasty has three essential components2: 1. Lateral orbital and zygomatic arch osteotomy to mobilize the entire zygomatic complex 2. Repositioning to a more attractive position 3. Secure bony fix tion In this chapter, we introduce the detailed methods of reposition malarplasty through a coronal approach as a standard technique for treating various problems of the malar contour and through an intraoral approach as an alternative procedure applicable to a narrower range of conditions, as with young patients with a mild to moderate deformity.

677

678

Part VII 

Cosmetic Surgery of the Facial Skeleton

Fig. 44-1  The zygomatic complex. The zygomatic bony structure has fi m connections to the frontal bone, maxilla, and temporal bone.

Anatomy The zygomatic complex is the main structure constituting the midface contour. It comprises the zygomatic body at the anterior surface and the zygomatic arch at the lateral surface of the zygoma. The zygomatic complex has three processes and resembles a tripod (Fig. 44-1). It is connected to the frontal bone and maxilla anteriorly and to the temporal bone posteriorly. Th s three-dimensional zygomatic complex plays an important role in determining the contour and size of the face. For example, the shape of the zygomatic arch determines the width of the midface.

Indications for Reposition Malarplasty Reposition malarplasty is indicated for patients with: • Anterior protrusion of the zygomatic body that causes the face to appear strong and tenacious • A laterally prominent zygomatic arch that makes the face appear wide and square • Inferior positioning of the zygomatic complex that produces a ptotic midface and an olderlooking face • An asymmetrical zygoma that causes disproportion to the entire face

Preoperative Assessment Preoperatively a detailed and precise measurement and evaluation of the whole face and malar area are necessary. Otherwise, results may be unsatisfactory, such as imprecise repositioning of the zygoma, asymmetry, cheek drooping, and a wider-looking face than a patient had preoperatively. Preoperative medical photographs of the frontal, bilateral oblique, and submental views should be obtained for an objective evaluation of the symmetry and level of protuberance of the zygomatic complex. Bilateral oblique views are especially important. Additional evaluation can be performed using planimetric photography and a basal skull radiographic view. The frontal surface area (located just before the beginning of the oblique surface of the bilateral zygomatic complex) and the lateral surface area (which represents

Chapter 44 

Aesthetic Corrections of Facial Skeleton: Midface Contouring

the degree of protuberance) can be analyzed using these graphical images. Reposition of the protuberance is based on these results. Some patients have depressed temporal fossae, which makes the zygomatic bone appear excessively prominent. For such patients, temporal augmentation should be considered, along with malar repositioning. In patients with a wide bitemporal distance as a result of hypertrophy of muscles or bones, malar reduction alone may not produce satisfying results. In a normal face, the bitemporal and bigonial distances are almost identical, whereas the bizygomatic distance is slightly longer. The relationship between the zygomatic complex and the mandible is extremely important. Patients with a slim lower face expect to have a lean and attractive oval face after reposition malarplasty. However, for patients with prominent mandibular angles, repositioning of the zygomatic arch will make the mandibular angle more prominent. Simultaneous mandibular angleplasty with the reposition malarplasty is indicated in this particular condition.

Surgical Technique Cor onal Appr oa ch

A coronal approach is performed with the patient under general endotracheal anesthesia. The patient is placed on the operating table in a lawn-chair position, with flexi n of the hips, minimal knee flexi n, and head elevation. Good illumination is essential. A fiberoptic headlight provides the best illumination of the malar area under the coronal flap. A local anesthetic solution (0.5% lidocaine with 1:300,000 epinephrine) is injected along the incision line 7 minutes before the incision is made. The incision is beveled parallel to the hair shafts to the pericranium. Subgaleal dissection is carried down to the supraorbital rims, where subperiosteal dissection is performed to expose the entire malar complex, including the zygomatic arch, lateral orbital wall, and anterolateral maxillary wall. The temporalis fascial insertion and masseter attachment to the malar complex are left intact to maintain balanced pulling forces, and the blood supply to the zygomatic bone is preserved, except in the osteotomy site. A combination of lateral orbital osteotomy and zygomatic arch osteotomy allows mobilization of the entire malar complex, which is needed to modify the position of the malar prominence. The lateral orbital osteotomy begins at the maxillary notch, which is located approximately 5 to 8 mm medial to the inferior end of the zygomaticomaxillary suture, continues in a straight direction, and ends near the frontozygomatic suture, preserving the lateral orbital rim (Fig. 44-2).3 The lateral orbital osteotomy is made with a reciprocating saw while soft tissue is protected with a retractor. The maxillary sinus can be opened during the osteotomy, without a signifi ant problem such as infection, sinusitis, or bleeding, based on our experience. Fear of injury to the orbital content may lead a surgeon to place the lateral orbital osteotomy line too far laterally. Th s can cause incomplete correction and a palpable step deformity in the anterior cheek area. A saw blade placed in the proper axis and direction will never enter the orbit or cut vital structures. A zygomatic arch osteotomy is performed just anterior to the zygomatic tubercle. The cut is made obliquely from the posterior to the anterior direction with a small reciprocating saw. After the malar complex is completely mobilized, it can be repositioned medially, superiorly, or posteriorly as planned and is stabilized using interosseous wires or miniplates and screws (Fig. 44-3, A through E).4 It is often necessary to place the bone graft to bridge the bony gap in revision malarplasty for the correction of malunion or nonunion of the zygomatic complex (Fig. 44-3, F through I).

679

680

Part VII 

A

Cosmetic Surgery of the Facial Skeleton

B

Zygomatic body

C

Zygomatic arch

D

Fig. 44-2  A, Lateral orbital osteotomy. B, Zygomatic arch osteotomy. C, Complete mobilization of the zygomatic com-

plex. D, Repositioning of the zygomatic arch to the medial side. (From Baek R, Lee SW. Face lift with reposition malarplasty. Plast Reconstr Surg 123:701-708, 2009.

A

B

Fig. 44-3  A, The lateral orbital osteotomy and zygomatic arch osteotomy line. B, Medial mobilization with three-point plate fix tion.

K23345_Pu_c44_Aesth Cx Midface_r6_cl_677-690pp.indd 680

4/8/2015 7:58:16 AM

Chapter 44 

Aesthetic Corrections of Facial Skeleton: Midface Contouring

681

D

C

E

F

G

H

I

Fig. 44-3, cont’d  C, Superior reposition with wire fix tion. Superomedial repositioning allows fi m bony contact to

correct zygomatic malunion. D, After the dissection, usually a bony gap exists at the zygomatic body, and the malar complex is displaced inferiorly. E, After an oblique osteotomy at the posterior zygomatic arch, the malar complex is repositioned superomedially and fi ed. F, In revision malarplasty the bony gap resulting from nonunion is present at the zygomatic body area, and the malar complex is displaced inferiorly. G, After the osteotomy at the posterior zygomatic arch, the malar complex is repositioned superomedially and fi ed with plates and screws. H, The bony gap (arrow) at the posterior zygomatic arch is bridged with an interpositional calvarian bone graft I, The arch is fi ed with a plate and screws. (From Baek RM, Kim J, Lee SW. Revision reduction malarplasty with coronal approach. J Plast Reconstr Aesthet Surg 63:2018-2024, 2010.)

K23345_Pu_c44_Aesth Cx Midface_r6_cl_677-690pp.indd 681

4/8/2015 7:58:17 AM

682

Part VII 

Cosmetic Surgery of the Facial Skeleton

Box 44-1  Pros and Cons of a Coronal Approach Pros • Accurate reposition of the zygomatic complex in any direction. • Suitable for any age. • Simultaneous forehead and midface lifts can be performed. • Easier correction of asymmetry. Cons • Coronal scar; it is hidden by hair. However, special consideration is needed for the patient with potential baldness. • The possibility of frontal branch injury. • Lazy learning curve.

Fig. 44-4  Subperiosteal dissection on the ante-

rior aspect of the left zygomaticomaxillary complex.

When indicated, the subperiosteal face lift s usually recommended to improve the upper and midfacial soft tissue aging process. The subperiosteal face lift is just a part of closing the coronal incision after malarplasty. There are no additional procedures other than lifting, the excision of excessive skin, and the fixation suture. When redundancy is encountered around the lower face and neck, a subcutaneous rhytidectomy is performed with superfic al myoaponeurotic system plication.3 The pros and cons of this approach are listed in Box 44-1.

Intra oral Appr oa ch

Patient preparation for the intraoral approach is similar to that of the coronal approach. An incision is made on the upper gingivobuccal sulcus from the canine to the fi st molar area. A subperiosteal dissection is performed up to the lateral margin of the orbit, anterior wall of the maxilla, and anterolateral aspect of the zygomaticomaxillary complex (Fig. 44-4).

Chapter 44 

Aesthetic Corrections of Facial Skeleton: Midface Contouring

Fig. 44-5  Endoscopic view of an ostectomy line of a lateral orbital osteotomy.

Fig. 44-6  A zygomatic osteotomy is made with a reciprocating saw through a sideburn approach.

Two parallel, straight lateral orbital osteotomies begin at the temporal border of the zygomatic bone and extend inferomedially to connect with the transverse osteotomy of the zygomaticomaxillary buttress. The distance between the two parallel osteotomy lines depends on the amount of reduction. If the anterior zygomatic body is not very wide and prominent, and the laterally prominent zygomatic arch is the main target of the operation, a single lateral orbital osteotomy is enough for satisfactory repositioning (Fig. 44-5). The zygomatic arch is cut through by the preauricular or sideburn approach with a small incision, shorter than 20 mm. Th ough the incision, the posterior zygomatic arch anterior to the temporomandibular joint is fully exposed with subperiosteal dissection. An osteotomy at the arch is performed obliquely at the anterior part of the glenoid tubercle (Fig. 44-6). Two-point rigid fix tion on the zygomatic body with onepoint rigid fix tion at the zygomatic arch is necessary to secure the bony fix tion (Fig. 44-7). Pros and cons for this approach are listed in Box 44-2.

683

684

Part VII 

Cosmetic Surgery of the Facial Skeleton

A

B

Fig. 44-7  A, Two-point rigid fix tion on the zygomatic body. B, Plate fix tion at the zygomatic arch.

Box 44-2  Pros and Cons of an Intraoral Approach Pros • Easier and simpler than the coronal approach. • No visible scar. • Indicated in mild to moderate deformity. Cons • Steep learning curve. • Although the repositioning vector has the advantage of medial movement (see Issues for the Approach), the other vector is almost impossible in an intraoral approach. • Less secure bony fix tion. • Cheek droop may occur.

Postoperative Care The patient is given a semifluid diet for 3 days, followed by a soft, blended diet for 2 weeks to minimize the pulling action of the masseter muscle. The patient is asked to take precautions to protect the surgical site.

Results All of our patients were satisfi d with their results, and no serious complications occurred. Several patients had numbness above the incision line, but this symptom resolved in all patients after 6 months.

K23345_Pu_c44_Aesth Cx Midface_r6_cl_677-690pp.indd 684

4/8/2015 7:58:18 AM

Chapter 44 

Aesthetic Corrections of Facial Skeleton: Midface Contouring

685

When the strip ostectomy was wide, penetration into the antrum of the maxillary sinus occurred. However, adequate irrigation was performed before wound closure to prevent postoperative problems. In several patients, widened scalp scars were partially revised with simple scar excision. Patients were pleased with their younger-looking faces and balance and harmony in the malar area.

Fig. 44-8 Th s 23-year-old woman had an intraoral reposition malarplasty, a mandibular angle reduction, blepharoplasty, and rhinoplasty. Six months postoperatively, she has a smoother facial line, with a superiorly repositioned malar highlighted point.

K23345_Pu_c44_Aesth Cx Midface_r6_cl_677-690pp.indd 685

4/8/2015 7:58:19 AM

686

Part VII 

Cosmetic Surgery of the Facial Skeleton

Fig. 44-9 Th s 25-year-old woman had an intraoral reposition malarplasty, a mandibular angle reduction, genioplasty, and rhinoplasty. Six months postoperatively, she has a more oval and feminine lower face.

K23345_Pu_c44_Aesth Cx Midface_r6_cl_677-690pp.indd 686

4/8/2015 7:58:19 AM

Chapter 44 

Aesthetic Corrections of Facial Skeleton: Midface Contouring

687

Fig. 44-10 Th s 52-year-old woman had a coronal reposition malarplasty with a subperiosteal face lift.

K23345_Pu_c44_Aesth Cx Midface_r6_cl_677-690pp.indd 687

4/8/2015 7:58:20 AM

688

Part VII 

Cosmetic Surgery of the Facial Skeleton

Management of Complications Asymmetr y Asymmetry is the most common complication of malarplasty. In reality, there is asymmetry in all patients with prominent malar bones. Practically, we cannot make completely symmetrical malar contour with malarplasty. In the preoperative consultation, it is very important for the surgeon to talk to the patient about asymmetry and to make the patient understand the realistic goals of malarplasty. However, if postoperative asymmetry is unacceptable to the patient, secondary malarplasty will be necessary.

Nonunio n and Pain

After the zygomatic complex is medially repositioned, the actions of the facial expression muscles, such as the zygomaticus major and minor muscles, or the masticatory muscles, such as the masseter, can pull down the mobilized zygomatic complex. To prevent this problem, the zygomatic complex should be precisely and rigidly fixed with plates and screws or at least wires. When nonunion with pain and tenderness occurs, operative intervention is usually the only solution.

Cheek Dr o op

Cheek droop sometimes occurs after intraoral malarplasty. It seems to be the result of the detachment of ligamentous attachment of the cheek to the malar and maxillary bones. Cheek droop can be prevented by minimizing the dissection on the malar and maxillary bones or through coronal malarplasty, which usually does not detach the periosteum over the anterior maxilla and the lower zygomatic body. Once cheek droop occurs, it is sometimes difficult to revert. The subperiosteal midface lift has a limited effect on cheek droop.

Tr ismus

Trismus can occur when the temporal muscle is compressed by the medially repositioned zygomatic arch or by iatrogenic damage to the temporomandibular joint during the osteotomy of the posterior zygomatic arch.

Other Complica tio ns

Aesthetic dissatisfaction, too much or too little correction or repositioning, irregular contours of the face, hematoma, and infection are other possible complications.

Issues for the Approach The coronal approach provides a wide surgical view over the entire zygomatic body and arch. It is easy to accomplish symmetric reposition of the mobilized zygomatic complex and to provide rigid and stable fix tion under direct vision. However, this requires the surgeon to have knowledge of and experience with the temporal anatomy to perform the coronal approach safely. Moreover, forehead and midface lifts an be performed concomitantly.3,4 The dissection area in coronal malarplasty is exactly the same as that in subperiosteal forehead and midface lifts. An intraoral approach is more acceptable to patients and is easier and faster for the surgeon to perform than the coronal approach. However, a limited operative fi ld makes the fix tion at the superior part in lateral osteotomy almost impossible. Insuffici t fix tion of the malar complex may produce nonunion and malunion, pain, depression, and crepitus. We recommend at least two-point rigid fix tion on the zy-

Chapter 44 

Aesthetic Corrections of Facial Skeleton: Midface Contouring

gomatic body and one-point rigid fix tion at the zygomatic arch. The level of fix tion should be as high as possible. A poor fix tion in the inferior zygomatic body may result in external rotation of the zygomatic complex. A movable zygomatic arch without proper fix tion can produce symptoms such as a clicking sound or pain when opening the mouth. Several advantages such as repositioning of the zygoma under direct vision, wide exposure for potential harvesting of calvarial bone graft, and the option of lifting ptotic cheeks make the coronal approach an ideal choice for revision malarplasty.3,4

Pearls for Success • Surgeons should choose an appropriate plan customized to each patient to ensure satisfactory results. The best results of repositioning malarplasty can be obtained only when the malar highlights are placed at an attractive position. • Rigid fix tion must be ensured with complete bone-to-bone contact. The recommended amount of bone excision at the zygomatic body is less than 3 mm. • Combined malar repositioning and subperiosteal lifting can reestablish a younger appearance.

Refer ences 1. Baek SM, Chung YD, Kim S. Reduction malarplasty. Plast Reconstr Surg 88:53-61, 1991. 2. Baek SM, Baek RM, Oh KS. Refi ement in reduction malarplasty. Plast Surg Tech 1:129-135, 1995. 3. Baek RM, Lee SW. Face lift with reposition malarplasty. Plast Reconstr Surg 123:701-708, 2009. 4. Baek RM, Kim J, Lee SW. Revision reduction malarplasty with coronal approach. J Plast Reconstr Aesthet Surg 63:2018-2024, 2010.

689

K23345_Pu_c44_Aesth Cx Midface_r6_cl_677-690pp.indd 690

4/8/2015 7:58:20 AM

45 Aesthetic Corrections of Facial Skeleton: Mandibular Contouring

I

Raymond C.W. Goh, Hye-Young Kim, Lun-Jou Lo

ntrinsic anthropometric differences in facial landmark measurements that exist between different races play a role in determining the facial characteristics typical among certain races. Asians have long been thought of as possessing wider faces with a relative lack of anterior-posterior projection. Furthermore, the concept of what constitutes aesthetic beauty varies widely among different cultural groups. In regions of Asia, most people, especially younger women, consider a slender, oval face attractive and desirable. In contrast, a square face with prominent mandibular angles is considered harsh, masculine, and unattrac­ tive. A relatively wide midfacial skeletal structure and the small chin that is commonly seen among Asians can further accentuate the square face appearance.1-7 When properly planned and accurately executed, mandibular contouring surgery can produce dramatic results that soften the contour of the lower face, and remove much of the negative connotations associated with the square face. As such, mandibular contouring, with or without concurrent reduction of the zygoma and genioplasty to correct a square face, has become one of the frequently performed aesthetic procedures for women in Asian countries.1 In this chapter, we discuss essential anatomic aspects, key factors to consider in patient evaluation, surgical indications, and our preferred operative technique for mandibular contouring.

Anatomic Considerations A clear understanding of the anatomic basis underlying the square face is vital for determining the optimal method of treatment and making certain that any surgical intervention is directed at the appropriate areas (Fig. 45-1). Compared with sex-matched controls, square-faced patients have been shown to have a significantly greater volume of osseous hemimandible as well as masseter muscle.8 Assessment of a square-faced patient and treatment planning must therefore take into consideration the variable contribution made to the appearance of the lower face by both bony and soft tissue components. In addition to resection of the mandibular angle, modification of the masseter muscle and buccal fat pad may be required to achieve the desired outcome.2 It is essential to preserve the inferior alveolar nerve during mandibular contouring surgery, since a breach of this sensory nerve can result in bothersome and potentially permanent alterations to lower lip and chin

691

692

Part VII 

Cosmetic Surgery of the Facial Skeleton

Inferior alveolar nerve Intergonial distance

Fig. 45-1  Radiograph showing mandibular angle prominence. The intergonial distance is marked, and the inferior alveolar nerve is indicated (arrow).

sensation. Anatomic studies that document the course of the inferior alveolar nerve within the mandible provide valuable knowledge to guide surgical planning and to ensure safe execution of mandibular contouring surgery.9 The average distance of the inferior alveolar nerve to the outer cortical surface of the mandible is 4.7 mm. Thus the amount of lateral cortical bone that can be removed in an angle-splitting ostectomy must not exceed this amount if the integrity of the nerve is to be preserved. When angle resection is being performed, the oblique distance between the angle of the mandible and the inferior alveolar nerve is of particular importance. The nerve typically courses at least 20 mm from the angle in females and 23 mm in males. 10 This distance should be kept in mind when designing the osteotomy and determining the width of bone at the angle that can be safely resected. To guide the surgeon in mandibular contouring surgery, instruments have been specifi ally developed with these safety margins in mind.

Indications For the majority of patients with mandibular angle prominence, our preferred method of contouring involves resection of the angle through a combined intraoral approach plus a small submental cutaneous stab incision. Angle resection is particularly applicable in patients in whom the intergonial width is acceptable, and prominence is predominantly caused by an acute, posteriorly projected gonial angle. On the other hand, if the principal problem is a wide lower face attributable to a wider intergonial distance with acceptable angularity at the gonial angle, an angle-splitting ostectomy may be more appropriately employed to simply narrow the width of the lower face. Occasionally, patients may present with variable combinations of both wide intergonial distances and sharp angularity at the gonial angles, in which case a blend of techniques may be required. An angle-splitting ostectomy should also be considered when the oblique length of the angle is short, when a minor reduction is required, in older patients, and in patients who cannot accept any external scarring. The disadvantage of this technique is the potential risk of injury to the inferior alveolar nerve.6

Chapter 45 

Aesthetic Corrections of Facial Skeleton: Mandibular Contouring

Preoperative Assessment Several classifi ation schemes, together with associated treatment protocols, have been proposed for the patient with prominent mandibular angles.3,4 Each patient should be individually assessed and the treatment plan tailored to meet that individual’s specific equirements. Both the surgeon and patient need to have a mutual understanding of the specific natomic structure or deformities present and the goals of the surgical intervention. Does the patient dislike the sharpness of the gonial angle when viewed from the side? Or does the patient’s complaint primarily concern the width of the lower face? Having patients bring in a photo depicting what they wish to look like can be helpful in understanding the desired outcome. However, the surgeon must not raise the patient’s hopes unduly by promising unrealistic results beyond that which can be achieved by surgery. In addition to extracting an account from the patient of his or her perception of a deformity, the physical morphology of the patient’s mandible must be ascertained. The patient should be examined from both the front and the side. The width of the lower face (intergonial distance) in relation to the whole face and the degree of angularity at the mandibular angle (gonial angle) should be documented, since this will help determine whether an angle resection, an angle-splitting ostectomy, or a combination of the two techniques is to be applied. The degree of bony and soft tissue contribution to the contour of the lower face must be assessed. Performing bony contouring alone in a patient with signifi ant soft tissue fullness in the lower face may fall short of achieving the desired outcome. A patient with appreciable masseter muscle hypertrophy may require administration of botulinum toxin or partial masseter muscle resection in addition to angle reduction. Removal of buccal fat can also help to narrow the lower face in certain circumstances.2-3,11 A general impression of the patient’s chin should always form an integral part of the clinical assessment. The squareness of the face is often made more obvious by an existing degree of microgenia.5 Advancing and/or lengthening the chin with an alloplastic implant or osteotomy can help enhance the slimming effects of angle contouring alone and promote overall lower facial harmony. A lengthening genioplasty can additionally benefit in recruiting some of the soft tissue laxity that can result from volume changes in skeletal support after angle resection. Patients are often unaware of any preexisting facial asymmetries, and these must be clearly demonstrated to the patient before surgery to avoid postoperative disappointment.1 Although facial asymmetry can be complex and is often not limited to just one area of the face, every attempt should be made to incorporate correction of these asymmetries into the surgical plan. The calculated amount of angle resection or narrowing may need to vary, depending on the clinical presentation, and any chin asymmetries, if present, can be corrected at the same time. Caution and a conservative approach should be adopted for patients in their midthirties who request mandible contouring. The emotional adaptability of older patients in response to dramatic changes in facial shape and appearance appears to be less accommodating. Furthermore, the facial soft tissue envelope of older patients tends to be less elastic and conforms less snugly to volume changes in skeleton support. Consequently, soft tissue in the lower face may droop after mandibular contouring, which can be of concern to patients. Patients in their midthirties or older should be warned of this and cautioned that regional liposuction or a secondary face lift ay be required to correct the unwanted effects. Other ways to minimize soft issue drooping after mandibular contouring include limiting the extent of subperiosteal soft tissue degloving, performing an angle-splitting ostectomy instead of an angle resection, and concurrently lengthening the chin to take up soft tissue laxity.2

693

694

Part VII 

Cosmetic Surgery of the Facial Skeleton

A

B

Fig. 45-2  Radiographs of two patients who requested reduction of their lower facial width. A, Th s patient requires angle resection. B, Th s patient needs an angle-splitting ostectomy.

Photographic documentation is routinely obtained. Plain radiographs (Fig. 45-2) and three-dimensional CT scans are requested if they are thought to be helpful toward analyzing mandibular morphology and surgical planning, particularly in patients who present with signifi ant facial asymmetry.

Surgical Technique Anes thes ia

The procedure is performed with the patient under general anesthesia, preferably with nasotracheal intubation. The patient is positioned supine on the operating table with a transverse roll under the shoulders to extend the neck and a padded ring to stabilize the head. The endotracheal tube is secured intranasally with a transseptal suture and fi ed centrally over the patient’s head. The entire face should be exposed to allow adequate evaluation of facial symmetry. Blood pressure is kept at a mean arterial pressure between 50 and 60 mm Hg with hypotensive agents to minimize intraoperative blood loss. A single dose of intravenous antibiotics is administered. The oral cavity is kept open with a mouth gag, and the mouth is cleaned and teeth brushed with dilute Betadine solution. The operative fi ld is infiltrated with a solution containing 1% lidocaine and 1:200,000 epinephrine.

Incis io n and Expos ur e

An incision is placed along the buccal vestibulum, starting from the anterior border of the ramus and extending anteriorly onto the mandibular body up to the fi st molar or second premolar (Fig. 45-3). A generous cuff of mucosa should be preserved to facilitate ease of wound closure later on. The incision is taken down to the bone using a scalpel or electrocautery. A periosteal elevator is then used to easily elevate the lateral cheek tissue off the mandible in the subperiosteal plane, exposing the area to be resected. A mandibular angle stripper is used to ensure that all masseter muscle fibers are released from the inferior border of the body, angle, and posterior border of the ramus.

Des igning the Osteo t omy

Any preexisting asymmetry in the degree of angle prominence between the two sides must be taken into account and the relative amount of mandibular bone resection adjusted accordingly. The surgeon must always be mindful of the location of the inferior alveolar nerve when designing the osteotomy and de-

Chapter 45 

Aesthetic Corrections of Facial Skeleton: Mandibular Contouring

Fig. 45-3  An incision is made along the buccal vestibulum (dashed line).

Fig. 45-4  Inferior border hook with graduated markings in millimeters.

termining the amount of bone to be resected. A specially designed inferior border hook with graduated markings in millimeters is particularly helpful for confi ming the precise quantity of bone removal, and ensuring that a safe distance is maintained between the osteotomy and the course of the inferior alveolar nerve (Fig. 45-4). The hook is placed around the angle of the mandible, and the proposed level of osteotomy is marked onto the bone with a burr. The resected segment is typically an elongated triangle with an oblique height of 12 to 20 mm.

Per fo rming the Angle Res ectio n

The osteotomy is performed through the combined use of reciprocating and right-angled oscillating saws (Fig. 45-5). A stab incision is placed under the border of the mandible. Th ough this opening, a protective cannula is passed into the operative fi ld. The cannula acts to protect the surrounding soft issue against the friction of the reciprocating saw, which is subsequently passed through the cannula and used to cut the posterior portion of the osteotomy under direct vision intraorally. The anterior portion of the osteotomy is completed using a right-angled oscillating saw through the intraoral incision. Once the osteotomy is complete, a bone clamp retrieves the osteotomized segment while remaining fibers of the medial pterygoid muscle still attached to the medial surface of the bone segment are detached with an elevator. A burr can be used to smooth the transition between the osteotomy and both the posterior border of the ramus and the inferior border of the mandibular body. This creates a softer, more natural curvature at the angle. At this time, a portion of the remaining lateral cortex can also be removed with a burr if narrowing

695

696

Part VII 

Cosmetic Surgery of the Facial Skeleton

A

B

C

D

Fig. 45-5  Osteotomy for angle resection. A, A reciprocating saw is used for the osteotomy of the upper two thirds, the posterior part, through the extraoral skin incision. B, For the remaining third, the anterior-inferior part, an oscillating right-angled saw is used. C and D, The application of the two saws is demonstrated on the skull model.

of the lower facial width is desired. The area limits for lateral cortical burring are the same as those applied in the angle-splitting technique of mandibular reduction. The use of a reciprocating saw through an external incision is chosen by the authors to allow for a more direct and accurate way of completing the posterior portion of the osteotomy. If this part of the osteotomy is performed conventionally through the intraoral approach with a right-angled oscillating saw, there is a possible risk predisposing to unfavorable fractures along the ramus up to the condyle.7,12

Angle-S plit ting Ostect omy

The indications for performing an angle-splitting ostectomy have been mentioned earlier in the chapter. The area where lateral cortex can be removed is limited superiorly by an extension of the occlusal plane, and anteriorly by the convergence of the anterior oblique line with the lower mandibular border. The operative technique is similar to that described by Deguchi et al13 and Han and Kim.14 A groove in the lateral

Chapter 45 

Aesthetic Corrections of Facial Skeleton: Mandibular Contouring

Fig. 45-6  For the angle-splitting ostectomy, the boundaries of the resection area are marked and cut with a 3 mm round burr. The occlusal plane roughly coincides with the upper boundary.

cortex is burred along the superior and anterior boundaries of the area planned for resection (Fig. 45-6). It is vital to ensure that the superior groove reaches the posterior margin of the ramus to prevent a misdirected fracture from extending up the ramus and onto the mandibular condyle. An osteotome is then introduced through the groove and directed through the cancellous bone to split off he lateral cortex. Further refi ement and adjustment of contour can be achieved with burring.

Soft Tiss ue Red uctio n

The decision to implement soft issue reduction should be made during the preoperative evaluation and planning. A combination of partial masseter muscle resection and removal of buccal fat can be performed simultaneously to further slim the lower facial contour, especially if soft tissue contribution is signifi ant. The anterior 5 mm border of the periosteum overlying the masseter muscle is preserved. Then the inner third of the masseter muscle, together with the periosteum, is evenly resected with electrocautery. A hemostat is used to bluntly enter through the buccinator muscle into the buccal fat pad. Buccal fat will typically herniate through this opening and can be resected with electrocautery. On average, about 5 cc of fat is removed on each side.

Cl os ur e

The operative fi ld is thoroughly irrigated and hemostasis ensured. A suction drain is brought out through the intraoral incision and remains in place overnight. The wound is closed in a single mucosal layer with 3-0 chromic catgut. No special dressing is required. Use of an elastic circumferential dressing is not advised, since this causes discomfort and offers limited advantage. The suction drain and submental sutures are removed the next morning.

Postoperative Care The patient is usually discharged after an overnight inpatient stay. Discharge information includes advising that the head should be elevated for rest and sleep. An oral antibiotic is prescribed for 5 days. Oral hygiene is maintained with regular mouth washes, and a liquid or soft diet s recommended for 2 weeks after surgery. A wheel type of face massage device can be used in an inferior-to-superior direction to help any swelling to subside.

697

698

Part VII 

Cosmetic Surgery of the Facial Skeleton

Results An outcome assessment of our patients revealed that most were happy with their facial symmetry and facial appearance after the surgery.1 A successful outcome has a positive influence on the patient’s psychosocial interactions. The preoperative and postoperative photos of some representative patients are presented here.

Fig. 45-7 Th s 25-year-old woman complained of her prominent zygoma and mandibular angle, which made her look angry. She was not happy with the wide appearance of her face and asked for reduction. We discussed appropriate operative procedures with her, including an L-shaped osteotomy with resection of 5 mm of the zygoma body through an intraoral incision, osteotomy of the zygomatic arch through preauricular sideburn incision, resection of the mandibular angle through intraoral and submental incisions, and partial resection of the masseter muscle. The operation went well and her recovery was smooth. The patient was happy with the results and requested additional cosmetic procedures.

Chapter 45 

Aesthetic Corrections of Facial Skeleton: Mandibular Contouring

699

Fig. 45-8 Th s woman presented with a very wide mandibular angle and loose facial soft tissue. She asked for reduction of the angle. At consultation, we explained that signifi ant reduction of the lower facial width would involve resection of the mandibular angle, masseter muscle, and buccal fat pad. A lengthening genioplasty was indicated to correct the drooping facial soft issue and to improve her facial proportions and profile. Lengthening of the chin was achieved using an interpositional bone graft aken from the resected angle. The patient was happy with the outcome.

K23345_Pu_c45_Aesth Cx Fac Skel_r4_cl_691-702.indd 699

4/3/2015 12:40:15 PM

700

Part VII 

Cosmetic Surgery of the Facial Skeleton

Fig. 45-9 This 21-year-old man requested correction of his square face. An angle-splitting ostectomy and partial masseter muscle resection were performed through intraoral incisions. The results were satisfactory, and the patient was pleased with the result.

Management of Complications Complications can happen with revision of the lower face, but they are most often temporary and resolve without long-term sequelae. Complications following mandibular contouring surgery are often the result of clinical misjudgment or errors in operative technique. Hematoma and edema can cause profound postoperative swelling and prolong the recovery, especially if masseter muscle resection has been performed. Infection may develop, requiring antibiotic therapy or open drainage and irrigation. Injury to the inferior alveolar nerve can be avoided or kept to a minimum by performing the bony resection within the anatomic safety margins of the nerve, aided by specialized measuring instruments (see Fig. 45-4) that can assist in accurately determining the position and amount of bone resected.2,7,15,16

Chapter 45 

Aesthetic Corrections of Facial Skeleton: Mandibular Contouring

Secondary Revision Secondary revision may be necessary in cases of postoperative asymmetry, overcorrection or undercorrection, or secondary angle formation. Sometimes revision is necessary when the patient has had unrealistic expectations and is dissatisfi d with the result. In a secondary operation, surgical dissection is usually more difficult and the results may be less predictable. Overresection can be avoided through careful cutting of the bone along the planned line without extending superiorally or medially. For patients with overresection of bone, additional bone graft can be used with rigid fi ation to the defect site. Drooping of soft tissue may occur in older patients with skin laxity and fullness in the cheeks, especially when a large volume of bone reduction is performed. For these patients, secondary liposuction, a thread lifting procedure, or a conventional face lift will provide good results. Fractures along the ramus extending up to the mandibular condyle can be avoided by ensuring that the osteotomy at the posterior margin of the ramus is complete. Fractures involving the condyle or subcondylar region may require treatment by open reduction and internal fix tion or a period of intermaxillary fix tion. The inherent morphology of the Asian face and the current appeal of the oval face in Asian society have contributed to an increasing number of patients seeking contouring of the lower face. As with other aesthetic procedures, rising patient expectations have necessitated refi ements in surgical techniques in mandibular contouring to deliver more favorable and predictable outcomes. Patient satisfaction after facial bone contouring surgery is high.1

Pearls for Success • An improved understanding of normal mandibular anatomy now permits much more precise and safer execution of surgery. • Each patient must be evaluated with particular attention to accurate preoperative analysis of the underlying mandibular morphology and recognition of preexisting facial asymmetries. • Operative planning must incorporate precautionary measures to safeguard against unfavorable fractures and injury to the inferior alveolar nerve. • Consideration must be given to the soft tissue contribution to the lower facial contour, and resection of the masseter muscle and buccal fat pad should be performed when indicated. • The position of the chin plays an underappreciated role in defini g the perceived shape of the lower face, and lengthening or advancing the chin can enhance the overall effects of mandibular contouring. • The long-term outcome of mandibular contouring is usually satisfactory; regeneration of osseous tissue is partial and has not occurred in the angle area.17

Refer ences 1. Choi BK, Goh RC, Moaveni Z, Lo LJ. Patient satisfaction after zygoma and mandible reduction surgery: an outcome assessment. J Plast Reconstr Aesthet Surg 63:1260-1264, 2010. 2. Morris DE, Moaveni Z, Lo LJ. Aesthetic facial skeletal contouring in the Asian patient. Clin Plast Surg 34:547556, 2007. 3. Yu CC, Chen PK, Chen YR. Botulinum toxin A for lower facial contouring: a prospective study. Aesthetic Plast Surg 31:445-512, 2007. 4. Baek SM, Kim SS, Bindiger A. The prominent mandibular angle: preoperative management, operative technique, and results in 42 patients. Plast Reconstr Surg 83:272-280, 1989.

701

702

Part VII 

Cosmetic Surgery of the Facial Skeleton

5. Li J, Hsu Y, Khadka A, et al. Contouring of a square jaw on a short face by narrowing and sliding genioplasty combined with mandibular outer cortex ostectomy in Orientals. Plast Reconstr Surg 127:2083-2092, 2011. 6. Shao Z, Peng Q, Xu Y, et al. Combined long-curved ostectomy in the inferior mandibular border and angle of the mandible with splitting corticectomy for reduction of the lower face. Aesthetic Plast Surg 35:382-389, 2011. 7. Kim YH, Cho BC, Lo LJ. Facial contouring surgery for Asians. Semin Plast Surg 23:22-31, 2009. 8. Lo LJ, Chen YR. The volume of muscles of mastication in patients receiving mandibular contouring surgery: a comparative study. J Plast Reconstr Aesthet Surg 60:125-129, 2007. 9. Kane AA, Lo LJ, Chen YR, et al. The course of the inferior alveolar nerve in the normal human mandibular ramus and in patients presenting for cosmetic reduction of the mandibular angles. Plast Reconstr Surg 106:1162-1174, 2000. 10. Lo LJ, Wong FH, Chen YR. The position of the inferior alveolar nerve at the mandibular angle: an anatomic consideration for aesthetic mandibular angle reduction. Ann Plast Surg 53:50-55, 2004. 11. Tabrizi R, Ozkan BT, Zare S. Correction of lower facial wideness due to masseter hypertrophy. J Craniofac Surg 21:1096-1097, 2010. 12. Kim Y, Park B. Resection of the prominent mandible angle with intraoral and external approach. Aesthetic Plast Surg 27:38-42, 2003. 13. Deguchi M, Iio Y, Kobayashi K, et al. Angle-splitting ostectomy for reducing the width of the lower face. Plast Reconstr Surg 99:1831-1839, 1997. 14. Han K, Kim J. Reduction mandibuloplasty: ostectomy of the lateral cortex around the mandibular angle. J Craniofac Surg 12:314-325, 2001. 15. Yoon ES, Seo YS, Kang DH, Koo SH, Park SH. Analysis of incidences and types of complications in mandibular angle osteotomy in Koreans. Ann Plast Surg 57:541-544, 2006. 16. Goh RC, Lin CL, Lo LJ. Ensuring safer mandibular angle resection surgery by using a calibrated mandibular angle hook. J Plast Reconstr Aesthet Surg 63:e411-e412, 2010. 17. Lo LJ, Mardini S, Chen YR. Volumetric change of the muscles of mastication following resection of mandibular angles: a long-term follow-up. Ann Plast Surg 54:615-621, 2005.

K23345_Pu_c45_Aesth Cx Fac Skel_r4_cl_691-702.indd 702

4/3/2015 12:40:16 PM

46 Aesthetic Osseous Genioplasty

T

Sanghoon Park, Taesung Lee

he   chin is the main component of the lower part of the face and plays an important role in overall facial appearance and harmony. An aesthetically and visually pleasing chin provides balance and symmetry to the rest of the face. The chin is also a major determinant of facial characteristics. For example, a short and weak chin conveys a soft, eminine look, whereas a prominent chin gives a strong and decisive impression. People have different preferences regarding chin shape, and these preferences may differ by time, nation, and race. For these reasons, the chin is considered to be a critical component of facial aesthetics and a symbol of ethnicity. Since Trauner and Obwegeser1 introduced osseous genioplasty through an intraoral approach in 1957, genioplasty has been used for more than half a century for solving various chin problems. Th s surgical technique is well described and established for treating tumors, traumatic injuries, and deformities, as well as for cosmetic changes. Genioplasty is now one of the most widely performed surgical procedures, especially in the Asian population. Despite its popularity and simplicity, however, genioplasty is an errorprone procedure that frequently results in complications and unsatisfactory results. A surgeon can achieve satisfactory results with genioplasty through a good knowledge of anatomy, an understanding of ethnicity, and excellent surgical skills. The versatility of genioplasty makes it a great approach for improving the facial aesthetics of Asians.

Anatomy Inner vatio n

The inferior alveolar nerve courses through the mandibular canal, although the course may vary by individual. The mandibular canal is just below the dental roots in some individuals and just above the inferior border of the mandible in others. A branch of the inferior alveolar nerve, which becomes the mental nerve, exits the mental foramen and supplies sensation to the lower lip and chin.2 The mandibular canal may draw a downward curve below the level of the mental foramen. An anatomic study by Hwang et al3 reported that the average distance from the mental foramen to the mandibular canal is 4.5 6 1.9 mm (Fig. 46-1). Therefore the osteotomy should be at least 5 to 6 mm below the foramen to prevent any direct nerve injuries. A branch from the mylohyoid nerve provides additional sensation to the lower chin. During an osteotomy, however, some nerve branches are inevitably damaged, which may result in postoperative hypesthesia.

703

704

Part VII 

Cosmetic Surgery of the Facial Skeleton

G I H

Fig. 46-1  Looping terminal mandibular canal and mental foramen. G 5 the distance from the terminal mandibular canal to the mental foramen (average: 4.5 6 1.9 mm); H 5 the advanced anterior distance from the terminal mandibular canal to the mental foramen (average: 5.0 6 1.8 mm); I 5 the distance from the terminal mandibular canal to the inferior border of the mandibular body (average: 9.2 6 2.7 mm).

Trigeminal nerve

Maxillary artery

Inferior alveolar artery

Inferior alveolar nerve

Fig. 46-2  Innervation and blood supply to the chin.

Va scul ar it y

The mandible is mainly supplied by the inferior alveolar artery, a branch from the maxillary artery (Fig. 46-2). Supplemental blood supplies are derived from numerous vessels that enter the mandible, particularly the sublingual and submental arteries, which supply blood to the mandible through the lingual gingiva and muscle insertion sites.4

Muscles

The mentalis muscle is one of the most functionally important muscles in the chin. 5 The mentalis originates from the incisive fossa on the anterior surface of the mandible, and its fibers fan out and insert into the skin of the chin, inferior to its origin (Fig. 46-3, A). The position of the mentalis is the main determinant of the depth of the labial sulcus. The muscle is innervated by the marginal mandibular branch of the facial nerve. The mentalis acts as an elevator for the lower lip and contributes to chin dimpling. Improper repair of the muscle may result in an incompetent lower lip and chin ptosis. With the anterior portion of the mandible exposed, the dissection should be made along the inferior border to preserve as much as possible the insertions of the labiomental muscles. The geniohyoid, genioglossus, and anterior bellies of the digastric muscle are muscles that attach along the posterior and inferior surfaces of the mandibular symphysis (Fig. 46-3, B). The labiomental muscles include the mentalis, depressor anguli oris, depressor labii inferioris, and part of the orbicularis oris (pars labialis)(Fig. 46-3, C).

Chapter 46 

705

Aesthetic Osseous Genioplasty

A

B Angle of mandible Stylohyoideus Symphysis Mylohyoideus Digastricus muscle

Sternocleidomastoideus muscle

Hyoid bone

C Levatort labii superioris alaeque nasi muscle Levator labii superioris muscle Zygomaticus minor muscle Zygomaticus major muscle

Orbicularis oris muscle (pars labialis) Mentalis muscle

Depressor septi nasi muscle Buccinator muscle Orbicularis oris muscle (pars marginalis) Depressor anguli oris muscle Depressor labii inferioris muscle Platysma muscle

Fig. 46-3  Musculatures of the chin. A, Mentalis muscle. B, Neck muscles. C, Perioral muscles.

Dentitio n

In general, mandibular growth is completed in the late teens or early twenties with the eruption of the third molars. In any mandibular osteotomies including genioplasty, the surgeon should exercise caution to avoid injuring the dental roots. The dental roots may lie close to the mandibular canal, especially in adolescents and adults with deficie t mandibular height.

Preoperative Assessment The genioplasty can be performed in isolation or in combination with other facial bone surgeries such as orthognathic surgery or bone contouring surgery. Before determining the appropriate surgical approach for genioplasty, the surgeon has to fi d out whether the problem is limited to the chin or involves the entire face. Most patients and even some surgeons overlook the importance of seeing the face as a whole, and this oversight may cause unsatisfactory results. When analyzing the chin, the surgeon must consider the face as a whole and evaluate its proportions. Proper assessment of the chin must consider the balance and harmony between the chin and other parts of the face. The evaluation has to include the relationship between the maxilla and mandible. Soft tissue and bony cephalometric analyses are useful, and occlusal examinations are important. In patients with normal

K23345_Pu_c46_Aesthet Osseous_r4_cl_703-728.indd 705

4/3/2015 10:42:43 AM

706

Part VII 

Cosmetic Surgery of the Facial Skeleton

A

B

C

D

E

F

Fig. 46-4  Classifi ation of chin deformities. A, Normal chin. B, Microgenia. C, Retrogenia. D, Pseudoretrogenia. E, Macrogenia. F, Pseudomacrogenia.

occlusion, a chin deformity can be corrected with a genioplasty; however, in patients with malocclusion, combinations of orthognathic surgery may be required. The chin itself has to be evaluated for proportion and symmetry in all planes: anteroposteriorly, transversely, and vertically.

Cl a ss ifica tio n of Chin Defo rmities

Deformities of the chin can be classifi d in a practical manner based on the chin’s volume and spatial position (Fig. 46-4). 6,7 In microgenia, the chin is small horizontally or vertically or even in combinations. If the chin is positioned posterior to its ideal position, the term retrogenia is used to describe the chin, regardless of its size. Retrogenia as a result of mandibular retrognathia can be called pseudoretrogenia. In macrogenia, the chin is large in either a horizontal or vertical plane or in both planes. A large chin caused by soft tissues only is known as pseudomacrogenia. A long-face deformity producing clockwise rotation of a normal mandible may cause pseudomicrogenia. These classifi ations of chin dysmorphology can assist in guiding the surgeon to the appropriate surgical approach.

Pr opor tio nate Anal ysis

The height of the lower face is important when evaluating the chin and selecting the appropriate surgical approach. For example, elongation of the chin may be needed if the patient has a short lower face, whereas shortening is required if the patient has a long lower face. Th s assessment can be performed through a proportionate analysis by dividing the face into three equal parts along anatomic landmarks such as the trichion, glabella, subnasale, and menton. With the face divided in three equal parts, it is considered to be ideally proportioned.7 However, a ratio of 1:1:0.8produces a result that is presently considered to be more aesthetically ideal by Asians (Fig. 46-5).

Chapter 46 

A

Aesthetic Osseous Genioplasty

B

C

Fig. 46-5  A, The aesthetic facial proportion of 1:1:0.8.B, In microgenia, the lower face is vertically deficie t. C, In retrogenia, the proportions may be the same as those in a normal ideal face. A

B

N

Pg Zero meridian

Fig. 46-6  In González-Ulloa’s analysis,8 the reference line (zero meridian) passes the soft tissue nasion perpendicular to the Frankfort horizontal plane. A, The soft ­tissue pogonion of the chin should be at or just posterior to the zero meridian. B, In retrogenia, the soft tissue pogonion is posterior to the zero meridian. (N 5 Nasion; Pg 5 pogonion.)

Pr ofile Anal ysis

Surgeons can use various methods to assess a facial profile. Some of these methods can be used as a guide to evaluate the chin relative to the overall face, nose, and lips, including González-Ulloa’s analysis, Riedel’s plane, Rickett’s E-line, McNamara’s analysis, Arnett’s analysis, and the pogonion to the N-B line (cephalometric line from nasion to B point). González-Ulloa and Stevens8 discussed the chin pogonion relative to the facial plane called the zero meridian, the line perpendicular to the Frankfort horizontal plane that intersects the nasion (Fig. 46-6). According to González-Ulloa’s analysis, the pogonion should ideally be at or just posterior to the zero meridian line. Another method to assess chin position is by using Riedel’s line.9 Rickett’s E-line, a line drawn from

707

708

Part VII 

Cosmetic Surgery of the Facial Skeleton

Fig. 46-7  Rickett’s E-line is a line drawn from the tip of the nose to the soft tissue pogonion.

1 2

Fig. 46-8  In McNamara’s analysis, a line perpendicular

to the Frankfort horizontal plane (line 1) is dropped through the nasion (line 2, nasion perpendicular line).

TRUE VERTICAL LINE

Fig. 46-9  In Arnett’s soft tissue cephalometric analysis, a line perpendicular to the

G9

natural horizontal head position is dropped through the subnasale (true vertical line). (Landmarks: A9, soft tissue A9 point; AB9, alar base; B9, soft tissue B9 point; CB9, cheekbone height of contour; G9, glabella; LLA, lower lip angle; Md1, fi st mandibular incisor; Mx1, fi st maxillary incisor; NT, ­nasal tip; OR, orbital rim; Pog9, pogonion; Sn, subnasale; SP9, subpupil; ULA, upper lip angle.)

OR9 CB9 SP9

NT

AB9 Sn

Md1

A9 ULA Mx1 LLA B9 Pog9

Fig. 46-10  Pogonion to N-B line. The distance from the pogonion to the N-B line is assessed.

K23345_Pu_c46_Aesthet Osseous_r4_cl_703-728.indd 708

4/3/2015 10:42:47 AM

Chapter 46 

Aesthetic Osseous Genioplasty

the tip of the nose (pronasal point) to the soft tissue pogonion (Fig. 46-7),10 is useful to assess the position of the lips rather than the chin. In McNamara’s analysis, a line perpendicular to the Frankfort horizontal plane is drawn through the nasion, and then the distance from the pogonion to this line is assessed11(Fig. 46-8). Arnett’s analysis is used for soft tissue cephalometric analysis to measure the distance between the soft tissue pogonion and the true vertical line, a line placed through the subnasale perpendicular to the natural horizontal head position (Fig. 46-9).12 In patients with a small chin, however, the maxilla may protrude and the subnasale may not be suitable as a reference line. Another method to analyze chin position is by assessing the projection of the pogonion to the N-B line10 (Fig. 46-10). We have found McNamara’s analysis and Arnett’s analysis to be the most useful methods for assessing the chin relative to the overall facial profile. In the West, an Apollonian face was historically considered to be an ideal facial profile. In Asia, however, this facial profile is considered too flat in appearance. Asians tend to have flat, wide faces, and the Apollonian face makes Asian faces look even flatter. Therefore Asians generally prefer a slightly protruding mouth with a small chin, because it looks more stereoscopic and has a “baby face” appearance. Asian women, in particular, prefer a short, small chin, because they think it gives them a soft, feminine look. However, these opinions differ among Asian nations and regions. For example, Japanese and southern Chinese people favor a slightly protruding maxilla with a weak chin, whereas people from the middle eastern regions of Asia or northern China prefer a flat maxilla and a strong chin.

Fr ont al Anal ysis

Although an ideal facial profile is well described in the literature, the anterior appearance of the face is rarely described or analyzed. The shape of the chin as viewed from the front should not be seen in isolation. Assessing the shape of the chin from the front is critical, because the frontal view enables the surgeon to determine the impression of the chin as well as the contour of the entire lower face. Frontal chin shape is characterized by bony and soft issue components, and it is associated with the adjacent mandibular border and soft tissues (Table 46-1).

Table 46-1  Components of the Frontal Chin Component

Characteristic

Lower border of chin

Smooth/angular/pointed

Width-length ratio

Wide or narrow/long or short

Prominence of chin button

Prominent/flat

Chin pad

Full/flat

Continuity of lower border from mandible

Smooth/pear-shaped

Defin tion from neck

Good/poor

Marionette line

Flat/deep

709

710

Part VII 

Cosmetic Surgery of the Facial Skeleton

CHIN TYPES

Round

Broad

Blunt

Angular

Trapezoid

Triangular

Pear-shaped

Pointed

Fig. 46-11  Classifi ation of the chin in anterior view.

Frontal chin shape can be classified by using various aesthetic components of the chin 13 (Fig. 46-11). A round chin has a round, continuous contour from the mandible. A broad chin is defi ed as a vertical elongation of a round chin. A blunt chin has more chin pad, whereas an angular chin has less chin pad and thus prominently shows the chin button. A trapezoid chin has some horizontal components in the lower border of the chin, while a triangular chin has minimal horizontal components. A pear-shaped chin has discontinuity or depression between the chin and the lower facial line, whereas a triangular chin and a pointed chin have no discontinuities or depressions. The triangular chin has a broad base in the adjacent lower face; the lower facial width is narrow in a pointed chin. Although the incidence of each type of frontal chin shape is quite evenly distributed in the Asian population, more Asians prefer triangular and trapezoidal chins.13

Fa ci al Dysmor pho l o gy

When the surgeon identifies disharmony in a patient’s profile, the underlying occlusal and skeletal deformities should be determined. Deformity of the chin may be only a part of an overall dentofacial deformity (Fig. 46-12). For example, a small, weak chin may be a sign of class II malocclusion, although other features may coexist, such as a procumbent lower lip, steep mandibular plane, accentuated labiomental fold, and a long facial height with vertical maxillary excess. A heavy chin may be a part of mandibular prognathism or a prominent mandible. The surgeon must assess the whole dentofacial deformity, not just the chin problem to determine the most appropriate treatment. When no skeletal malformation is present except for the chin, genioplasty can be considered as the treatment of choice.

Chapter 46 

A

B

711

Aesthetic Osseous Genioplasty

C

Fig. 46-12  Dysmorphology of the facial skeleton related to chin deformities. A, Anterior open bite. B, In a patient with

class II malocclusion after correction of retrognathia with mandible advancement, the chin may also have to be advanced to obtain optimal occlusion and facial profile. C, In mandibular prognathism, usually the chin should also be moved anteriorly or posteriorly to achieve an optimal facial profile, because the ideal occlusion can be achieved through orthognathic surgery.

Surgical Technique Anes thes ia

A general anesthetic is recommended for osseous genioplasty, so it is important to thoroughly assess the patient’s health preoperatively, and the patient must be closely monitored during surgery, especially in patients with severe microgenia or micrognathia, because airway control may be complicated even after successful induction of the anesthetic. Bleeding, aspiration, and airway control can be problematic during an osseous genioplasty with a local anesthetic; therefore patients should be told preoperatively that these potential complications could lead to the need for a general anesthetic instead.

Intra oral Appr oa ch

Soft issue dissection to expose the midsymphysial area is generally identical for all intraoral approaches in genioplasty. A local anesthetic with a vasoconstrictor is infiltrated along the proposed incision line and dissection area, both submucosally and subperiosteally. After an adequate amount of time allows the local anesthetic and vasoconstrictor to act, the lower lips are retracted anteriorly. A labial incision midway between the labial sulcus and the lower lip vermilion is made from the canine to the opposite canine, avoiding division of the frenulum. When the incision cuts through the mucosa, any superficial branches of the mental nerve should be identifi d. The mentalis muscle is divided, leaving a suffici t stump on the gingival side to ease the wound closure. Inferior dissection to the inferior border of the mandible is performed subperiosteally. The dissection should not completely deglove the inferior border of the mandible, because that may disturb blood supply to the bone segment. The surgeon should take great care to identify the mental nerves and to protect them during the dissection. Limited dissection near the nerve bundles avoids excessive traction during the surgery and diminishes potential neurosensory defic ts. The surgeon should perform the dissection posterior enough to ensure adequate visualization and access for performing the osteotomy (see Fig. 46-13).

712

Part VII 

Cosmetic Surgery of the Facial Skeleton

A

B

C

D

Fig. 46-13  Advancement genioplasty. A, The labial incision should be at least 5 to 6 mm inferior to the sulcus. B, Th

mandible is exposed below the mental foramen and lateral along the inferior mandibular border. C, The distal bone segment is mobilized and advanced as planned. D, Fixation is done with a plate and screws.

Advancement Genioplasty An advancement genioplasty can be performed to correct the deformity of an anteroposterior deficie cy and to achieve proper anteroposterior chin positions. After the dissection is completed, the surgeon should use a bur or saw to mark the symphysial midline both above and below the planned osteotomy to prevent asymmetry. The osteotomy line should be drawn at least 5 mm below the mental foramen. The surgeon should double-check that the osteotomy line is horizontal, because a right-handed surgeon tends to draw the line higher on the left sid , and a left- anded surgeon tends to draw the line higher on the right side. Then the osteotomy is completed with a reciprocating saw. When the distal bone segment gains enough mobility to allow manipulation, the segment should be advanced as planned and rigidly fi ed with plates and screws (Fig. 46-13). A prebent plate is preferred to precisely control the amount of advancement. At least two screws should be placed in each mobile segment, because postoperative stability is essential for aesthetic refi ements. Each amount of advancement should be conservative, usually not exceeding 6 mm. Excessive advancements may lead to a deepened and exaggerated labiomental fold; to avoid this potential problem, a twotier osteotomy may be performed. However, a two-tier osteotomy may result in a wider-looking lower face without the expected improvements on the deepened folds, and it has a higher chance of bone segment absorption. Therefore this procedure is rarely advocated. In addition, characteristics such as the age and sex of the patient should be considered, because in general, smaller amounts of advancement have to be planned for women and elderly patients. The advancement can be planned through preoperative cephalometric analysis (see also Fig. 46-10). Regardless of the analysis method used, it is important to plan for the bony pogonion not to advance beyond the lower incisor and for the soft issue pogonion not to advance beyond the lower lips. The intramandibular harmony of the chin should be considered before the intermaxillary (chin to maxilla) harmony.

Chapter 46 

Aesthetic Osseous Genioplasty

713

Res ul t s

Fig. 46-14 Th s 20-year-old man had advancement genioplasty of 5 mm to correct his retruded chin. He was pleased with the results after 6 months.

K23345_Pu_c46_Aesthet Osseous_r4_cl_703-728.indd 713

4/3/2015 10:42:49 AM

714

Part VII 

Cosmetic Surgery of the Facial Skeleton

Fig. 46-15 Th s 25-year-old woman had advancement genioplasty of 7 mm to correct her weak-looking chin. Her retrogenia improved signifi antly. She was satisfi d with the result 6 months after surgery.

K23345_Pu_c46_Aesthet Osseous_r4_cl_703-728.indd 714

4/3/2015 10:42:51 AM

Chapter 46 

Aesthetic Osseous Genioplasty

Setback Genioplasty Setback genioplasty is performed to correct a deformity of anteroposterior excess (Fig. 46-16). Setback genioplasty has to be performed selectively in patients with excessive chin advancement, when the hyperplasia of the mandible itself is not too severe. Th s procedure must be avoided as a treatment strategy for mandibular prognathism. Patients who have a chin with a flat appearance are also poor candidates for a chin setback, because if the pogonion is pushed back behind the B point, the labiomental fold may be flattened too much, leading to an unaesthetic result (Fig. 46-17).14 Setback of the chin usually results in chin widening and produces irregularities in the inferior border of the mandible with the loss of a normal smooth contour. Th s problem can be prevented by the surgeon’s performing the divergence control technique, a simultaneous narrowing procedure to control the divergence of the bone segments. A midline split osteotomy or midline wedge ostectomy can be performed, and the two segments are then fi ed separately after the amount of setback is determined (Fig. 46-18).15 When fixi g the segments, it is important to reduce the angle of divergence, because this may prevent unsightly protrusions in the inferior borders of the mandible.

Mental foramen At least 6 mm to avoid nerve

Reciprocating saw

Fig. 46-16  Setback genioplasty.

A

B

Fig. 46-17  The change in the labiomental fold after setback genioplasty. A, The defin tion of the labiomental fold has to remain clear after setback of the chin. B, A flat or retroclined labiomental fold is aesthetically unpleasing.

A

B

Fig. 46-18  The divergence control technique. A, After setback genioplasty, the reduced angle of divergence of the bone segments diminishes the irregularity in the inferior border of the mandible. The segments are narrowed by removing a midline bony wedge from the lingual side, and B, by medial bending of the bone plates.

715

716

Part VII 

Cosmetic Surgery of the Facial Skeleton

Res ul t s

Fig. 46-19 Th s 28-year-old woman had setback genioplasty of 2 mm to correct her protruding chin. Optimal profiles were achieved, and she was satisfi d with the result 6 months after the surgery.

K23345_Pu_c46_Aesthet Osseous_r4_cl_703-728.indd 716

4/3/2015 10:42:53 AM

Chapter 46 

Aesthetic Osseous Genioplasty

717

Fig. 46-20 Setback genioplasty of 3 mm was performed to correct the protruding chin on this 25-year-old man. He was satisfi d with the result 6 months after the surgery.

K23345_Pu_c46_Aesthet Osseous_r4_cl_703-728.indd 717

4/3/2015 10:42:54 AM

718

Part VII 

Cosmetic Surgery of the Facial Skeleton

Reduction Genioplasty Reduction genioplasty is performed to correct a chin deformity with vertical excess. When chin shortening through a vertical reduction procedure is required, a horizontally parallel bone segment is usually removed from the chin (Fig. 46-21). A lower osteotomy should be performed before an upper osteotomy to avoid losing control of the distal segment. Because surgeons are tempted to reduce more of the chin during the surgery, the chance of nerve injury increases. Surgeons should keep in mind that safety is of paramount importance in reduction genioplasty, and they should always be cautious to avoid jeopardizing the nerve when trying to reduce the height. Although easy to overlook, soft tissue control is one of the most important factors when performing reduction genioplasty. Minimizing muscle stripping of the remaining bone segment is important to maximize soft issue mobilization, allowing the soft issues to go into the desired position. A suspension suture for soft tissue lifting may also be helpful. By using an absorbable suture, the surgeon can pull the muscles and periosteum upward and affi them to the plate. Such procedures assist the soft tissues in redraping properly and avoiding soft tissue sagging and ptosis as a result of bone reduction.

A

B

C

D

Fig. 46-21  Reduction genioplasty. A, The labial incision is designed to avoid division of the frenulum. B, Midsymphysial exposure and design of the osteotomy line. Note that the midline is marked and the shaded part is going to be removed. C, Removal of the middle bone segment. D, Fixation with a plate and screws.

Chapter 46 

Aesthetic Osseous Genioplasty

A wedge-shaped resection can be performed to control the axis of the vertical reduction in either the anteroposterior dimension or the transverse dimension (Fig. 46-22). However, modifying this axis in the anteroposterior dimension may yield results that fall short of the surgeon’s expectations. After reduction genioplasty, an additional marginal osteotomy or shaving is required, because a step deformity can be seen on each side of the chin. Usually, the steps can be approached through the same genioplasty incision with or without an extension, but an additional incision may be needed in cases with large steps. However, excessive reduction may cause the soft tissues of the chin pad to bunch, making the chin look more advanced and the labiomental fold look deeper. To avoid this problem when the amount of vertical reduction is more than 3 mm, the surgeon should perform a setback of approximately 1 mm to maintain a natural-looking soft tissue contour. The response rates of the soft tissues after bone movement depend on the vectors of the movements and the type of osteotomy performed. For example, the response rate is approximately 90% to 100% in advancement genioplasty and 50% in setback genioplasty. However, the responses of the soft tissues are extremely low in reduction genioplasty, in which they are nearly down to 25%.14,16 Therefore certain amounts of overcorrection may be required when performing reduction genioplasty, especially when correcting for asymmetry.

A

C

B

D

Fig. 46-22  Wedge osteotomy to control the axis of the vertical reduction. A, Posterior-based wedge resection. B, ­Anterior-based wedge resection. C and D, Lateral-based wedge resection.

719

720

Part VII 

Cosmetic Surgery of the Facial Skeleton

Res ul t s

Fig. 46-23 To achieve an optimal facial proportion, this 42-year-old woman had reduction genioplasty of 4 mm to reduce the vertical length of her chin. She was satisfi d with the result 6 months after the surgery.

K23345_Pu_c46_Aesthet Osseous_r4_cl_703-728.indd 720

4/3/2015 10:42:57 AM

Chapter 46 

Aesthetic Osseous Genioplasty

Narrowing Genioplasty Narrowing genioplasty is indicated to correct a deformity of transverse excess and to make a slim lower face, and it helps to feminize the facial impression. It can be performed as a single procedure or combined with a simultaneous advancement, setback, or reduction procedure. Narrowing genioplasty is frequently used in conjunction with mandible contouring surgery. One horizontal osteotomy and two vertical osteotomies are designed for the narrowing genioplasty procedure. The amount of resection in the middle bony segment should be determined preoperatively. The amount to be narrowed depends on several factors such as the width of the chin, the patient’s desire, and the course of the mandibular canal, which usually ranges between 6 mm and 12 mm. In patients with asymmetry, the center of the middle segment should be lateralized to the more prominent side. After the osteotomy is completed, the middle segment is removed and the two lateral segments are fi ed in the center (Figs. 46-24 and 46-25). To obtain a more natural-looking and smooth curvature in the lower border of the mandible, an additional osteotomy or shaving on the lateral aspects of the mandible is usually required. When it is performed in combination with the mandible contouring procedure, resection of the bony steps can be extended to the mandible angle.9 However, the narrowing process can cause bunching of the soft issues, especially in patients with fatty faces and chins. Partial redraping of the soft tissue attachments in the chin during the surgery minimizes soft tissue bunching and improves the results. A

B

C

Fig. 46-24  A narrowing genioplasty of 8 mm. A, One horizontal osteotomy and two vertical osteotomies were de-

signed. B, The middle segment was removed and the two lateral segments were fi ed in the center. C, Further contouring on the lateral steps may be required.

A

B

Fig. 46-25  A narrowing genioplasty of 11 mm. A, One horizontal osteotomy and two vertical osteotomies were designed. B, The middle segment was removed and the two lateral segments were fi ed in the center.

721

722

Part VII 

Cosmetic Surgery of the Facial Skeleton

Res ul t s

Fig. 46-26 Th s 28-year-old woman with a history of reduction malarplasty requested a narrowing genioplasty. She wanted to correct her broad chin, which was relatively prominent after the prior malarplasty. The patient’s chin was narrowed by 8 mm. She was satisfi d with the result 6 months after the surgery.

K23345_Pu_c46_Aesthet Osseous_r4_cl_703-728.indd 722

4/3/2015 10:42:59 AM

Chapter 46 

Aesthetic Osseous Genioplasty

723

Fig. 46-27 Narrowing genioplasty was performed on this 27-year-old woman. The patient desired a slender appearance; therefore reduction malarplasty was performed simultaneous with the genioplasty. Her chin was narrowed by 11 mm. She was satisfi d with the result 6 months after the surgery.

K23345_Pu_c46_Aesthet Osseous_r4_cl_703-728.indd 723

4/3/2015 10:43:00 AM

724

Part VII 

Cosmetic Surgery of the Facial Skeleton

Discussion Neur os enso r y Deficit s Neurosensory loss of the lower lip is a common postoperative complication after genioplasty, but it is usually transient. Previous studies on neurosensory alteration after genioplasty report that the incidence of temporary paresthesia ranges widely from 12% to 70%.17-19 However, these reports usually conclude that the temporary paresthesia does not leave any permanent numbness and that the risks for permanent defic ts are negligible. Transient neurosensory defic ts after genioplasty usually result from neurapraxia of the mental nerve during retraction. Th s complication is often unavoidable, but it can be reduced by minimizing dissection and exposure near the mental foramen. Also, if the osteotomy is too close to the mental foramen, the chance of nerve injury increases. The surgeon should be aware of the course of the mandibular canal, especially near the mental foramen.

Hemat oma

Hematoma is the most life-threatening complication after genioplasty, because a hematoma extending to the fl or of the mouth may result in tongue elevation and airway obstruction. Hematoma can be prevented through meticulous hemostasis of the soft issues and bone. Signifi ant bleeding can occur from the exposed cancellous marrow, especially in patients with high bleeding tendencies or hypertension. Surgeons should exercise caution when removing the sutures to decompress the airway, because this may compromise the airway with blood. If the hematoma expands rapidly, the airway has to be controlled with a nasopharyngeal airway, or occasionally it can be controlled with endotracheal intubation. Fortunately, most hematomas in the fl or of the mouth are small and self-limiting.

Deep ened Labio ment al Sul cus and Ment alis Overa ctio n

Even before undergoing surgery, many patients have abnormal morphology of the labiomental fold. Patients with decreased lower facial height tend to have an exaggerated and deep sulcus with an acute angle, whereas those with increased lower facial height tend to have a shallow and effac d sulcus. Isolated advancement of the chin tends to deepen the sulcus and to close the angle between the chin pad and the lower lip (Fig. 46-28). Before the surgery, the surgeon should explain the hypertrophy of the mentalis muscle to the patient. After the surgery, the growth of the mentalis muscle tends to be exaggerated, but this condition will improve over time. However, to minimize this problem, the surgeon should avoid stripping the mentalis during surgery. If chin shortening is planned, some amount of chin setback should also be considered simultaneously. If chin advancement will be performed, chin lengthening might be considered at the same time, which will deemphasize the sulcus. During wound closure, it is important to avoid pulling the mentalis muscle too tightly to avoid overtension on it. Occasionally, if the labiomental fold remains deep, the surgeon’s use of an AlloDerm graft will help the deepened fold. After subcutaneous dissection, a narrow strip of AlloDerm is inserted and sutured. Botulinum toxin injections in the mentalis might also be helpful.

Step Defo rmities and Bor der Ir r egul ar ities

Step deformities and border irregularities can be caused by either the soft tissue origin or the bony origin. If there is a bony step exceeding 3 mm after the osteotomy and fix tion, further contouring should be performed to diminish it. Such situations usually occur after reduction genioplasty or narrowing genioplasty. A step deformity caused after setback genioplasty can be prevented through simultaneous narrowing ge-

Chapter 46 

Aesthetic Osseous Genioplasty

Fig. 46-28  Labiomental fold deepening after advancement genioplasty. nioplasty or the divergence control technique (see also Fig. 46-18). In patients with class II malocclusion or severe micrognathia, depression at the genioplasty-mandible junction can occur after chin advancement, in which case it is proper to limit the amount of advancement. Sometimes, to reduce the contour deformity, the surgeon has to perform an additional bone graft or apply an alloplastic graft such as a sheet of expanded polytetrafluoroethylene, better known as Gore-Tex.

725

726

Part VII 

Cosmetic Surgery of the Facial Skeleton

Asymmetr y

In general, asymmetry after genioplasty results from either a technical error or a failure to detect preexisting asymmetry before the surgery. Before the surgery, it is important for the surgeon to routinely assess the chin for asymmetry. In patients with macrogenia, asymmetry will be quite evident, but in patients with a very small chin (microgenia), any asymmetry may be camouflaged. Patients themselves usually do not recognize the asymmetry before surgery; therefore the surgeon should point out any asymmetries before surgery to prevent potential patient dissatisfaction after the surgery. Asymmetry caused by malposition of the bony segments can be prevented by marking the midline before the osteotomy. The surgeon should take the greatest possible care in cases in which different amounts of reduction are required to correct any asymmetry. If there is asymmetry on the anterior surface of the chin, shaving the surface can be helpful, but the surgeon should be careful to avoid injuring the incisor teeth. Usually, shaving the lower border of the mandible is not recommended; however, if shaving is required to correct mandibular asymmetry, only minimal muscle stripping should be performed.

Soft Tiss ue Ir r egul ar ities and Deep ened Mar io net te Lines

Soft tissue problems can also cause contour irregularities, along with dimpling formation or exaggeration of the marionette lines. These conditions occur more frequently in elderly patients with sagging cheek tissues. Patients with a class II profile also show a higher incidence of these conditions. Soft tissue augmentation with autologous fat grafts r alloplastic grafts nd liposuction of the drooping soft issues may be solutions for these patients.

Chin Pt os is

Chin ptosis results from a patient’s having excessive soft tissue or from the surgeon’s failing to reattach the mentalis muscle during wound closure. Chin ptosis is more common after a shaving osteotomy or a setback genioplasty, because the removal of the prominent symphysis leaves the chin pad unsupported, leading to chin ptosis.20 Elderly patients with excessive skin redundancy or an edentulous mandible are more likely to have this problem. For patients with chin ptosis, it is important to reapproximate and secure the mentalis muscle when closing the soft issue. If the mentalis is not properly approximated, foreshortening of the residual muscle will occur. The inferior portion of the mentalis muscle will progressively droop, resulting in postoperative chin ptosis. In addition, the position of the lips can descend, and dimpling can occur at the chin pad with lip closure; frequently these conditions are aesthetically unpleasing. A proper incision and reapproximation of the mentalis muscle during closure will prevent this condition. Delayed management of this problem involves stable, superior resuspension of the mentalis muscle to the alveolus at the appropriate level, with wide undermining of the soft tissue to allow redraping.

Speci al Consid era tio ns

Considering the previously mentioned complications and unfavorable results, the following types of patients should be treated with extra caution: those with a noticeable chin asymmetry, a long face, skin redundancy, a class II malocclusion, or a pointed chin.

Asymmetry Since asymmetry is one of the most common patient complaints after genioplasty, the surgeon should pay close attention to the symmetry of the patient’s chin and entire face during the operation. Because undercorrection causes the problem the patient complains of, it is important to thoroughly assess the patient’s chin for asymmetry before surgery and to correct the asymmetry during surgery. It is essential to point out and discuss the asymmetry preoperatively with the patient and the surgeon’s intended extent of correction.

Chapter 46 

Aesthetic Osseous Genioplasty

727

Long Face In patients with an excessive maxillary height, a simple chin reduction will not lead to a satisfactory result. In patients with class II malocclusion with a vertical maxillary excess, advancement genioplasty may result in a longer-looking face and a steeper jawline. In addition, discordance between the normal mandibular line and the modifi d chin line can occur. Irregularities are more likely to occur in the mandibular border and with hypertrophy of the mentalis muscle. Thus patients with long-face syndromes are defin tely not good candidates for genioplasty, especially advancement genioplasty. If chin surgery must be performed, advancement should be performed conservatively.

Skin Redundancy Skin redundancy can cause soft issue problems such as chin ptosis, double-chin deformity, or exaggeration of the marionette lines.

Class II Malocclusion It may be difficult to achieve satisfactory results in patients with severe class II malocclusion. If the mandible itself is small and weak, there may not be a suffici t amount of bone to advance. Also, if the jawlines are indistinct before the surgery, the effects of chin advancement may not be satisfactory.

Pointed Chin A preexisting pointy chin, especially one caused by overadvancements in previous surgeries, may result in a witch’s-chin deformity after the genioplasty.

Pearls for Success • When selecting candidates for osseous genioplasty, the surgeon must identify patients who are high risk for complications. • Patients with asymmetry such as a long-face syndrome, a class II profile, and other facial dysmorphologies should be screened and carefully evaluated. • Direct injury to the mental nerve during genioplasty is relatively rare, but it may occur when the surgeon performs an osteotomy too high when attempting a large vertical reduction or when trying to dissect the nerves off the foramen for a better view of the osteotomy. • Conservative placement of the osteotomy is strongly advocated, especially for inexperienced surgeons. • Injury to the marginal mandibular branch of the facial nerve may be caused by either direct injury with a saw or inadvertent retraction. To secure a complete cut, the surgeon has to be certain that the blade of the saw is not pushed too far laterally. • The osteotomy should not be beveled high on the lateral sides, because that can increase the risk of nerve injury. Retraction injury to the nerve during the surgery should also be avoided. • The amount of advancement should be conservative, because even a small amount can make a big change in the facial profile. In contrast, reduction or setback genioplasty might result in undercorrection. • To ensure a successful outcome when completing the genioplasty procedure, the surgeon has to properly handle the mentalis muscle and the soft tissue envelope surrounding the chin. The surgeon needs to carefully suture the muscle and soft tissue back to their normal anatomic position, secure them with dressings, and provide appropriate postoperative care.

K23345_Pu_c46_Aesthet Osseous_r4_cl_703-728.indd 727

4/3/2015 10:43:02 AM

728

Part VII 

Cosmetic Surgery of the Facial Skeleton

Refer ences 1. Trauner R, Obwegeser H. Surgical correction of mandibular prognathism and retrognathia with consideration of genioplasty. I. Surgical procedures to correct mandibular prognathism and reshaping of the chin. Oral Surg Oral Med Oral Pathol 10:677-689, 1957. 2. Precious D. Genioplasty. In Fonseca R, Marciani R, Turvey TA, eds. Oral and Maxillofacial Surgery, ed 2. St Louis: Mosby-Elsevier, 2009. 3. Hwang K, Lee W, Song YB, et al. Vulnerability of the inferior alveolar nerve and mental nerve during genioplasty: an anatomic study. J Craniofac Surg 16:10-14; discussion 14, 2005. 4. Jones B, Vesely MJ. Osseous genioplasty in facial aesthetic surgery—a personal perspective reviewing 54 patients. J Plast Reconstr Aesthet Surg 59:1177-1187, 2006. 5. Zide B, McCarthy J. The mentalis muscle: an essential component of chin and lower lip position. Plast Reconstr Surg 83:413-420, 1989. 6. Guyuron B, Michelow BJ, Willis L. Practical classifi ation of chin deformities. Aesthetic Plast Surg 19:257-264, 1995. 7. Ward JL, Garri JI, Wolfe SA. The osseous genioplasty. Clin Plast Surg 34:485-500, 2007. 8. González-Ulloa M, Stevens E. The role of chin correction in profileplasty. Plast Reconstr Surg 41:477-486, 1968. 9. Guyuron B. MOC-PS(SM) CME article: genioplasty. Plast Reconstr Surg 121(4 Suppl):1-7, 2008. 10. Stanton DC. Genioplasty. Facial Plast Surg 19:75-86, 2003. 11. McNamara JA Jr. A method of cephalometric evaluation. Am J Orthod 86:449-469, 1984. 12. Arnett GW, Jelic JS, Kim J, et al. Soft tissue cephalometric analysis: diagnosis and treatment planning of dentofacial deformity. Am J Orthod Dentofacial Orthop 116:239-253, 1999. 13. Park S, Noh JH. Importance of the chin in lower facial contour: narrowing genioplasty to achieve a feminine and slim lower face. Plast Reconstr Surg 122:261-268, 2008. 14. Betts NJ, Edwards SP. Soft tissue changes associated with orthognathic surgery. In Miloro M, ed. Peterson’s Principles of Oral and Maxillofacial Surgery, vol 2, ed 2. Hamilton, Ontario, Canada: BC Decker, 2004. 15. Reyneke JP, Sullivan SM. A simplifi d technique of genioplasty with simultaneous widening or narrowing of the chin. J Oral Maxillofac Surg 59:1244-1245, 2001. 16. Shaughnessy S, Mobarak KA, Høgevold HE, et al. Long-term skeletal and soft- issue responses after advancement genioplasty. Am J Orthod Dentofacial Orthop 130:8-17, 2006. 17. Guyuron B, Raszewski RL. A critical comparison of osteoplastic and alloplastic augmentation genioplasty. Aesthetic Plast Surg 14:199-206, 1990. 18. Gianni AB, D’Orto O, Biglioli F, et al. Neurosensory alterations of the inferior alveolar and mental nerve after genioplasty alone or associated with sagittal osteotomy of the mandibular ramus. J Craniomaxillofac Surg 30:295303, 2002. 19. Westermark A, Bystedt H, von Konow L. Inferior alveolar nerve function after mandibular osteotomies. Br J Oral Maxillofac Surg 36:425-428, 1998. 20. Garfein ES, Zide BM. Chin ptosis: classifi ation, anatomy, and correction. Craniomaxillofac Trauma Reconstr 1:1-14, 2008.

K23345_Pu_c46_Aesthet Osseous_r4_cl_703-728.indd 728

4/3/2015 10:43:02 AM

47 Aesthetic Augmentation of the Facial Skeleton With Alloplastic Implants Yi-Chieh Chen, Fuan Chiang Chan, Raymond C.W. Goh, Yu-Ray Chen

A

lthough augmentation of various aspects of the facial skeleton can be achieved through the traditional tools of bone or cartilage grafting orthognathic surgery and prolonged orthodontic treatment, patients are increasingly seeking quick and relatively simple solutions for aesthetic improvement of the facial skeleton. Alloplastic implants not only permanently improve the contours of the facial skeleton, but also there is no limit to their supply, as there would be with an autologous augmentation, and no donor site morbidity is incurred. Facial skeletal augmentation with alloplastic material is a well-established technique that is frequently used in aesthetic surgery in Asian patients. In the Asian face, the majority of implants are used for augmentation rhinoplasty and genioplasty. The use of malar and mandibular angle implants is rare, because Asian patients typically have wider and shorter facial features on frontal view and have less anterior projection on lateral view. Subsequently, Asian patients often undergo reduction malarplasty and angle reduction surgery. In this chapter we discuss the most commonly used alloplastic materials in facial skeletal augmentation. Our focus is mainly on chin augmentation and includes our preferred alloplastic material, followed by a brief discussion on augmentation to correct temporal hollowing.

Implant Materials for Facial Skeletal Augmentation The four commonly used alloplastic implant materials for facial skeletal augmentation are silicone, highdensity polyethylene (HDPE), expanded polytetrafluoroethylene (better known as Gore-Tex), and hydroxyapatite. A brief introduction to these four types of implant materials is presented in Table 47-1. More detailed implantology information on these alloplastic materials can be found in other chapters.

729

730

Part VII 

Cosmetic Surgery of the Facial Skeleton

Table 47-1  Comparison of Common Implant Materials Used for Facial Skeletal Augmentation Silicone

HDPE (Medpor)

Gore-Tex

Hydroxyapatite

Indication

Soft tissue and bone augmentation

Bone augmentation

Soft tissue and bone augmentation

Bone augmentation

Physical properties

Elastic fi m

Hard

Soft

Hard

Intraoperative manipulation

Easy

Easy

Easy

Easy

Soft tissue integration

No

High

Minimal

Minimal

Biocompatibility

Low

High

High

High

Plane of positioning

On bone or muscle

On bone

On bone or muscle

On bone

Capsule formation

Yes

No

Mild

Mild

HDPE, High-density polyethylene.

Silic one

Silicone is a synthetic polymer that is the most commonly used solid alloplastic implant material for facial skeletal augmentation. Solid silicone is available in numerous forms with smooth surface contours that allow simple implantation. Solid silicone is easily sculpted intraoperatively and stabilized by suture or screw fixation. The smooth surface of solid silicone implants does not allow vascular or soft tissue ingrowth; hence a capsule is formed that may facilitate implant removal when required. However, the capsule formation may be deleterious, because this capsule can thicken and be subjected to bacterial colonization from micromotion and chronic inflammation.1 The reported complications from silicone implants include discoloration, dislocation, extrusion, contraction resulting from foreign body reaction, and infection.

High-D ens it y Pol ye thylene

High-density polyethylene (HDPE), available commercially as Medpor, is a stable, inert, porous implant that was fi st developed in the 1970s. It is nonresorbable and biocompatible, with no tendency for chronic inflammatory reactions. The pore sizes of HDPE range from 100 to 300 mm in diameter and allow the ingrowth of both bone and soft issue, which minimizes capsule formation and anchors the implant to the skeletal surface.2,3 Together these factors contribute to HDPE’s having lower infection and extrusion rates. Removal of these implants can be challenging, because there is less implant motion with minimal underlying bone resorption with HDPE, especially in areas with overlying soft issue tension, such as the chin. The implant is technically easy to work with, because it is thermoplastic and can be contoured by heat or sterile saline and shaped intraoperatively to achieve the optimal result. Moreover, before insertion, the HDPE implant can be loaded with antibiotics through syringe vacuum impregnation, which displaces the air within the material. The implant can be readily drilled and is most commonly fi ed with metal screws anchored to the bone. However, when HDPE implants are placed under thin skin, extrusion can occur from trauma or infection. In the event of extrusion, the implant material can be partially resected up to the areas where normal tissue infiltration into the pores is seen.4 HDPE implants are available in block and sheet forms and as preformed implants.

Gor e-Tex

Gore-Tex is an expanded synthetic polymer composed of solid polytetrafluoroethylene nodes with interconnecting thin polytetrafluoroethylene fibrils that form a grid pattern. These fibrils cross-link and provide

Chapter 47 

Aesthetic Augmentation of the Facial Skeleton With Alloplastic Implants

great strength while maintaining the flex bility of the implant material. The pore size of Gore-Tex ranges from 10 to 30 mm in diameter, allowing limited tissue ingrowth, less fibrous encapsulation, and less tendency to migrate. These implants can easily be cut to the required shape, resterilized (stable at temperatures up to 163° C), and anchored to adjacent tissues by screws or sutures. Gore-Tex is available in sheet, strip, strand, and mesh forms, in blocks, and as preformed chin and malar implants. However, the most common use of a Gore-Tex implant in reconstructive surgery is for augmentation of the nasal dorsum.

Hyd r oxyapatite

Hydroxyapatite, a calcium phosphate compound, is the major mineral component of bone. The porous form of hydroxyapatite allows fibrous osseous conduction at the tissue-implant interface. Hydroxyapatite is available in both granule and block form. The granular variant is associated with more predictable results and fewer complications.5 One advantage of using hydroxyapatite over other alloplastic materials is its inherent biologic fixation, which leads to less displacement, extrusion, or resorption, thereby improving long-term results. Hydroxyapatite is also readily incorporated within the subperiosteal layer without inducing a foreign-body reaction.6 Despite these advantages, hydroxyapatite is not used as widely as would be expected for facial shape augmentation. The absence of conclusive data regarding the long-term maintenance of augmented volume with hydroxyapatite is likely the main reason that surgeons have reservations about the use of this material as an implant.7 Another potential reason is its excessive fi mness, which can feel unnatural under the skin when used in facial skeletal augmentation.

Our Pr efer r ed All opl a stic Mater ial fo r Chin Augment atio n

We prefer Medpor for chin augmentation, mainly because it is inherently firm yet flexible, it contours well to the underlying bone, and it is easily secured with titanium screws. We have found that screw fixation consistently improves the predictability and precision of reconstruction by preventing implant displacement, obliterating gaps between the implant and the facial skeleton, and facilitating fi al implant contouring. We use the Medpor contoured two-piece chin implant system for chin augmentation (Fig. 47-1). Th s implant is designed for in situ assembly, which facilitates insertion and placement into the subperiosteal pocket. The gradual tapering of the lateral ends of this implant allows a smooth transition between the implant and the mandibular border. If necessary, the ends of this implant can be easily trimmed with a scalpel or scissors. We do not regularly use silicone implants because of their potential for capsular formation, which predisposes the implant to motion, bone erosion, and soft issue distortion, resulting in contour irregularity over the implant.8-11 The size of the implant to be used is determined in the clinic during the surgeon’s preoperative evaluation and discussion with the patient. The ratio of soft tissue advancement to implant placement is about 0.9 to 1; thus an implant that is slightly thicker than the anticipated movement has to be used to achieve the desired advancement.

Fig. 47-1  The Medpor contoured two-piece chin implant system.

731

732

Part VII 

Cosmetic Surgery of the Facial Skeleton

Chin Augmentation Ind ica tio n

A chin implant is used mainly to correct the projection as well as the length of the chin. Implants can also be used to increase the width of the chin and modify the central part of the jawline. Th s procedure can be applied to patients with retruded and pointed chins without malocclusions. For patients with severe mandibular retrusion, class II malocclusion, and a narrowed pharyngeal airway, a sliding genioplasty with mandibular advancement by orthognathic surgery should be offered as an alternative treatment option. Chin augmentation by implant insertion can be considered at a later stage if the projection is not adequate. For patients with a small chin and shortened lower facial height, an osseous genioplasty should be considered to increase the vertical dimension while altering the facial proportion.

Pr eo pera tive Ass ess ment

For patients with associated dentofacial problems, such as a square face, very short or asymmetrical chin, abnormal maxillomandibular relationship, occlusal cant, or gummy smile, a chin implant will not produce a satisfactory aesthetic result. Therefore a complete head and neck examination, including the patient’s dental condition, should be performed. When combined with panoramic images, cephalometric studies in both the lateral and frontal views can provide objective measurements, thereby revealing problems such as skeletal asymmetry, a protruded or retruded jaw, condyle abnormality, or a hypertrophic mandibular angle. The surgeon should discuss these findings with the patient before the procedure. The location of the mental foramen and the degree of chin retrusion can also be identifi d by plain radiographs to avoid mental nerve injury and to determine the appropriate implant size. Standard photographs in the frontal, lateral, and oblique views should be obtained.

Sur gical Techniq ue

Although a submental approach avoids contamination with organisms in the oral cavity and is associated with a decreased risk of lip ptosis, the intraoral approach is our preferred access, because it avoids a submental scar. In addition, we have not found that placing the implant intraorally is more difficult from a technical perspective, as others have reported.2 Unless the patient requests general anesthesia, the intraoral procedure is usually carried out through intravenous sedation with a local anesthetic. We routinely infiltrate the surgical site with a premixed solution of 0.5% bupivacaine with epinephine at a concentration of 1:100,000. We wait 7 minutes before incision to allow for maximal vasoconstriction. Th s short interval is used to prepare and set up the Medpor chin implant. The two-piece implant is soaked in gentamicin solution for 5 to 10 minutes with the air bubbles expelled (Fig. 47-2). To minimize the risk of infection, prophylactic antibiotics are given to the patient in conjunction with soaking the implant in an antibiotic solution: a single dose of antibiotic is administered 1 hour before the surgery. The labiovestibular incision is placed 5 mm from the mucogingival junction, avoiding the frenulum between the lower canine teeth. The incision is carried out beyond the mentalis muscle and then angled inward to reach the mandibular bone; thus the labiovestibular incision preserves a cuff of the mentalis muscle and mucosa for repair and wound closure. A periosteal elevator is used to create the subperiosteal plane. A subperiosteal pocket is made overlying the anterior border of the chin to accommodate implant insertion, preserving the mental nerve. The subperiosteal dissection is extended inferiorly 1 cm below the lower border and laterally 4 to 5 cm from the midline on each side. The medial border of the masseter muscles is the standard limit for the lateral dissection (Fig. 47-3).

Chapter 47 

Aesthetic Augmentation of the Facial Skeleton With Alloplastic Implants

733

Fig. 47-2  Antibiotics can be preloaded in the

Medpor implant before it is inserted by syringe vacuum impregnation, which displaces the air within the material. Th s process is facilitated by tapping the syringe with a periosteal elevator as shown.

A

B

C

D

E

F

G

H

I

Fig. 47-3  Intraoperative views of chin augmentation with a Medpor implant. A-C, The intraoral approach starts by mark-

ing the midline and the incision line. Then local anesthetic is infiltrated along the gingivolabial sulcus and the surrounding soft issue. A transverse incision is carried down, and the mentalis muscle is incised vertically. The subperiosteal plane is dissected, extending 4 to 5 cm laterally on either side of the midline, with the lateral limit of the dissection at the medial border of the masseter muscles. During lateral subperiosteal pocket dissection, care should be taken to avoid injuring the mental nerve. D-F, The fi st piece of the implant is inset on one side, allowing the second piece to be placed precisely on the contralateral side. The two-piece system is then reapproximated to reconstitute the Medpor construct. G-I, The alloplastic material is then fi ed to the bone with titanium screws for precise placement and added stability. The mentalis muscle is meticulously repaired, and the wound is then closed with 3-0 absorbable synthetic sutures.

K23345_Pu_c47 49_Aesth Augmen_r3_cl_729-742.indd 733

4/3/2015 10:56:19 AM

734

Part VII 

Cosmetic Surgery of the Facial Skeleton

In principle, the size of the implant pocket must be bigger than the prosthesis. If it is too small, the implant may buckle, extrude, or create overlying soft tissue changes. Some authors recommend creating a dissection pocket that is 10% larger than the implant itself.12 Based on our intraoperative surgical judgment, we create the subperiosteal pocket just large enough to fit the implant. The implant is placed below the tooth roots and secured to the underlying tissues to prevent implant mobility. The gradual tapering of the lateral ends allows a smooth transition between the implant and mandible, and the implant can be easily trimmed further if indicated. The mandible’s anterior surface must be checked to ensure proper apposition of the implant’s posterior surface. The implant is then fi ed to the bone with titanium screws, ensuring precise and stable positioning of the implant while obliterating the dead space between the anterior surface of the bone and the posterior surface of the implant. Other fixation methods include tying sutures to the soft tissue or through holes in the bone. Next the modified Rickett’s E-line is checked for adequate chin projection. The labiomental crease and lip projection are assessed for aesthetic appearance, and the mandibular contour is checked bilaterally for step irregularities at the interface between the implant and mandible. After irrigation, the wound is closed with absorbable sutures; particular attention should be paid to the anatomic repair of the mentalis muscle to preserve lip competence and prevent chin ptosis. We do not use splints or tapes after alloplastic chin augmentation. Patients are discharged on the same day of the surgery. Postoperative instructions include eating a soft diet, elevating the head, and applying cold packs to the area. Patients are also advised to maintain good oral hygiene and to avoid engaging in strenuous activity for 2 weeks. Patients are prescribed a 5-day course of antibiotics and pain medications as needed. Patient follow-up is performed weekly for the fi st month after surgery and then at 3 months, 6 months, and 1 year postoperatively for potential late complications and to monitor the long-term surgical results (Figs. 47-4 and 47-5).

Res ul t s

Fig. 47-4 Th s 30-year-old woman is shown 1 year after alloplastic chin augmentation with a Medpor implant. The lower lip now contacts the upper lip in repose, and the shallow mentolabial sulcus and mentalis strain are improved.

Chapter 47 

Aesthetic Augmentation of the Facial Skeleton With Alloplastic Implants

Fig. 47-5 Th s 21-year-old man is shown 1 year after alloplastic chin augmentation with a Medpor implant. There is increased fullness of the jawline and an improved cervicomental angle.

Temporal Augmentation The temples lose their fullness as a result of atrophy of the temporal fat pad, temporalis muscle wasting, or temporal bone deformity, which can be caused by aging, weight loss, trauma, or previous surgery. People with depressed temples can be perceived as harsh, aged, and ill; if the cheekbones are also prominent, these two problems should be considered jointly. There are several options to fill the sunken temples: mild depressions can be corrected by filler injections or autologous fat injections, whereas moderate to pronounced temporal hollowing usually requires alloplastic implant augmentation. The application of Gore-Tex to correct temporal hollowing was fi st described in 1992 when Mole13 placed a single 1 mm-thick piece of Gore-Tex sheet in the temporal hollow as an aesthetic enhancement during a coronal face lift. Gore-Tex has also been used to augment the temporal regions of patients who had either bone or the temporalis muscle removed. We have used Gore-Tex as a reconstructive and aesthetic tool for patients who desire correction of defects in the temporal region. In recent years, Medpor has been used for temporal augmentation because of its inherent advantages, as previously mentioned.

Ind ica tio ns

Temporal augmentation by alloplastic implants is indicated in patients with congenital or acquired temporal depression, temporal asymmetry, or a narrow forehead. Thin atients can demonstrate temporal hollowing as a result of fat atrophy. These patients should be encouraged to gain weight, especially if they have recently lost weight. Occasionally the patient’s zygomatic arch is too prominent, making the temporal depression more obvious. In such a case, cheek bone reduction should be considered and carried out together with temporal augmentation, or in stages, to reduce the gap between the temple and the zygomatic arch.

735

736

Part VII 

Cosmetic Surgery of the Facial Skeleton

Pr eo pera tive Ass ess ment

The initial cosmetic consultation is essential to planning for proper implant placement. A detailed discussion with the patient should include gaining an understanding of his or her expectations for temporal augmentation and discussing the various materials that are available for use. Any existing facial asymmetry and disproportion should be noted, documented, and discussed preoperatively with the patient so that his or her expectations for correction are realistic. A complete medical history, including allergies, medications, immunosuppression, history of autoimmune or connective tissue disease, keloids, and pregnancy, should be obtained. Any history of weight loss, trauma, surgery, or augmentation should also be documented. Standard photographs, including frontal, oblique, and profile views, should be taken both before and after surgery. Th ee-dimensional computer tomography will be helpful for surgical planning, especially if an anatomic variation is suspected.

Sur gical Techniq ue

To minimize the risk of infection, prophylactic antibiotics are given 1 hour preoperatively, and the implant is soaked in an antibiotic solution. The coronal or hemicoronal approach is used to provide wide surgical exposure of the temporal area. Th s exposure facilitates insertion and proper fix tion of the implant to the surrounding structures to achieve maximum stability. After the region of deformity is identifi d and exposed, a template of the defect is fashioned from foil. It is important to ensure that the implant is shaped so that its thickest point is located at the junction of the zygomatic arch and the lateral orbital rim. The implant is intentionally tapered for contouring along the edges and then secured with titanium screws. When Medpor is used for temporal augmentation, it should be placed directly on the bone. Next, the implant is sutured to the remaining temporalis fascia and pericranium. The wound is closed with 3-0 absorbable sutures in the galea and with surgical staples on the scalp. Finally, the patient’s head is visually examined and palpated to ensure symmetry. When using Gore-Tex for temporal augmentation, it can be placed either above or below the temporalis muscle (Fig. 47-6), depending on whether the concavity is from a bony deformity or soft issue volume loss. If the Gore-Tex implant is to be placed above the temporalis muscle, a pocket between the superfic al and deep temporal fascia can be created by making a small incision. The implant is folded and inserted into the pocket and then maneuvered into the desired position. We recommend suturing this implant to the temporalis fascia to prevent displacement. We do not routinely use suction drains for this group of patients. Patients are usually discharged on the same day and given routine postoperative instructions. To evaluate for potential late complications and long-term surgical results, patients are seen at the outpatient clinic for staple removal 2 weeks postoperatively and subsequently at 3 months, 6 months, and 1 year (see Fig. 47-6).

Chapter 47 

Aesthetic Augmentation of the Facial Skeleton With Alloplastic Implants

Res ul t s

B A

*

C

D

Fig. 47-6 Th s 22-year-old man had posttraumatic left temporal hollowing. A 7 mm Gore-Tex implant was contoured to the desired shape and thickness and then placed into the subperiosteal plane, and the implant was sutured to the pericranium and covered by the temporalis muscle (Fig. 47-6, A). A postoperative CT scan revealed symmetrical temporal fullness and a smooth transition between the temple and the lateral orbital rim (Fig. 47-6, B). Note the radiopaque Gore-Tex implant (black arrow) under the temporalis muscle (asterisk), and another potential plane for prosthesis implantation is above the temporalis muscle between the superfic al and deep temporal fasciae (white arrowheads). He is shown before left temporal augmentation (Fig. 47-6, C) and 2 years after the procedure (Fig. 47-6, D).

737

738

Part VII 

Cosmetic Surgery of the Facial Skeleton

Discussion Augmentation of the facial skeleton has progressed signifi antly since the early use of onlay silicone implants to treat malar asymmetries in the early 1960s. Alloplastic implants derived from polymers and ceramics, usually in preformed shapes, have been favored in facial augmentation for aesthetic purposes. Preformed silicone and porous polyethylene (Medpor) are currently the most widely used alloplastic materials for augmentation of the facial skeleton. The recognized risks associated with these materials are minimal but include malposition, infection, thinning of the overlying soft tissues, and exposure.11 Having performed more than 100 cases of chin augmentation over a 4-year period, we have found that infection and extrusion are uncommon occurrences. Another study demonstrated that no infections occurred in a series of more than 100 patients, confirming our observations.14 Occasionally patients may require secondary procedures to adjust the position or change the size of the implants. Asymmetry can result from an assymetrical dissection of the implant pockets or displacement of the implant as a result of improper fix tion. If the subperiosteal pocket is not adequately dissected, the ends of the implant may buckle or catch overlying soft tissue, causing contour changes. Dissection over the lower border of the anterior mandible should be carried out completely so that the soft tissue envelope can be advanced without tension, thereby facilitating primary repair of the divided mentalis muscles. Another potential pitfall to avoid during the procedure is placing an inappropriately sized implant. The silicone sizer is a helpful adjunct to judge whether the implant pocket was dissected adequately and if the prosthesis size is appropriate. Because postoperative edema can obscure malposition and/or an improperly sized implant, conservative treatment of non-infection-related complications is recommended until the edema subsides completely. If revision surgery is demanded or otherwise unavoidable, the implant should be approached through the same incision and be removed from the pocket. The soft issue ingrowth can be readily dissected from the surface of the Medpor implant using a periosteal elevator or an electric coagulator. However, in cases of recurrent infection, the dissection might be very difficult, making complete explantation impossible (Fig. 47-7).

A

B

Fig. 47-7  Th s 32-year-old man presented 3 years after having Medpor chin augmentation for a posttraumatic deformity. He had a history of lower face swelling, erythema, and low-grade fevers recalcitrant to oral antibiotics. A, Physical examination revealed a sinus with purulent discharge over the submental area. Because the patient’s history and examination fi dings were consistent with a chronic foreign-body infection, we removed the implant and debrided the wound. We noted purulent fluid and granuloma around the Medpor implant. The implant had signifi antly integrated into the surrounding soft issue despite the infection. B, The implant was friable and was removed in pieces. One week of oral antibiotics was prescribed, and the patient remained free of symptoms 8 months after implant removal.

Chapter 47 

Aesthetic Augmentation of the Facial Skeleton With Alloplastic Implants

Glabella Rickett’s E-line

Subnasale Stomion Mentolabial sulcus Menton

Fig. 47-8  Measurements of the facial parameters for chin analysis.

For cases in which the implant malposition is the result of inadequate pocket dissection, a subperiosteal pocket can be further dissected and an appropriately sized implant can be placed and secured to the underlying bone with screws. The soft tissue should be advanced and the divided mentalis muscle repaired without tension. For infection-related complications, curettage of granuloma from the soft tissue pocket and then antibiotic solution irrigation should be performed. The wound is closed after meticulous hemostasis is ensured. Drain tubes and external compression are applied to diminish dead space and prevent hematoma formation. After complete resolution of the infection at 3 months after implant removal, a second implant can be inserted using the previously mentioned principles. Various facial measurements can be used for chin analysis (Fig. 47-8). For frontal evaluation, we follow a simple rule that the ideal ratio of the midface (measured from the glabella to the subnasale) to the lower face (measured from the subnasale to the menton) is 1:1. The ratio of the upper part of the lower face (measured from the subnasale to the stomion) to the lower part of the lower face (measured from the stomion to the menton) is 1:2 to 2.2. For lateral-view evaluation, we use Rickett’s E-line (aesthetic line) to determine chin position and the relationship between the nose, lip, and chin. Slight overcorrection is preferred for patients with a flat mentolabial sulcus, and undercorrection is preferred for patients with a deep sulcus. For patients with a strong profile and high nose, overcorrection to create a stronger chin is preferred. In repose, the lips should be able to touch each other. A small interlabial gap of less than 1 or 2 mm is acceptable. However, a gap larger than 2 mm will result in lip incompetence, which is often compensated for by increased mentalis activity, resulting in mentalis muscle strain. Lip incompetence can occur if the chin implant is inserted through an intraoral incision and an excessively large amount of augmentation is performed. To prevent this untoward result, surgeons should consider a smaller implant or a submental approach without dividing the mentalis muscle fibers. Alloplastic implants for the chin are primarily indicated if the required aesthetic improvement is mainly for augmentation in the sagittal plane. However, an osseous genioplasty is generally required if the chin requires three-dimensional movement. In our experience, augmentation with a chin implant is unlikely to produce a good result in a patient with an asymmetrical chin or an excessively retruded chin. Similarly, for a patient with a short chin or one who requires chin augmentation of more than 9 to 10 mm, we recommend an advancement or elongating genioplasty and then placement of a chin implant as needed. In addition, because a genioplasty does not alter the occlusion, patients with signifi ant malocclusions are more appropriately treated with orthodontic and orthognathic surgery.

739

740

Part VII 

Cosmetic Surgery of the Facial Skeleton

Although temporal hollowing does not result in any signifi ant functional defic t, patients often perceive it as a visible cosmetic defect and request correction. There are various autologous materials that can be used for the correction of hollowing, such as dermal fat grafts, fat injections, muscle flaps, bone grafts, and microvascular free tissue transfers. However, these applications of autologous tissue result in donor site morbidity and may increase the length of the patient’s hospital stay and the transfer cost; atrophy of dermal fat grafts and muscle flaps may occur, and there is a limited supply of donor tissues.15 The use of Gore-Tex or Medpor eliminates the disadvantages of autologous tissue transfer for the correction of these defects. The Medpor implant is hard and should be placed directly onto the bone, fi ed by screws, and then covered by the temporalis muscle. Th s technique needs direct vision and wide-open access through a long scalp incision, and it is usually preferred in patients with skull deformities resulting from previous trauma or surgery. In patients with a mild temporal depression caused by a skull deformity, a flex ble implant such as Gore-Tex can be placed on the temporalis muscle through a smaller incision. The indentation along the posterior margin of the lateral orbital rim and the upper border of the zygomatic arch should be appropriately addressed. The implant should be sutured to the fascia for immobilization. The incidence of complications related to Gore-Tex is low. In a single series of 120 patients treated with Gore-Tex implants for facial augmentation, Hanson et al16 reported that only two patients required removal of the implants because of foreign-body reaction. Overcorrection is not preferred for cosmetic augmentations, because increased fullness is just as unnatural appearing as a concavity. If revision surgery is required, the same principles established for chin implant revision surgery should be followed, including proper sizing, precise contouring, and secure fix tion of the implants.

Pearls for Success • The surgeon should be familiar with the properties, indications, and potential complications of the various implant materials that are available. • Implants for facial skeletal augmentation should be trimmed properly and immobilized to prevent displacement. • Chin augmentation can provide projection in the sagittal plane, with minimal vertical lengthening and no effect on the occlusion or airway. • The extent of chin augmentation can be judged by measuring the proportions of the face and Rickett’s E-line, and the relationship between the nose, lips, and chin. • The surgeon should carefully preserve the mentalis muscle function. • In patients with both temporal hollowing and prominent cheekbones, correction of both should be performed in the same surgery. • Any perceivable indentation along the posterior margin of the lateral orbital rim and the upper border of the zygomatic arch should be properly corrected. • The implant should always be secured to the underlying bone or surrounding fascia for immobilization.

Refer ences 1. Peled ZM, Warren AG, Johnston P, et al. The use of alloplastic materials in rhinoplasty surgery: a meta-analysis. Plast Reconstr Surg 121:85e-92e, 2008. 2. Menderes A, Baytekin C, Topcu A, et al. Craniofacial reconstruction with high-density porous polyethylene implants. J Craniofac Surg 15:719-724, 2004. 3. Spector M, Flemming WR, Kreutner A. Bone growth into porous high-density polyethylene. J Biomed Mater Res 10:595-603, 1976.

Chapter 47 

Aesthetic Augmentation of the Facial Skeleton With Alloplastic Implants

741

4. Berghaus A, Stelter K. Alloplastic materials in rhinoplasty. Curr Opin Otolaryngol Head Neck Surg 14:270-277, 2006. 5. Byrd HS, Hobar PC, Shewmake K. Augmentation of the craniofacial skeleton with porous hydroxyapatite granules. Plast Reconstr Surg 91:15-22; discussion 23-26, 1993. 6. Costantino PD, Friedman CD, Jones K, et al. Hydroxyapatite cement. I. Basic chemistry and histologic properties. Arch Otolaryngol Head Neck Surg 117:379-384, 1991. 7. Mendelson BC, Jacobson SR, Lavoipierre AM, et al. The fate of porous hydroxyapatite granules used in facial skeletal augmentation. Aesthetic Plast Surg 34:455-461, 2010. 8. Wellisz T, Lawrence M, Jazayeri MA, et al. The effects of alloplastic implant onlays on bone in the rabbit mandible. Plast Reconstr Surg 96:957-963, 1995. 9. Yaremchuk MJ. Improving aesthetic outcomes after alloplastic chin augmentation. Plast Reconstr Surg 112:14221432; discussion 1433-1434, 2003. 10. Robinson M. Bone resorption under plastic chin implants. Follow-up of a preliminary report. Arch Otolaryngol 95:30-32, 1972. 11. Robinson M, Shuken R. Bone resorption under plastic chin implants. J Oral Surg 27:116-118, 1969. 12. McCollough EG, Hom DB, Weigel MT, et al. Augmentation mentoplasty using Mersilene mesh. Arch Otolaryngol Head Neck Surg 116:1154-1158, 1990. 13. Mole B. The use of Gore-Tex implants in aesthetic surgery of the face. Plast Reconstr Surg 90:200-206, 1992. 14. Gui L, Huang L, Zhang Z. Genioplasty and chin augmentation with Medpore implants: a report of 650 cases. Aesthetic Plast Surg 32:220-226, 2008. 15. Boyce RG, Nuss DW, Kluka EA. The use of autogenous fat, fascia, and nonvascularized muscle grafts in the head and neck. Otolaryngol Clin North Am 27:39-68, 1994. 16. Hanson LJ, Donovan MG, Hellstein JW, et al. Experimental evaluation of expanded polytetrafluoroethylene for reconstruction of orbital fl or defects. J Oral Maxillofac Surg 52:1050-1055; discussion 1056-1057, 1994.

K23345_Pu_c47 49_Aesth Augmen_r3_cl_729-742.indd 741

4/3/2015 10:56:21 AM

K23345_Pu_c47 49_Aesth Augmen_r3_cl_729-742.indd 742

4/3/2015 10:56:21 AM

48 Aesthetic Orthognathic Surgery

T

Yu-Ray Chen, Yi-Chieh Chen, Fuan Chiang Chan, Raymond C.W. Goh, Cheng-Hui Lin

A

he   skeletal foundation of the human face serves as the invisible determinant of facial morphology. Aesthetic surgery performed on facial soft tissue alone, without dual consideration for the skeletal structural abnormalities that caused the patient’s undesired facial appearance, will consistently fall short of achieving the best possible outcome. Correction of facial skeletal disproportions and disharmony necessitates a keen aesthetic sense of the soft issue changes that can result from making alterations to the underlying skeletal base. Although dental occlusion and skeletal stability were once the surgical priorities in orthognathic surgery, most patients now present for orthognathic surgery because of aesthetic discontent. Aesthetic considerations now dictate the goals of surgery. More consistent and favorable outcomes in aesthetic orthognathic surgery have resulted from advancements in surgical technique, a paradigm shift in surgical planning away from rigid cephalometric measurements to parameters that are guided by the surgeon’s aesthetic sense, and improved patient care. In Asia, an increasing number of patients, especially young women, are presenting for correction of dentofacial deformities. Conditions that are particularly common in Asia include mandibular prognathism, bimaxillary protrusion, and facial asymmetry. Optimal management of these patients requires equal contribution and shared responsibility from both the surgeon and the orthodontist. In this chapter, we will provide an overview of patient evaluation and surgical indications for dentofacial deformities common to the Asian patient, our preferred operative techniques, and caveats for avoiding complications in orthognathic surgery.

Preoperative Assessment The patient’s signifi ant aesthetic concerns should be fi mly established during the initial consultation, because these concerns will form the priorities on which decision-making and surgical planning will be determined. To ascertain an accurate diagnosis and to formulate an appropriate treatment plan, the surgeon must perform a thorough and systematic appraisal of the patient’s facial morphology, elucidating the

743 K23345_Pu_c48 50_Aesth Ortho_r7_cl_743-760.indd 743

4/6/2015 7:23:24 AM

744

Part VII 

Cosmetic Surgery of the Facial Skeleton

Table 48-1  Components of Intraoperative Assessment of Facial Aesthetics Assessment Points

Assessment Point Considerations

Facial proportions

Vertical, transverse, and sagittal proportions Nasolabial angle Lip protrusion Soft tissue pogonion

Facial and dental midlines

Correlation of midline anatomic structures (glabella, nasal tip, cupid’s bow, upper dental midline, lower labial frenulum, piriform aperture)

Facial asymmetry

Chin deviation Mandibular prominence

Occlusal plane

Comparison of lower eyelid to commissure distances

Teeth show

A 2 to 3 mm upper incisor display is ideal

Chin projection

Rickett’s E-line

patient’s skeletal, dental, and soft tissue features1 (Table 48-1). Cephalometric and panoramic radiographs are useful in determining skeletal and dental relations, demonstrating the state of the temporomandibular joint, and identifying pathologic lesions. Appropriate photographic documentation of the patient smiling and in repose should be recorded (Fig. 48-1). The skeletal evaluation should include a description of the overall symmetry of the patient’s face. The most commonly detected lower facial asymmetries are chin point deviations from the midline, the discrepancy between the vertical position of the inferior border of the mandible between the left and right, and occlusal canting, which may result in tilting of the oral commissure. Vertical proportionality of the face is elucidated by comparing the height of the lower face from the menton to the subnasale relative to the midface from the subnasale to the glabella. From the lateral view, the sagittal position of the maxillary and mandibular skeletal bases can be compared. Overall facial convexity or concavity can be established by connecting a line from the glabella to the subnasale to the pogonion. Patients with mandibular prognathism typically present with an overall concave facial profile with a divergent chin point, whereas patients with bimaxillary protrusion often have an overall convex profile with chin retrusion. Dental evaluation should verify the occlusion type and include an assessment of the dental alignment, arch coordination, dental midline, and incisor inclination. The amount of upper incisor and gingival display in repose and while smiling should be noted. A gummy smile can be derived from a number of causative factors. Periodontal causes such as a shortened incisor height may be suffici tly treated with crown-lengthening procedures, although surgery may be necessary when the underlying basis is bimaxillary protrusion or vertical maxillary excess. More recently, increased emphasis has been placed on the value of the smile arc (Fig. 48-2) and the aesthetic enhancement that can be brought to a patient’s smile through orthognathic means. The smile arc is the relationship of the curvature of the maxillary incisors and canines to the curvature of the lower lip in the posed smile. The ideal or consonant smile arc has the maxillary incisal edge curvature parallel to the

Chapter 48 

A

Aesthetic Orthognathic Surgery

B

Fig. 48-1  A, Th s 22-year-old woman has excess gingival show and a “gummy” smile. These major concerns must be part of the surgical planning. B, However, these characteristics cannot be seen in her photos in repose.

Fig. 48-2  The smile arc is defi ed as the upper incisal edge line

(yellow dotted line), which should be concordant with the lower lip line (white dotted line) when the patient is smiling.

curvature of the lower lip.2 A nonconsonant or flat smile arc can often be improved by performing posterior impaction of the maxilla and clockwise rotation of the maxillomandibular complex, with occlusal plane neglect. The facial soft tissue attributes should be assessed in both static and dynamic poses. The features that should be assessed include the nasolabial angle, mentolabial fold, interlabial gap, and the presence of mentalis strain. The adequacy of skeletal support of the soft tissue is important so the surgeon can anticipate changes that may occur to the face after surgical alteration of its skeletal foundation. Soft issue does not always respond favorably to skeletal displacements intended to achieve normal facial measurements and proportions; therefore patients should be informed of potential soft tissue changes, such as lengthening of the upper lip, deepening of the nasolabial fold, and widening of the nasal base that may result from surgery.3

Surgical Planning and Preoperative Treatment The patient’s aesthetic concerns and desires should dictate the priorities in formulating the surgical treatment plan. Once a clinical examination and radiographic analysis have been completed, prediction tracings and preoperative model studies are performed to formulate the necessary vector and amount of bony movement. A surgical splint is then constructed. For two-jaw surgery, we prefer to use a single fi al occlusal splint, making fi e three-dimensional adjustments to the maxillomandibular complex intraoperatively based on our assessment of the patient’s facial aesthetics4 (see Table 48-1). Therefore the surgical plan may consist of a selected combination of LeFort I osteotomy of the maxilla, bilateral sagittal split osteotomy (BSSO) of the mandible, upper and lower anterior segmental osteotomies (ASO), and genioplasty. In recent years, patients have been offered preoperative cone-beam computed tomography (CBCT) as part of

745

746

Part VII 

Cosmetic Surgery of the Facial Skeleton

Fig. 48-3  CBCT provides detailed information regarding the proximity of the inferior alveolar nerve canal (pink line and dot) to the buccal cortex of the ramus and the inferior border of the mandibular body.

the surgical planning. There is evidence to suggest that CBCT images can reliably assess the risk of postoperative neurosensory disturbance5-8 (Fig. 48-3). We have found that patients have a signifi antly lower incidence of inferior alveolar nerve injury after presurgical CBCT evaluation. Traditionally, a period of presurgical orthodontics is required to obtained optimal dental alignment in preparation for surgery. More recently, however, the surgery-fi st approach has become an alternative. With this approach, a minimal amount of presurgical orthodontics is performed before the skeletal deformity is corrected surgically, and the majority of orthodontic adjustment is subsequently undertaken after surgery has been completed. The surgery-fi st approach utilizes the greater potential for rapid teeth movement after maxillary and mandibular osteotomies; therefore this approach is able to achieve the necessary orthodontic treatment goals in a much shorter period.9-14

Indications Mand ibul ar Pr o gn athis m In addition to having an overall concave facial profile, patients with mandibular prognathism commonly present with a retrodisplaced maxilla and a class III malocclusion. Occasionally, when the maxilla is already in an optimal position, surgical correction through a BSSO and setback of the mandible will suffi . More commonly, however, treatment for mandibular prognathism involves two-jaw surgery, comprising a LeFort I osteotomy of the maxilla and BSSO of the mandible. A LeFort I osteotomy with posterior impaction and advancement of the maxilla can provide better upper lip fullness, reduce the amount of mandibular setback required and thus reduce the likelihood of relapse, and improve the consonance of the smile arc. Segmental maxilla osteotomies may be used to correct deformities in the curve of Spee and for transverse maxillary plane adjustments. Once the mandible has been set back, chin projection should be assessed to determine whether a genioplasty is required (Fig. 48-4).

Chapter 48 

Aesthetic Orthognathic Surgery

747

A

B

Fig. 48-4  A, Cephalometric study. B, A tracing of a 22-year-old woman with mandibular prognathism.

K23345_Pu_c48 50_Aesth Ortho_r7_cl_743-760.indd 747

4/6/2015 7:23:26 AM

748

Part VII 

Cosmetic Surgery of the Facial Skeleton

Bimaxill ar y Pr otr us io n

Bimaxillary protrusion is a condition characterized by dentoalveolar flaring of the upper and lower incisors that causes upper and lower lip protrusion and an overall convex facial profile. Th s deformity is commonly associated with lip incompetence, an excessive display of frontal teeth, a gummy smile, mentalis strain, an anterior open bite, and a class II malocclusion. A combination of surgical procedures may be indicated to correct bimaxillary protrusion. The simplest method of correction involves extraction of four of the fi st premolars, and performing ASO of the mandible and maxilla through the extraction sites. The segments are then set back and tilted to reduce inclination of the incisors. In certain patients, maxillary excess may be corrected solely with a LeFort I osteotomy and maxillary setback, without the need for dental extractions and ASO. In patients in whom bimaxillary protrusion and vertical maxillary excess are coexistent problems, a LeFort I osteotomy with superior impaction of the mandible combined with an ASO may be needed.1 A BSSO may be required to advance or set back the mandible.

Fa ci al Asymmetr y

The multifaceted mechanisms that generate differential bony growth between the two sides of the face can result in complex facial asymmetries that can involve both skeletal and soft tissue discrepancies. Orthognathic means of correcting these asymmetries are limited to the lower face. Chin asymmetry can be corrected with simple burring if the deformity is minor. In more severe patients, the surgeon may need to perform an osseous genioplasty with the required displacement of the segment to return the chin point centrally. Discrepancies in the vertical position of the inferior borders of the mandible are best treated with a BSSO and an appropriate shift to level the two sides. Contouring of the angle and lower borders of the mandible by burring can further refi e the symmetry of the mandible. Occlusal canting frequently requires a LeFort I osteotomy and differential superior impaction or downgrafting of the maxilla to level the occlusion.

Surgical Technique Anes thes ia

Aesthetic orthognathic surgery is carried out with a general anesthesic, preferably with nasotracheal intubation. The patient is positioned with a transverse roll under the shoulders to extend the neck. A dilute solution of epinephrine is infiltrated into the operative site, and blood pressure is maintained at a mean of approximately 60 mm Hg with hypotensive agents to minimize intraoperative blood loss. A single dose of intravenous antibiotics is administered.

Bil ateral

Sa git t al Split Osteo t omy

Our preferred technique of performing a BSSO of the mandible is a modifi ation of the technique described by Hunsuck15 (Fig. 48-5). The mandible is incised and exposed16 (Fig. 48-6). Subperiosteal dissection of the medial aspect of the ascending ramus is then performed to expose the lingula and the inferior alveolar neurovascular bundle. The inferior alveolar nerve is retracted and protected, and a burr is used to perform a horizontal corticotomy on the medial aspect of the ascending ramus just superior to the mandibular foramen (Fig. 48-7). The posterior extent of this corticotomy ends distal to the mandibular foramen. The sagittal osteotomy of the mandibular body is performed with a reciprocating

Chapter 48 

A

749

Aesthetic Orthognathic Surgery

Fig. 48-5  Bilateral sagittal split-ramus osteotomy. The drawing shows the technique described by Hunsuck, with our modifications. A, Configuration of osteotomy lines. B, Full detachment of the pterygomasseteric muscle sling. C and D, Ostectomy of the pterygoid protuberance facilitates concomitant angle contouring and is a good source of bone grafts if needed. (From Honda T, Lin CH, Yu CC, Heller F, Chen YR. The medial surface of the mandible as an alternative source of bone grafts in orthognathic surgery. J Craniofac Surg 16:123-128; discussion 128, 2005.) C

D

B

A

B

C

D

Fig. 48-6  Incision and exposure of the mandible. A and B, Markings for the buccal vestibular incision and identifi a-

tion of the papilla of Stensen’s duct (black arrow). A buccal vestibular incision begins at the anterior border of the ramus and extends anteriorly along the mandibular body up to the second premolar. C and D, A suffici t cuff of mucosa should be left n the mandible to facilitate later closure. The incision is taken onto the bone, and subperiosteal dissection is performed to expose the lateral aspect of the mandible.

K23345_Pu_c48 50_Aesth Ortho_r7_cl_743-760.indd 749

4/6/2015 7:23:28 AM

750

Part VII 

A

Cosmetic Surgery of the Facial Skeleton

B

C

D

Fig. 48-7  A and B, Subperiosteal dissection of the medial aspect of the ascending ramus. C and D, The sagittal split

osteotomy of the mandibular ramus. Completion of the osteotomy (BSSO) is performed according to the technique described by Hunsuck, with our modifications.

saw and follows the anterior oblique line up to the level of the fi st molar, where it is joined by the vertical osteotomy of the buccal cortex of the mandibular body. A similar procedure is completed on the other side before actual splitting is performed. The proximal and distal segments are split through a variety of osteotomies. The medial cortex of the mandibular angle remains with the proximal segment, and an osteotomy of the medial cortex of the mandibular angle is performed. Th s modifi ation allows greater long-term stability after repositioning the mandible, because muscular forces are no longer restricting its excursion. Concurrent mandibular angle contouring can be performed, and the resected medial cortex of the angle can be a source of bone graft if necessary. The mobile medial segment of the mandible is now guided into its new position with the occlusal splint, and intermaxillary fix tion (IMF) is accomplished. Bony adjustments are made as necessary to provide optimal contact between the segments. The condyle should be in a relaxed position within the glenoid fossa. Osteosynthesis is achieved with two 2.0 mm plates secured with monocortical screws along the body of the mandible. The IMF is released and occlusion is verifi d. Intraoral drains are placed and the wound is closed with resorbable sutures.

LeFor t I Osteo t omy

An intraoral labial-buccal incision is made, preserving an adequate mucosal edge to facilitate fi al closure. Subperiosteal dissection then exposes the anterior maxillary wall, infraorbital foramen, lateral zygomaticmaxillary buttress, and pterygomaxillary junction. The nasal mucosa is elevated off he nasal piriform, and intranasal dissection extends onto the nasal fl or and the lateral nasal wall, and medially onto the septum and vomer. The nasal septum is separated from the maxillary crest by sweeping an elevator across its junction.

K23345_Pu_c48 50_Aesth Ortho_r7_cl_743-760.indd 750

4/6/2015 7:23:30 AM

Chapter 48 

A

B

D

E

G

Aesthetic Orthognathic Surgery

C

F

H Thin e

otom

Oste

Fig. 48-8  LeFort I osteotomy. A-C, Markings for an intraoral labial-buccal incision to ensure an adequate mucosal edge

are preserved to facilitate final closure. Note that the papilla of Stensen’s duct is identified to avoid injury (black arrow). Subperiosteal dissection with a periosteal elevator exposes the anterior maxillary wall. The planned osteotomy is marked (yellow line) 5 mm above the canine root apices (canine root apex is marked with an asterisk). D-F, The pterygomaxillary osteotomy is initiated with a right-angled oscillating saw and subsequently completed with a curved thin-blade osteotome. G and H, A posterior maxillary wall osteotomy is performed with a thin osteotome and gentle tapping. Once the osteotomies are complete, the maxilla is downfractured with digital pressure alone (white arrow marks the descending palatine vessels).

The planned osteotomy is then marked, maintaining a distance of 5 mm above the tooth root apices. A reciprocating saw is used to perform the horizontal osteotomy, proceeding from the posterior-lateral maxillary wall, across the anterior maxillary wall, and onto the lateral nasal wall. The pterygomaxillary osteotomy begins with the use of a right-angled oscillating saw, and completion of its disjunction is confi med with a curved osteotome. A posterior maxillary wall osteotomy is performed through gentle tapping with a thin osteotome. Once the osteotomies are complete, the maxilla can then be downfractured with digital pressure alone. To prevent unfavorable fractures, the surgeon must avoid using force to accomplish the downfracture (Fig. 48-8).

751

752

Part VII 

Cosmetic Surgery of the Facial Skeleton

When the maxilla has been fully mobilized, either as a single piece or in multiple segments, the occlusal splint is introduced and IMF is performed. If a BSSO is performed concurrently, the maxillomandibular complex is placed in the desired position as directed by the preoperative calculations and on-table assessment of facial aesthetics (see Table 48-1). In patients with superior impaction or setback of the maxilla, any areas of bony interference should be removed. Maxillary setback occasionally presents as a somewhat difficult maneuver, but it can be facilitated by reducing the pterygoid process, resecting the maxillary tuberosity, and extracting the third molar. If there is signifi ant inferior maxillary repositioning, bone from the medial cortex of the mandibular angle can be used as interpositional grafts. e nasal septum may need to be partially removed to prevent septal buckling. With the maxilla in the desired position, it is stabilized with plates and screws at the medial and lateral buttresses. The IMF is released and the occlusion is verifi d. An alar cinch suture is placed to control the width of the alar base, and the wound is closed with absorbable sutures.

Anter io r Segment al Osteo t omy

An ASO of the maxilla and mandible (the Wassmund and Kole procedures, respectively) are usually performed through extraction spaces at the first premolars or through interdental osteotomies. For an ASO of the mandible, the exposure is identical to that for a genioplasty. The labial gingival bridges at the sites of extraction or interdental osteotomy are elevated and kept intact to avoid a vertical scar and to provide an extra source of vascular supply to the anterior segment. The vertical osteotomy lines must be kept at least 5 mm central to the mental foramen, and the horizontal osteotomy line must be at least 5 mm from the canine roots. If BSSO is indicated, it is performed initially without complete splitting. The split is completed after an ASO of the mandible, providing better control of the segment. For an ASO of the maxilla, palatal tunnels are elevated subperiosteally through the extraction spaces and interdental osteotomies to meet at the midline. The width of the palatal tunnel should be around 10 mm to prevent palatal mucosal kinking after setback of the segment. Gingival bridges at the osteotomy sites are kept intact. If required, a LeFort I osteotomy of the maxilla is performed at this time. The horizontal osteotomy of the LeFort I osteotomy or an ASO is kept at least 5 mm above the canine roots. The vertical osteotomies with the appropriate amount of bone removal are designed according to the necessary incisor inclination. If a three-piece LeFort I osteotomy is indicated, parasagittal splits of the posterior maxillary segment are performed. Once completely mobilized, the anterior segment17 is guided into the desired position with the occlusal splint. Areas of premature bony contact are burred to allow optimal fit, and fix tion is performed with plates and screws (Fig. 48-9).

Chapter 48 

753

Aesthetic Orthognathic Surgery

A

B

C

D

E

F

G

H

I

Fig. 48-9  ASO of the maxilla. A-C, Extraction of the fi st premolar is required to create suffici t space for the ASO.

The palatal tunnels are elevated subperiosteally through the extraction spaces and interdental osteotomies to meet at the midline. D-F, The horizontal osteotomy of the ASO is kept at least 5 mm above the canine roots (asterisk). The vertical osteotomies are designed according to the necessary incisor inclination. G-I, If a three-piece LeFort I osteotomy is indicated, parasagittal splits of the posterior maxillary segment are performed. Once completely mobilized, the anterior segment is guided into the desired position with the occlusal splint.

Postoperative Care The IMF is routinely removed after surgery. For multiple-segment osteotomies of the maxilla or mandible, the dental splint is maintained for 2 weeks to provide additional stability, if necessary. The intraoral drain tubes are removed on the fi st postoperative day. Patients routinely rinse their mouths with chlorhexidine solution to remove blood clots. Patients are encouraged to initiate a liquid diet as soon as possible after surgery and to gradually shift to a soft diet within 2 weeks. Nonsteroidal antiinflammatory drugs are routinely prescribed for pain relief. For those patients who have moderate to severe pain, meperidine 50 mg IM is given every 4 hours. Broad-spectrum parenteral antibiotics are given after the operation and then converted to an oral form for 1 week. Soft issue swelling is a major concern to these patients. To reduce the discomfort, patients should routinely use ice packs and elevate their head, and they should take a nasal decongestant for the fi st few days after surgery.

K23345_Pu_c48 50_Aesth Ortho_r7_cl_743-760.indd 753

4/6/2015 7:23:30 AM

754

Part VII 

Cosmetic Surgery of the Facial Skeleton

Most patients receive autologous blood transfusions during the surgery, and a postoperative hemoglobin level is not routinely checked unless clinically indicated. The majority of patients are discharged 2 days after the surgery once their oral intake is adequate and they are able to ambulate. Patients routinely follow up at 1 week, 1 month, 4 months, and 1 year after surgery. Postoperative orthodontic treatment is initiated 4 weeks after surgery.

Results From 2003 to 2011,the senior author (Y.R. Chen) performed 2054 orthognathic procedures at the Craniofacial Center of Chang Gung Memorial Hospital. The majority of these patients had class III malocclusions with mandibular prognathism, followed by class II malocclusion with bimaxillary protrusion (Fig. 48-10), facial asymmetry (Figs. 48-11 through 48-13), midfacial hypoplasia resulting from a cleft, obstructive sleep apnea, or posttraumatic maxillofacial deformities. Two-jaw surgery with or without genioplasty is used in more than 95% of aesthetic orthognathic surgery cases.

Fig. 48-10 Th s 39-year-old woman presented with bimaxillary protrusion and chin retrusion. Note the lip incompetence and mentalis muscle strain over her chin preoperatively (Fig. 48-10). She is shown 11 months after having a LeFort I osteotomy, setback and intrusion of the maxilla, bilateral sagittal split osteotomy with mandibular setback, and advancement genioplasty.

Chapter 48 

Aesthetic Orthognathic Surgery

The most common complication is inferior alveolar nerve injury. Transient sensory disturbance of the lower lip is observed in 90% of patients immediately after the procedure but lasts longer than 6 months in only 10% of patients. Unexpected fracture of the mandibular ramus occurred in 1% to 3% of the patients. An unexpected fracture usually results from the surgeon’s attempt to prevent an inferior alveolar nerve injury and, in the process, making the mandibular ramus too thin. Most unexpected fractures are incomplete and can be identifi d before the ramus has been split completely. For those completely unexpected ramus fractures, rigid fix tion by miniplates is mandatory. Injury to the descending palatine artery is not uncommon when performing LeFort I osteotomies; the bleeding is controlled with cauterization to prevent postoperative hematoma. The chance of injury to the facial artery is low. However, if it occurs, we recommend ligation to prevent the development of a late pseudoaneurysm. In our study, no patients had permanent facial palsy resulting from facial nerve injury. Eight patients in this series received revision orthognathic surgery after the fi st operation. The indications for repeated surgery include residual asymmetry or midline deviation,6,8 uncorrectable malocclusion,1,8 and relapse.1,8

Fig. 48-11 Th s 22-year-old man presented with mandibular prognathism and chin deviation (Fig. 48-11). After undergoing a LeFort I osteotomy to improve his left posterior maxilla, bilateral sagittal split osteotomy for mandible setback, and genioplasty to advance his chin, his facial profile and symmetry improved as shown at his 11-month follow-up.

755

756

Part VII 

Cosmetic Surgery of the Facial Skeleton

Fig. 48-12 Th s 20-year-old woman presented with facial asymmetry and an anterior open bite (Fig. 48-12). After having a LeFort I osteotomy of the maxilla with a three-piece anterior segmental osteotomy and a bilateral sagittal split osteotomy of the mandible and genioplasty, she shows an improved symmetrical facial profile and an aesthetic smile arc at her 7-month follow-up.

Chapter 48 

Aesthetic Orthognathic Surgery

757

Fig. 48-13 Radiographs of the same 20-year-old woman reveal the improvement in her facial asymmetry and anterior open bite after surgery.

K23345_Pu_c48 50_Aesth Ortho_r7_cl_743-760.indd 757

4/6/2015 7:23:37 AM

758

Part VII 

Cosmetic Surgery of the Facial Skeleton

Discussion Avoiding complications in orthognathic surgery begins with the surgeon’s careful aesthetic and functional evaluation of the patient as well as strategic surgical planning. Certain undesired outcomes should be considered sequelae rather than unexpected complications. Examples include patients with bimaxillary protrusion and older patients, who are at the highest risk of developing an aged appearance after surgery as a result of setback or superior positioning of the maxilla and relaxation of midfacial soft issue support. These patients should be forewarned and prepared to accept this likely consequence. Vascular compromise and segmental necrosis is uncommon, but can occur as a result of extensive soft tissue degloving, previous scarring, loss of gingival attachment, and excessive stripping of the palatal mucosa. Subperiosteal dissection should only be performed to complete the osteotomies. Efforts should be made during a LeFort I osteotomy of the maxilla to protect and maintain the integrity of the descending palatine artery, which provides an additional source of vascularity to the maxilla. Relapse and postoperative malocclusion typically become evident in the immediate operative period or shortly thereafter. The minimal tendency toward early relapse can be managed with the IMF, dental elastics, or orthodontic appliances, whereas signifi ant relapse necessitates a return to the operating room. Early relapse can be caused by inadequate mobilization of bony segments, bony interference or instability, dislocation of the mandibular condyles from the glenoid fossa, or failure of fix tion. All bony segments should be suffici tly mobilized to allow a passive and precise fit into the occlusal splint, and fix tion of BSSO segments should ensure that the condyles are in a relaxed position within the glenoid fossa. A signifi ant percentage of patients undergoing mandibular surgery will develop potentially long-term defic ts as a result of injury to the inferior alveolar nerve. During splitting of the mandible, the osteotome should be directed closely against the inner surface of the buccal cortex, keeping a safe distance from the course of the inferior alveolar nerve. Similarly, the osteotomy line for a genioplasty should be placed at least 5 mm below the mental foramen, because the nerve within the canal descends before exiting the foramen. If nerve transection is identifi d during surgery, repair should be carried out. Facial palsies that develop after BSSO are likely to be caused by facial nerve compression or traction. Complete recovery is expected for the majority of patients, and conservative management is recommended. Unfavorable fractures that occur during a LeFort I osteotomy of the maxilla can extend up to the cranial base when downfracture is attempted forcefully, despite incomplete osteotomies or when the osteotome is directed in a superior direction during pterygomaxillary disjunction. Unfavorable fractures can also occur in BSSO, and can involve the condylar neck, lingual plate, or buccal plate. The key to preventing these unwanted mandibular fractures is to ensure proper direction and complete corticotomies of the horizontal and vertical mandibular osteotomy lines. Among those patients demanding revision, postoperative asymmetry is the most common indication, followed by untreatable malocclusion and relapse. Postoperative occlusion is established according to the occlusal splint, which is applied intraoperatively to bring the maxilla and mandible to a predetermined position. However, during the procedure, the surgeon judges the facial profile and adjusts it if necessary. To create an aesthetically pleasing facial profile, the surgeon uses several soft tissue parameters as a guide (see Table 48-1) to determine where to place the maxillomandibular complex. In certain patients with facial asymmetry, symmetry in repose and with a smile cannot be achieved simultaneously, especially in those severe patients with asymmetries involving not only the skeleton but also the teeth and soft tissue. To reach a harmonious profile, the surgeon needs to make a compromise between the dental, skeletal, and soft tissue midline; the priority of soft tissue symmetry is usually higher than that of skeletal and dental symmetries.

Chapter 48 

Aesthetic Orthognathic Surgery

759

Pearls for Success • The priorities in orthognathic surgery have evolved from a focus on rigid cephalometric calculations based on population norms and achieving ideal occlusion to its current art form, in which each treatment plan is customized to the aesthetic needs of the patient. • Effective collaboration between the surgeon and orthodontist is essential to obtain a balanced outcome that incorporates both facial and dental ideals. • The functional outcome should consider both occlusion and temporomandibular joint function. • Functional issues, such as malocclusion, can often be corrected utilizing single-jaw surgery. However, most aesthetic concerns require a two-jaw operation. • The aesthetic outcome should include both static (facial symmetry, facial proportion, occlusal cant) and dynamic (smile arc, gingival show) parameters. • The surgeon must be cautiously aware of the soft tissue changes that can result from displacement of the underlying skeletal support. An intraoperative systematic evaluation to the facial aesthetics must be performed to appropriately adjust bony movement.

Refer ences 1. Chu YM, Po-Hsun Chen R, Morris DE, Wen-Ching Ko E, Chen YR. Surgical approach to the patient with bimaxillary protrusion. Clin Plast Surg 34:535-546, 2007. 2. Sarver DM. The importance of incisor positioning in the esthetic smile: the smile arc. Am J Orthod Dentofacial Orthop 120:98-111,2001. 3. Chu YM, Bergeron L, Chen YR. Bimaxillary protrusion: an overview of the surgical-orthodontic treatment. Semin Plast Surg 23:32-39, 2009. 4. Yu CC, Bergeron L, Lin CH, Chu YM, Chen YR. Single-splint technique in orthognathic surgery: intraoperative checkpoints to control facial symmetry. Plast Reconstr Surg 124:879-886, 2009. 5. Nakagawa K, Ueki K, Takatsuka S, et al. Trigeminal nerve hypesthesia after sagittal split osteotomy in setback cases: correlation of postoperative computed tomography and long-term trigeminal somatosensory evoked potentials. J Oral Maxillofac Surg 61:898-903, 2003. 6. Ma J, Lu L, Song CX. [The position and course of mandibular canal through mandibular ramus in patients with prognathism] Shanghai Kou Qiang Yi Xue 17:200-203, 2008. 7. Tsuji Y, Muto T, Kawakami J, et al. Computed tomographic analysis of the position and course of the mandibular canal: relevance to the sagittal split ramus osteotomy. Int J Oral Maxillofac Surg 34:243-246, 2005. 8. Yoshioka I, Tanaka T, Khanal A, et al. Relationship between inferior alveolar nerve canal position at mandibular second molar in patients with prognathism and possible occurrence of neurosensory disturbance after sagittal split ramus osteotomy. J Oral Maxillofac Surg 68:3022-3027, 2010. 9. Yu CC, Chen PH, Liou EJ, Huang CS, Chen YR. A surgery-fi st approach in surgical-orthodontic treatment of mandibular prognathism—a case report. Chang Gung Med J 33:699-705, 2010. 10. Wang YC, Ko EW, Huang CS, Chen YR, Takano-Yamamoto T. Comparison of transverse dimensional changes in surgical skeletal Class III patients with and without presurgical orthodontics. J Oral Maxillofac Surg 68:18071812, 2010. 11. Liao YF, Chiu YT, Huang CS, Ko EW, Chen YR. Presurgical orthodontics versus no presurgical orthodontics: treatment outcome of surgical-orthodontic correction for skeletal class III open bite. Plast Reconstr Surg 126:20742083, 2010. 12. Liou EJ, Chen PH, Wang YC, Yu CC, Huang CS, Chen YR. Surgery-first accelerated orthognathic surgery: orthodontic guidelines and setup for model surgery. J Oral Maxillofac Surg 69:771-780, 2011.

K23345_Pu_c48 50_Aesth Ortho_r7_cl_743-760.indd 759

4/6/2015 7:23:38 AM

760

Part VII 

Cosmetic Surgery of the Facial Skeleton

13. Liou EJ, Chen PH, Wang YC, Yu CC, Huang CS, Chen YR. Surgery-first accelerated orthognathic surgery: postoperative rapid orthodontic tooth movement. J Oral Maxillofac Surg 69:781-785, 2011. 14. Ko EW, Hsu SS, Hsieh HY, Wang YC, Huang CS, Chen YR. Comparison of progressive cephalometric changes and postsurgical stability of skeletal Class III correction with and without presurgical orthodontic treatment. J Oral Maxillofac Surg 69:1469-1477, 2011. 15. Hunsuck EE. A modifi d intraoral sagittal splitting technic for correction of mandibular prognathism. J Oral Surg 26:250-253, 1968. 16. Honda T, Lin CH, Yu CC, Heller F, Chen YR. The medial surface of the mandible as an alternative source of bone grafts in orthognathic surgery. J Craniofac Surg 16:123-128; discussion 128, 2005. 17. Dodson TB. Corticosteroid administration in oral and orthognathic surgery. Evid Based Dent 12:49-50, 2011.

K23345_Pu_c48 50_Aesth Ortho_r7_cl_743-760.indd 760

4/6/2015 7:23:38 AM

Part VIII

Plastic Surgery of the Breast

K23345_Pu_c49p_Plast Surg Asian Breast_r5_cl_761-770.indd 761

4/6/2015 7:25:57 AM

K23345_Pu_c49p_Plast Surg Asian Breast_r5_cl_761-770.indd 762

4/6/2015 7:25:57 AM

49 Special Considerations in Plastic Surgery of the Asian Breast Ming-Huei Cheng, Jung-Ju Huang

T

he   aim of breast surgery, either cosmetic or reconstructive, is to create symmetrical, beautiful breasts. What defi es beautiful breast shape depends on the individual patient’s body stature and what she considers attractive, as well as on her particular cultural concepts of aesthetics. The surgeon should consider the patient’s attitude toward disease and treatment of the breast, in addition to her disease status, which will affect the method and type of surgery that the patient will choose when considering breast reconstruction after cancer surgery. The surgeon must also consider the fact that the breasts and nipple-areola complex differ between Asian women and white women (Table 49-1).

Table 49-1  Comparison of Characteristics of the Breast and Nipple-Areola Complex of Asian and White Women Asian

White

Dermis

Thi k

Thi

Soft tissue

Dense and fi m

Loose and soft

Scar

Hypertrophy

Fine

Gland

Small and dense

Large and loose

Projection

Projected

Ptotic

Diameter

Small

Large

Color

Dark

Light

Diameter

Large

Small

Projection

Projected

Flat

Breast

Areola

Nipple

763

764

Part VIII 

Plastic Surgery of the Breast

Unique Characteristics of Asian Women Asian women are smaller in body stature than Westerners and tend to be more slender. The average body mass index (BMI) in Asian women is lower, and they usually have a proportionally smaller breast with small, dark areolas and proportionally larger nipples that project more. Compared with white women, the tendency toward developing darker, more conspicuous and hypertrophic scarring is higher in the Asian population. Therefore placing the scar in a less conspicuous area is an important issue when performing breast surgeries in Asian women.

Augmentation Mammaplasty Among the commonly performed cosmetic breast surgeries, augmentation mammaplasty is the most favored in Asia. Fig. 49-1 shows a typical Asian patient for breast augmentation. Most Asian women consider a C or D cup size as the most attractive breast size, but many of them have A or B cup breasts. Therefore augmentation mammaplasty using a saline-filled or cohesive gel implant becomes the preferred procedure for these patients. A 200 to 320 cc implant is commonly selected by Asian women. Unfortunately, some women have opted to undergo liquid silicone or “amazing gel” (polyacrylamide) injections directly into the breasts in a beauty salon to achieve the augmented effect they desire— with often disastrous results. In the past two to four decades, these salon treatments have commonly led to the need for many often-complicated revision augmentation mammaplasties in Asian countries, especially in mainland China, Taiwan, and Southeast Asia.

Pr eo pera tive Ass ess ment

Preoperative assessment of the patient’s breasts and chest wall are important. Approximately 10% to 15% of patients desiring augmentation mammaplasty have chest wall hypoplasia, with asymmetrical breasts or a concave chest wall unilaterally and mild scoliosis, the so-called anterior thoracic hypoplasia.1 Their asymmetrical chest wall requires selection of different sizes of implants to achieve satisfactory, symmetrical breast mounds.

A

B

Fig. 49-1  A, Th s typical Asian woman requested breast augmentation. B, Postoperative result.

Chapter 49 

Special Considerations in Plastic Surgery of the Asian Breast

A pinch test is performed to determine the thickness of the native breasts. If the breast has more than 2 cm thickness, either a submuscular or subglandular augmentation could be performed and will produce a good aesthetic result. If the native breast tissue is extremely thin, submuscular insertion of the mammary implant is recommended. Th s allows better coverage of the implant by the overlying muscle and glandular tissue and helps to create a natural-looking augmentation with a lower incidence of palpable implants after surgery. Most Asian patients seeking augmentation mammaplasty prefer to have more projected breasts. High profile implants are preferred for this augmentation because of the narrow chest wall width in Asian women. Augmentation mammaplasty with implants can be performed through transaxillary, periareolar, or inframammary fold incisions. Because of the concern of hypertrophic scarring, the transaxillary approach is the most favored, followed by the periareolar approach. An inframammary incision with a subglandular implant is commonly performed in Western countries but is not as accepted in Asia in an effort to avoid visible scarring on the inferior border of the breasts. A transaxillary incision from the axilla can be well hidden under a natural skin fold. For patients with proportionally larger nipples, the areolas will be distended and will become even larger after augmentation mammaplasty. Concurrent nipple reduction is a preferred adjuvant procedure with augmentation mammaplasty.2

Mastopexy Because of the concern about hypertrophic scarring, mastopexy alone is not a welcome procedure among Asian women. Despite this, some patients with ptotic breasts ask for mastopexy with fat grafting, which is usually limited to 100 cc per section per side. A large amount of fat grafting with the use of Brava is not popular among Asian women, because it is not easy to comply with the continuous use of Brava for 10 hours per day for 10 weeks. Fig. 49-2, A, shows a typical Asian patient who requested a mastopexy. Either a periareolar or vertical incision can be used, depending on the severity of ptosis. The periareolar incision confi es the scar around the areola only, but the scar will widen over time, and the nipple may become flat. Th s procedure is reserved for patients with mild breast ptosis only. A vertical incision with a vertical scar, J scar, or mini inverted-T scar is usually required and produces better postoperative results (Fig. 49-2, B).

A

B

Fig. 49-2  A, Th s 40-year-old woman with ptotic breasts requested mastopexy. B, After mastopexy with areolar revision, a vertical scar is seen on her breasts below the areolas.

765

766

Part VIII 

Plastic Surgery of the Breast

Reduction Mammaplasty Although augmentation mammaplasty is much more common than reduction mammaplasty in Asian patients, some women with hypertrophic breasts do require reduction. The number of reduction mammaplasties continues to increase because more and more patients are presenting with breast hypertrophy, which may be related to increased body weight from a diet with more meat and fatty foods (Fig. 49-3). Reduction mammaplasty usually requires a keyhole incision with an inverted-T scar. The selection of a medial pedicle, inferior pedicle, or central mound pedicle depends on the surgeon’s preference. We prefer the central mound pedicle, which provides a better blood supply to the nipple-areola complex.

A

B

C

D

E

F

Fig. 49-3  Th s 53-year-old woman presented for breast reduction. Her breasts were hypertrophic and ptotic; her nipple-

areola complex was distended. Six months after reduction mammaplasty using an inverted scar and the central mound pedicle technique, she was satisfi d with her reduced and symmetrical breast mounds.

Chapter 49 

Special Considerations in Plastic Surgery of the Asian Breast

Breast Reconstruction More and more Asian breast cancer patients are opting to undergo breast reconstruction after mastectomy. In the past, most of these surgeries were performed as a delayed procedure after cancer treatments were fin shed. With confi mation of the oncologic safety regarding immediate breast reconstruction after mastectomy, immediate breast reconstruction is more and more accepted in Asia.3 On average, an Asian woman with breast cancer is about 10 years younger than her Western counterpart, despite the fact that there are fewer smokers among Asian women.3 Although autologous tissue reconstruction is generally preferred because of the long-lasting, satisfactory results, patients with a low BMI usually have insufficient autologous tissue for breast reconstruction. One-stage direct implant reconstruction or two-stage tissue expander–implant reconstruction are the preferred choices for breast reconstruction in these patients.3

Br ea st Rec onstr uctio n With Aut ol o go us Tiss ue

Abdominal-based flaps, such as the pedicled transverse rectus abdominis myocutaneous (TRAM) flap or free TRAM/deep inferior epigastric perforator (DIEP) flap, are preferred for autologous breast reconstruction. Fig. 49-4 shows a typical Asian patient who underwent breast reconstruction using autologous tissue. Because of the low BMI of most Asian women, the abdominal flap procedure is more suitable for breast reconstruction with adequate volume than tissue from the buttock or upper thigh. A signifi ant portion of breast cancer patients receive contralateral breast augmentation during or after reconstruction.4 A few patients require reduction of the contralateral healthy breast to fit the size of the reconstructed breast because they have inadequate abdominal tissue for a symmetrical breast reconstruction.5 Th s refl cts the relatively larger percentage of the entire abdominal flap procedures for unilateral breast reconstruction in Asia. In contrast to procedures performed in Western patients, in whom a hemi-DIEP or hemi-TRAM flap is usually adequate for unilateral breast reconstruction, surgeons of Asian populations almost always have to include the contralateral medial or even the contralateral lateral part of the DIEP/TRAM flap for unilateral breast reconstruction.6,7 Other flaps for breast reconstruction include the gluteal artery perforator (GAP) flap, Ruben flap, gracilis perforator flap, profunda artery perforator flap, and anterolateral thigh (ALT) flaps. Among these flaps, the GAP flap is the second most commonly used for reconstruction in Asian patients. However, the

A

B

C

Fig. 49-4  Th s 34-year-old woman with left reast cancer underwent modifi d radical mastectomy and immediate

breast reconstruction. A, Before surgery. B and C, At 1-month follow-up, the reconstructed breast using a DIEP flap has a symmetrical and pleasing breast mound.

767

768

Part VIII 

A

Plastic Surgery of the Breast

B

Fig. 49-5  A, Th s 47-year-old woman was diagnosed with ductal carcinoma in situ in her left breast. B, She underwent a nipple-sparing mastectomy and immediate breast reconstruction, as well as contralateral breast augmentation with cohesive gel smooth silicone implants (left 240 cc and right 180 cc).

perforators for the GAP flap are usually extremely tiny in Asian patients, with a tortuous intramuscular course that requires a tedious technique to harvest it without damaging the pedicle. Thus the GAP flap is far less popular than abdominal flaps.

Br ea st Rec onstr uctio n With Impl ant s

Implant-based breast reconstruction is an easy approach for breast reconstruction in patients who pre­ sent with insuffici t autologous tissue for reconstruction and in patients who wish to spend less time in surgery and recovery, or who cannot undergo prolonged operations for medical reasons. However, this procedure is associated with signifi ant complications, such as chest wall skin necrosis, implant exposure, capsular contracture, infection, and implant rupture. It is not recommended in patients who will receive radiotherapy after reconstruction or who have already undergone radiotherapy. Fig. 49-5 shows a slender patient who underwent a mastectomy on the left side because of breast cancer. Reconstruction with an implant was recommended, since she had insuffici t autologous tissue for reconstruction. With a nonptotic or more projected contralateral healthy breast, implant reconstruction becomes the treatment of choice in most thin patients undergoing immediate reconstruction. It is also the preferred procedure for augmentation of the contralateral breast. In general, reconstruction with an implant usually results in a younger, more projected breast. Traditionally, insertion of a tissue expander in the subpectoral plane and subsequent implant reconstruction in the same plane was the standard procedure after a skin-sparing mastectomy with subsequent implant reconstruction.8,9 However, in Asian women, we have found the circumstances to be otherwise. Insertion of a defin tive implant can usually be performed in one-stage immediately after a skin-sparing mastectomy. Asian women require relatively smaller breast implants (average of 283 cc of implant volume in our experience), are typically younger (average 42.9 years old), have healthy, thick dermis skin, and are usually nonsmokers. Immediate one-stage reconstruction with direct implant achieves a 96.6 % successful rate in patients who did not require postoperative radiotherapy.3

Chapter 49 

A

Special Considerations in Plastic Surgery of the Asian Breast

B

Fig. 49-6  A, Th s 56-year-old woman presented with bilateral nipple hypertrophy. B, She requested nipple reduction

using the modifi d top hat flap technique. At her 2-week follow-up, she was satisfi d with her smaller and proportionate nipples.

Nipple Surgeries Asian women tend to have a darker nipple-areola complex with a larger, projected nipple. Nipple reduction can be done along with augmentation mammaplasty, since the nipple-areola complex will be distended even more after implant insertion.10 Fig. 49-6 shows a patient with larger and more projecting nipples who requested nipple reduction. She had a typical larger, darker Asian nipple-areola complex. For nipple reconstruction after cancer surgery, creating adequate nipple projection that is equal to the contralateral nipple is important. To establish and maintain nipple projection, we prefer to insert costal cartilage wrapped with a modifi d top hat flap to enhance and maintain nipple projection.11

Discussion In general, using implants for augmentation mammaplasty or breast reconstruction is becoming popular for Asian patients with a low BMI and small, nonptotic breasts. However, implant selection can be very different from augmentation mammaplasty to breast reconstruction. High profile implants are more popular for patients desiring augmentation or those who received simultaneous breast augmentation along with unilateral breast reconstruction. On the other hand, moderate or moderate plus implants are more suitable for breast reconstruction in Asian women. Although most Asian patients have a relatively low BMI, autologous breast reconstruction is still quite an acceptable procedure in Asian women, because the results are more natural and consistent. Without contraindications such as a midline abdominal scar, previous liposuction, or inadequate fat tissue, autologous breast reconstruction, such as microsurgical breast reconstruction, can be performed with good results. Donor tissue is relatively inadequate in Asian women. However, with careful preoperative planning and perioperative management, most reconstructions can be performed with highly satisfactory results. Fat grafting has emerged as a popular procedure in breast surgeries around the world. To correct and contour a deformity or an asymmetrical result from breast reconstruction, a small amount of fat grafting during revision surgery can be a good option, especially if there is inadequate breast tissue or the breast contour looks unnatural with the implant in place. Fat grafting can also help to correct wrinkling in extremely thin patients undergoing augmentation mammaplasty.

769

770

Part VIII 

Plastic Surgery of the Breast

Pearls for Success • High profile implants are more popular for patients during augmentation. • Moderate or moderate plus implants are more suitable for breast reconstruction in Asian women. • Autologous breast reconstruction is still an acceptable procedure in Asian women. • Without contraindications such as a midline abdominal scar, previous liposuction, or inadequate fat tissue, autologous breast reconstruction—such as microsurgical breast reconstruction—can be performed with good results.

Refer ences 1. Spear SL, Pelletiere CV, Lee ES, Grotting JC. Anterior thoracic hypoplasia: a separate entity from Poland syndrome. Plast Reconstr Surg 113:69-77; discussion 78-79, 2004. 2. Cheng MH, Smartt JM, Rodriguez ED, et al. Nipple reduction using modified top hat flap. Plast Reconstr Surg 118:1517-1525, 2006. 3. Wang HY, Ali RS, Chen SC, Chao TC, Cheng MH. One-stage immediate breast reconstruction with implant following skin-sparing mastectomy in Asian patients. Ann Plast Surg 60:362-366, 2008. 4. Ulusal BG, Cheng MH, Wei FC. Simultaneous endoscope-assisted contralateral breast augmentation with implants in patients undergoing postmastectomy breast reconstruction with abdominal flaps. Plast Reconstr Surg 118:1293-1302, 2006. 5. Huang JJ, Wu CW, Leon Lam W, Lin CY, Nguyen DH, Cheng MH. Simultaneous contralateral breast reduction/ mastopexy with unilateral breast reconstruction using free abdominal flaps. Ann Plast Surg 67:336-342, 2011. 6. Cheng MH, Robles JA, Ulusal BG, Wei FC. Reliability of zone IV in the deep inferior epigastric perforator flap: a single center’s experience with 74 cases. Breast 15:158-166, 2006. 7. Ulusal BG, Cheng MH, Wei FC, et al. Breast reconstruction using the entire transverse abdominal adipocutaneous flap based on unilateral superfic al or deep inferior epigastric vessels. Plast Reconstr Surg 117:1395-1403; discussion 1404-1406, 2006. 8. Cordeiro PG, McCarthy CM. A single surgeon’s 12-year experience with tissue expander/implant breast reconstruction: part II. An analysis of long-term complications, aesthetic outcomes, and patient satisfaction. Plast Reconstr Surg 118:832-839, 2006. 9. Cordeiro PG, McCarthy CM. A single surgeon’s 12-year experience with tissue expander/implant breast reconstruction: part I. A prospective analysis of early complications. Plast Reconstr Surg 118:825-831, 2006. 10. Cheng MH, Smartt JM, Rodriguez ED, Ulusal BG. Nipple reduction using the modifi d top hat flap. Plast Reconstr Surg 118:1517-1525, 2006. 11. Cheng MH, Rodriguez ED, Smartt JM, et al. Nipple reconstruction using the modifi d top hat flap with banked costal cartilage graft: long-term follow-up in 58 patients. Ann Plast Surg 59:621-628, 2007.

K23345_Pu_c49p_Plast Surg Asian Breast_r5_cl_761-770.indd 770

4/6/2015 7:26:04 AM

50 Breast Implants

M

Rose Fu, Ernest S. Chiu

ore than 300,000 patients underwent breast implant augmentation in 2011, making it the second most popular cosmetic plastic surgery procedure performed in the United States, surpassed only by liposuction.1 With the multitude of breast implant options on the market, it is imperative that each plastic surgeon be well-informed about the benefits, safety profiles, and risks of each type of implant. The well-informed surgeon ensures educated and individualized patient decision-making and improves patient satisfaction. As the goal for breast augmentation surgery is self-explanatory, so then is the goal for the breast implant. The ideal breast implant should be durable, should have no toxicity and no risk of undesirable biological reactions, and when emplaced, should feel as natural as the surrounding native breast parenchyma. Since its introductory design by Cronin and Gerow in 1961, the initial breast implant—a silicone gel breast implant manufactured by the Dow Corning Corporation—has evolved into the myriad of gel and saline implants with varying shapes and textures on the market today. Each generation of implant has made steps toward attaining the ideal implant; however, no one implant satisfies all the criteria desired. Th s chapter summarizes the types, textures, and shapes of implants currently available for breast augmentation.

Types of Implants All implants on the market today are made of two separate components, the outer silicone elastomer shell and an inner filling that can be saline or silicone.

Shell

Silicone is more precisely called polymerized siloxanes [R2SiO]n, with an SiO backbone with attached R groups where R represents an organic group such as methyl, ethyl, or phenyl (Fig. 50- 1). Silicone has many of the characteristics required of the ideal implant: it is inert, synthetic, and durable; it is heat-resistant; and it is resistant to chemical reactions and to degradation with oxygen, ozone, and UV light. In addition, silicone has low thermal conductivity, low toxicity, and a low risk of biological reactions. It does not support microbiological growth and forms watertight seals. Finally, silicone feels akin to a soft rubber, which when emplaced, feels close to native soft tissue.

771

772

Part VIII 

R1

( Si

R2

Plastic Surgery of the Breast

R3

O )l

( Si

R5

O )m

R4

( Si

O )n

R6

Fig. 50-1  Silicone molecular structure.

The FDA currently identifies four levels of testing for silicones: 1. Food grade: The lowest requirement for testing. Food grade testing includes food packaging. 2. United States Pharmacopeia (USP) Class VI: Evaluates plastics used in drug packaging. USP Class VI testing includes a four-part evaluation involving animal (mouse and rabbit) testing of extracts of saline, oil, alcohol, and polyethylene glycol. It also has a 5-day rabbit intramuscular implantation test. 3. Medical grade: As defi ed by Dow Corning, medical grade testing includes USP Class VI testing, a tissue-culturing test, and a 90-day rabbit intramuscular implantation test with histopathology. It also includes tests for skin sensitization, pyrogenicity, and hemolysis. 4. Dow Corning medical grade equivalent: Th s testing level includes chemical, mechanical, and biologic analyses created by the Silicone Task Force in 1992 to identify silicones that are not substantially different from the Dow Corning medical silicones, which have been recognized as biocompatible. Currently, medical grade or Dow Corning equivalents are used for any implants for the body.2

Surface Characteristics: Smooth Versus Textured The outer shells of breast implants are either textured or smooth3 (Box 50-1 and Fig. 50-2). Most implants have been smooth with free rotation within the capsule. Because they are not tethered, smooth implants do not pull on the surrounding breast parenchyma and soft tissue; therefore they tend to have less incidence of visible rippling, creating a more natural breast appearance.4 However, because smooth implants are not tethered, the weight of the implant is not distributed over the entirety of the capsule; rather, the weight is gravity dependent. Over time, this may cause greater breast deformity at the inferior pole by causing ptosis and at the superior pole by stretching the implant pocket and reducing fill at the upper pole. Smooth implants also have a higher rate of capsular contracture.5,6 One postulated reason is that the scar tissue capsule is being laid down in linear fibers, which then contracts down, causing pain and an unnatural appearance. Textured implants are generally anatomically shaped. The development of textured implants stemmed from the desire to reduce rates of capsular contracture, with the rationale that a textured surface prevents linear scar tissue formation. Historically, this rationale was supported by the fact that polyurethane-coated implants, which were textured, had significantly lower capsular contracture rates. 5 Polyurethane-coated implants were eventually removed from the market because of the concern for complete removal and the theoretical concern of carcinogenic conversion, because the polyurethane wore away over time. However, the idea that texturing an implant decreases contracture remained, and textured implants today are made without the coating. Several prospective studies have noted the continued signifi ant decrease in capsular contracture in textured implants placed subglandularly.6,7 Other studies have demonstrated that this difference seems to be lost in the submuscular plane.4,8

Chapter 50 

Breast Implants

Box 50-1  Smooth Versus Textured Implants Smooth • Round • Free rotation within the capsule • May bottom out • Loss of superior pole fill • Possibly higher contracture rate • Greater patient satisfaction

Textured • Anatomic • Tethered to capsule • More rippling • Better retention of shape • Possibly low contracture rate

A

B

C

D

Fig. 50-2  Types of implants. A, Mentor smooth saline implant. B, Mentor Siltex textured contoured saline implant. C, Allergan smooth surface implant in scanning electron microscopy at 5923 magnifi ation with a 50 mm scale bar and 25 mm fibroblast representation. D, Allergan Biocell in scanning electron microscopy at 1043 magnifi ation. (C and D from Barr S, Hill E, Bayat A. Current implant surface technology: an examination of their nanostructure and their influence on fibroblast alignment and biocompatibility. Eplasty 9:e22, 2009.)

Additional advantages of a textured shell include the preclusion of rotation through adherence of the scar tissue capsule, promoting a one-breast feel, because the implant and the surrounding parenchyma are tethered together in one cohesive breast mound. Meticulous surgical dissection of the implant pocket is crucial to achieving a flattering aesthetic result, because any rotation of a contoured textured implant within the implant pocket, with subsequent tethering, can result in a disfi uring asymmetry. Additional disadvantages of textured implants include a greater frequency of visible rippling, especially in the upright position in the superior pole, with rates of visible rippling almost twice as high as those for smooth implants according to some studies.9 Th s is caused by the simultaneous tethering of the shell to the upper pole of the capsule as well as the loss of superior pole gel fill in the upright position as a result of gravity.9 Th s may explain why patients may prefer smooth implants even if the rate of capsular contracture is higher.9

773

774

Part VIII 

Plastic Surgery of the Breast

Sha pe

Breast implants can be round or contoured (see Fig. 50-2). Generally, round implants are smooth and contoured, and anatomically shaped implants are textured, to restrict rotation of the implant. Because they are tear-shaped, contoured implants curve with the natural slope of the breast. They are narrower at the superior pole and have increased fill at the inferior pole, congruent with the native breast. By contrast, round implants are symmetrical, thereby allowing them to have the softer and smooth shell. Round implants also have greater superior pole projection because of their shape. Depending on the type of projection, implants are generally offered in low, moderate, or high profile, each denoting the frontal projection of the implant from the base diameter.

Impl ant Fill Saline

First introduced in 1965 by French surgeon H.R. Arion, the saline implant was immediately regarded with excitement for its implications for breast augmentation. Because saline implants are filled with saltwater solution, which is found in the body naturally, the implant’s diffusion or deflation into the body would pose essentially no risk to the woman’s health. In addition, saline implants can be filled after implantation of the shell, allowing smaller incisions that are aesthetically more desirable for patients seeking cosmetic breast augmentation. However, despite the advantages of saline breast implants, they did not become widely popular until the FDA moratorium on silicone implants was put in place in the United States in 1992. Because the saline filler is more fluid, saline implants tend to have a greater incidence of rippling.10 This is especially seen in textured saline implants, which have upper pole collapse resulting from a loss of cohesion in the filler material when the patient is standing. The saline sinks to the dependent portion of the implant, decreasing upper pole fill and resulting in a rippled look, because the implant shell tethers to the overlying capsule. The saline filler, compared with its silicone counterpart, tends to feel more unnatural, because its water-based content has a different consistency than natural breast parenchyma. However, patients who choose saline implants continue to report high satisfaction, with more than 95% of patients willing to choose them again.9 Silicone Safety In earlier models there was a high incidence of spontaneous deflation—up to 76%—which proved to be unacceptable.11Subsequent designs with stronger, thicker outer silicone shells and variations in the filling valve have dramatically decreased the rates of spontaneous deflation, which were reported as 4.3% after 10 years in a multicenter retrospective review by Cunningham et al.10 At 8%, all-cause deflation rates double the spontaneous rate; the remainder represents iatrogenic causes or trauma at the time of surgery, serving as a constant reminder that meticulous surgical technique is paramount to implant survival. In that same study, Cunningham et al10 found an approximately 20% overall complication rate with saline implants 10 years after implantation, with capsular contracture (Baker grade III or IV) as the leading complication at 16.6% (Table 50-1). The overall patient reoperation rate was 25.8%. The most common reason for reoperation was implant replacement or removal, followed by open capsulotomy for contracture. The rates for repair of wound complications, wound infection, and dehiscence were extremely low, even after 10 years, accounting for less than 1%. Saline implant survival is over 98% after 10 years when excluding initial iatrogenic or intraoperative trauma as causes for rupture.

Chapter 50 

Breast Implants

775

Table 50-1  Retrospective Review on the Complications of Saline Implants* Complication

Capsular contracture

Implants (%)

16.6

Hematoma

1.7

Wound infection

0.5

Wound dehiscence

0.2

Seroma

0

Other

1.3

Data from Cunningham BL, Lokeh A, Gutkowski KA. Saline-filled breast implant safety and efficacy: a multicenter retrospective review. Plast Reconstr Surg 105:2143-2149; discussion 2150-2151, 2000. *The mean time of follow-up is 13 years.

Silicone Gel A discussion of silicone gel implants would be incomplete without including the controversies relating to its proposed health risks. Patients who are seeking breast implantation may have concerns over the purported relationship of silicone gel implants with the increased risks of cancer or other systemic autoimmune or connective tissue diseases. It is imperative for physicians to stay informed to address these questions and dispel myths. All patients should be well informed about the history, alleged health-related controversies, and safety profiles of silicone implants. These patients make better decisions regarding personal implant choice, have more realistic expectations, and have greater patient satisfaction. Although the fi st silicone implant was introduced in 1962, the U.S. government did not regulate it until the FDA added the Medical Device Amendment to the Federal Food, Drug, and Cosmetic Act in 1976. Initially classifi d as a class II device, breast implants were considered moderate risk, and companies were required to comply with only general controls and performance standards. However, in the 1980s the FDA reclassifi d breast implants as class III when case reports implied an association between implants and cancer, and between implants and connective tissue diseases. Th s class was usually reserved for devices such as implantable pacemakers or defibrillators, which are crucial in sustaining or supporting life. Using this classifi ation, the FDA labeled silicone breast implants as devices that may present a potential unreasonable risk to human health and required all manufacturers to submit premarket approval studies documenting the adverse events and potential health risks of their implant. Under this new scrutiny, the FDA deemed that there was inadequate information regarding the safety and complications of silicone implants, specifi ally both local complications such as implant rupture and gel diffusion, and systemic effects such as the alleged increased risk in connective tissue diseases. Therefore in 1992, the FDA instituted a moratorium on silicone breast implants, and silicone was taken off the general aesthetic plastic surgery market.

K23345_Pu_c50_Breast Implants_r5_cl_771-782.indd 775

4/3/2015 10:58:28 AM

776

Part VIII 

Plastic Surgery of the Breast

In the 1990s several large studies were published that reported no increased association between silicone breast implants and systemic disease or breast cancer.12 In 1999 the Institute of Medicine published a comprehensive report on the past, current, and ongoing studies of silicone breast implants.13 Although the report supported no association between silicone breast implants and systemic health effects such as cancer or autoimmune or connective tissue diseases, it did call attention to the relatively high frequency of local complications such as pain and capsular contracture, disfigu ement, rupture, infection, and implant diffusion or bleeding.13 These local complications continue to be the main safety concern for breast implants. In 2006 the FDA approved two silicone breast gel implants, the MemoryGel Silicone Gel implant made by Mentor and the Natrelle Silicone Gel implant made by Inamed, with the provision that postmarket studies continue to monitor the frequency of local complications and to screen for rare adverse events that were otherwise missed in small cohort studies. Silicone Gel Safety To decrease the frequency of local complications, the silicone gel implant has undergone several generations of development, with each generation of implants differing in gel consistency, shell thickness, barrier designs, and surface characteristics (textured or smooth). The fi st generation of silicone implants, developed by Cronin and Gerow, was an anatomic, teardrop-shaped, thick silicone shell filled with viscous silicone gel with a polyethylene terephthalate (Dacron, Terylene) fastener at the posterior surface for chest wall fixation, thereby preventing rotation. However, because of the high rate of capsular contracture and the subsequent unnatural appearance of this silicone, a second generation of silicone gel was developed in the 1970s with a thinner shell, more fluid gel, and a round shape. Predictably, this generation was fraught with implant rupture, with increased gel bleeding into the surrounding breast parenchyma. The third and fourth generations of implants are similar; these are the silicone implants available on the market today.14 The current generation has a multilayered elastomer silicone shell that is thicker than the second-generation shell, with a barrier coating and a more viscous gel to reduce gel diffusion if the loss of implant integrity occurs. The viscosity of the gel inversely correlates with the degree of gel diffusion. Because of the prolonged moratorium on silicone implants, prior safety and efficacy studies were mostly performed before 1992, thereby concentrating on the previous generations of silicone implants. In the two postmarket approval studies, the current third and fourth generations of implants are well studied. Thus far in the postmarket approval studies, most recently updated in 2011 by the FDA, Allergan has followed their patients for 10 years and Mentor for 8 years.15 The most common complications in both studies include implant rupture, implant removal, the need for reoperation, breast pain, and capsular contracture (Table 50-2). As expected, the cumulative incidence of each complication increases over time with the implant (Table 50-3). Table 50-3 also demonstrates that in general, complications tend to occur with greater frequency in those undergoing revision augmentations. For example, the rates of reoperation at both points of follow-up for Allergan and Mentor were higher for revision augmentation than for primary augmentation. The longer that women had breast implants, the more likely the cumulative rate of reoperation and implant removal. The most common reason for implant removal and reoperation was capsular contracture15 (Tables 50-4 and 50-5). Other common reasons included implant rupture and patient request for a change in implant size or style. In both the Allergan and Mentor studies, women were randomized into an MRI or non-MRI group. Those within the MRI group received scheduled imaging to screen for the loss of implant integrity. Again, as with the other complications, the cumulative incidence of rupture was higher for patients who had revision augmentation than for patients who had primary augmentation. Although the majority of implant rupture was accompanied by symptoms, certain cohorts reported that up to 35% of ruptures may be silent.

Chapter 50 

777

Breast Implants

Table 50-2  Local Complication Rates of Postmarket Studies for Silicone Implants* Allergan

Mentor

Primary Augmentation (%) (N 5 455)

Revision Augmentation (%) (N 5 147)

10.9

11.7

2.5

3.4

Skin/nipple sensation changes

1.6

2.2

2.8

1.4

Capsular contracture (Baker grade III/IV)

19.1

27.5

10.9

24.1

Hematoma

1.6

2.1

2.9

2.8

Implant malposition

6.3

6.0

0

2.5

Infection

0.5

1.4

1.6

1.4

Reoperation

36.1

46.0

20.1

37.8

Implant removal with or without replacement

20.8

32.4

7.3

21.1

Implant rupture

10.1

6.3

13.6

15.5

Complication or Outcome

Breast pain

Primary Augmentation (%) (N 5 552)

Revision Augmentation (%) (N 5 145)

Data from U.S. Food and Drug Administration. Silicone gel-filled breast implants, 2013. Available at http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/BreastImplants/ucm063871.htm. *Allergan: 10-year follow-up; Mentor: 8-year follow-up.

Table 50-3  Cumulative Incidence of Complications Increases Over Time* Allergan Complication or Outcome

Mentor

4-Year Follow-up (%)

10-Year Follow-up (%)

3-Year Follow-up (%)

8-Year Follow-up (%)

Primary augmentation

13.2

19.1

8.1

10.9

Revision augmentation

17.0

19.1

18.9

24.1

Primary augmentation

23.5

36.1

15.4

20.1

Revision augmentation

35.3

46.0

28.0

37.8

Primary augmentation

9.6

20.8

4.9

7.3

Revision augmentation

13.3

32.4

13.4

21.1

Capsular Contracture

Reoperation

Removal of Implant

Data from U.S. Food and Drug Administration. Silicone gel-filled breast implants, 2013. Available at http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/BreastImplants/ucm063871.htm. *Allergan: 4-year and 10-year follow-up; Mentor: 3-year and 8-year follow-up. Revision augmentation had a greater incidence of complications than primary augmentation.

778

Part VIII 

Plastic Surgery of the Breast

Table 50-4  Primary Reasons for Implant Removal* Allergan Reason for Removal

Mentor

Primary Augmentation (%)

Revision Augmentation (%)

Primary Augmentation (%)

Revision Augmentation (%)

Capsular contracture (Baker grade III/IV)

32.1

35.9

19.1

29.4

Implant rupture

17.3

7.7

4.4

7.8

7.1

18.0

0

0

19.9

14.1

52.9

35.3

7.7

7.7

0

0

Implant malposition Patient request for size/style change Ptosis

Data from U.S. Food and Drug Administration. Silicone gel-filled breast implants, 2013. Available at http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/BreastImplants/ucm063871.htm. *Allergan: 10-year follow-up; Mentor: 8-year follow-up.

Table 50-5  Primary Reasons for Reoperation* Allergan Reason for Reoperation

Mentor

Primary Augmentation (%)

Revision Augmentation (%)

24.9

24.1

30.1

30.8

Delayed wound healing

1.4

1.9

0.7

6.4

Hematoma/seroma

5.9

12.0

8.2

6.4

Implant malposition

12.2

11.1

2.7

1.3

Implant rupture

13.1

6.5

1.4

5.1

Infection

0.9

2.8

2.1

1.3

Patient request for size/style change

5.4

2.8

13.7

14.1

11.3

8.3

2.7

2.6

3.6

6.5

11.0

3.8

Capsular contracture (Baker grade III/IV)

Ptosis Scarring/hypertrophic scarring

Primary Augmentation (%)

Revision Augmentation (%)

Data from U.S. Food and Drug Administration. Silicone gel-filled breast implants, 2013. Available at http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/BreastImplants/ucm063871.htm. *Allergan: 10-year follow-up; Mentor: 8-year follow-up.

Chapter 50 

Breast Implants

Fig. 50-3  The linguini sign, a radiological fi ding demonstrating early rupture of a silicone gel implant. (From Talanow R. Linguini sign. Available at http://www.radiolopolis.com.)

Rupture of earlier generations of silicone gel implants with softer shells was accompanied by an increased frequency of symptoms and greater gel diffusion into surrounding breast parenchyma. Radiological fi dings such as the “linguini” sign on MRI or CT, resulting from a collapsed implant shell, could identify a loss of integrity16 (Fig. 50-3). Rupture of later generations may display an incompletely collapsed implant shell fl ating in a pool of silicone gel in the teardrop sign.14 The FDA currently recommends MRI (sensitivity and specific ty greater than 90%) surveillance every 2 years starting 3 years after implantation. For patients who are unable to undergo an MRI because of metal implants or a pacemaker, CT offers an alternative with comparable diagnostic value. However, depending on the age of the patient, a CT every 2 years may confer signifi ant cumulative radiation. Mammography and ultrasound are also alternatives, but the diagnostic accuracy of ultrasound is operator dependent and mammography only offers information for identifying extracapsular involvement. Unfortunately, because intracapsular rupture—where the silicone is retained within the capsule—constitutes 80% to 90% of all ruptures, CT and MRI should remain the cornerstone procedures for screening. To identify the mode of device failure, both Allergan and Mentor performed retrieval analyses of the implants that were returned. The most common cause for implant return was the patient’s request for a change in the implant size or shape. For these patients, the implants themselves were found to be intact and functional. In the group of patients who returned implants for defect, the most common mode of defect was openings in the implant shell. The most common reason for these openings was iatrogenic damage at the time of surgery through inadvertent sharp instrumentation.15 Regardless of the type of implant, it is imperative that plastic surgeons be fastidious in placing breast implants to reduce the amount of trauma and to prevent shell damage at the time of surgery.

779

780

Part VIII 

Plastic Surgery of the Breast

Cohesive Gel Implants Cohesive gel implants, also known as gummy bear implants, are a newer generation of silicone gel breast implants designed to solve the problem of gel diffusion. These implants increase cross-linkage between gel molecules, thus increasing the integrity of the gel fill. Th s directly decreases the rate of gel diffusion into surrounding parenchyma in the event of elastomer shell failure. The increased cross-linking also allows for better retention of shape, which decreases the likelihood of folding or collapse. Th s is of special concern at the upper pole, where rippling is likely to occur in the upright position. The cohesive gels resist the force of gravity to retain their upper pole fill, maintaining fullness and guarding against upper pole collapse. As previously mentioned, rippling at the upper pole was a problem with smooth implants, because the implant would sag toward the bottom of the implant pocket from the force of gravity. An additional problem that surfaced with the weight of the implant was the gradual deformity of surrounding breast tissue, eventually requiring surgical revision. The natural cohesive gel fill, with its greater memory in shape, may exert less deforming pressure on the surrounding breast tissue, allowing for better long-term maintenance of breast shape. It should be noted that because of the increased cross-linking, cohesive gels are fi mer than previous silicone gel implants, which should be a consideration when choosing between implants. Introduced by Inamed (now Allergan) in 1997, the style 410 implant offers the cohesive gel filler in a textured, contoured elastomer shell. The implants come in three different projections and three different heights, with each type coming in a variety of base widths and heights. Th s allows for careful selection of the appropriate implant based on a patient’s distinct physical measurements. Thus far, experience with cohesive gel implants has been positive. Brown et al17 followed 285 Inamed cohesive gel implants for an average of 21 months (16 to 36 months) after implantation with an overall complication rate of 3.5%. It is encouraging that during follow-up, there were no cases of signifi ant (Baker grade III/IV) capsular contracture and no cases of implant rupture. Silicone gel implants, especially textured and anatomically shaped implants, have been routinely used in Asian patients for breast augmentation through an endoscopically assisted transaxillary approach.18 However, the saline implant may still remain popular for some younger patients because of its proven safety, lower cost, and the small incision used for the procedure. In general, the most common size of implant preferred by Asian patients is 200 cc or 225 cc, with a range between 120 cc and 350 cc. Th s is clearly different from the preferences of white patients in the United States, who request larger (350 cc or more) implants. More smooth round implants are used in the United States than in Asia, possibly because this type of implant may have less rippling after breast augmentation.

Discussion The variety of breast implants on the market today offers a confusing array for patients considering cosmetic breast augmentation. Although each type of implant offers advantages, no one implant satisfies all the criteria for the ideal implant. The newest generation of implants—the cohesive silicone gel implant— promises increased gel integrity and a more natural appearance, but it remains a prefilled silicone gel implant; therefore it requires a longer incision for emplacement. Although patients undergoing breast reconstruction may have already committed to the longer scar because of their cancer resection, a longer incision may be unacceptable in a patient seeking cosmetic breast augmentation. Th s may be particularly true among Asian women, who have both an exquisite cultural sensitivity to the appearance of scars and a greater likelihood of hypertrophic scarring than white patients. Patients must be given appropriate information preoperatively so they can make a well-informed decision about their implant choice, have realistic expectations, and be satisfi d with the results.

Chapter 50 

Breast Implants

Pearls for Success • Although each type of implant offers advantages, no one implant satisfies ll the criteria for the ideal implant. • A longer incision may be unacceptable in a patient seeking cosmetic breast augmentation. Th s may be particularly true among Asian women, who have both an exquisite cultural sensitivity to the appearance of scars and a greater likelihood of hypertrophic scarring than white patients. • Patients must be given appropriate information preoperatively so they can make a well-informed decision about their implant choice, have realistic expectations, and be satisfi d with the results.

Refer ences 1. The American Society for Aesthetic Plastic Surgery. New trends in 2011 cosmetic surgery statistics, 2012 April 14. Available at http://www.surgery.org/consumers/plastic-surgery-news-briefs/trends-2011-cosmetic-surgery-statistics-1036407. 2. Applied Silicone Corporation. Applied silicone: factors in selecting medical-grade silicones. Available at http:// www.medicaldevice-developments.com/contractors/biomaterials-and-biotechnology/applied-silicone/. 3. Barr S, Hill E, Bayat A. Current implant surface technology: an examination of their nanostructure and their influence on fibroblast alignment and biocompatibility. Eplasty 9:e22, 2009. 4. Asplund O, Gylbert L, Jurell G, et al. Textured or smooth implants for submuscular breast augmentation: a controlled study. Plast Reconstr Surg 97:1200-1206, 1996. 5. Schaub TA, Ahmad J, Rohrich RJ. Capsular contracture with breast implants in the cosmetic patient: saline versus silicone—a systematic review of the literature. Plast Reconstr Surg 126:2140-2149, 2010. 6. Hakelius L, Ohlsén L. Tendency to capsular contracture around smooth and textured gel-filled silicone mammary implants: a five-year follow-up. Plast Reconstr Surg 100:1566-1569, 1997. 7. Malata CM, Feldberg L, Coleman DJ, et al. Textured or smooth implants for breast augmentation? Th ee year follow-up of a prospective randomised controlled trial. Br J Plast Surg 50:99-105, 1997. 8. Handel N, Jensen JA, Black Q, et al. The fate of breast implants: a critical analysis of complications and outcomes. Plast Reconstr Surg 96:1521-1533, 1995. 9. Burkhardt BR, Dempsey PD, Schnur PL, et al. Capsular contracture: a prospective study of the effect of local antibacterial agents. Plast Reconstr Surg 77:919-932, 1986. 10. Cunningham BL, Lokeh A, Gutowski KA. Saline-filled breast implant safety and efficacy: a multicenter retrospective review. Plast Reconstr Surg 105:2143-2149; discussion 2150-2151, 2000. 11. Lavine DM. Saline inflatable prostheses: 14 years’ experience. Aesthetic Plast Surg 17:325-330, 1993. 12. Sánchez-Guerrero J, Colditz GA, Karlson EW, et al. Silicone breast implants and the risk of connective-tissue diseases and symptoms. N Engl J Med 332:1666-1670, 1995. 13. Institute of Medicine. Safety of silicone breast implants, 1999. Available at http://www.nap.edu/catalog.php?record_ id59602. 14. Steinbrech DS, Lerman OZ. Breast implants: background, safety, and general considerations. In Aston SJ, Steinbrech DS, Walden J, eds. Aesthetic Plastic Surgery. St Louis: Elsevier, 2009. 15. U.S. Food and Drug Administration. Silicone gel-filled breast implants, 2013. Available at http://www.fda.gov/ MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/BreastImplants/ucm063871.htm. 16. Talanow R. Linguini Sign. Available at http://www.radiolopolis.com. 17. Brown MH, Shenker R, Silver SA. Cohesive silicone gel breast implants in aesthetic and reconstructive breast surgery. Plast Reconstr Surg 113:768-779; discussion 780-781, 2005. 18. Cheng MH, Huang JJ. Augmentation mammaplasty in Asian women. Semin Plast Surg 23:48-54, 2009.

781

K23345_Pu_c50_Breast Implants_r5_cl_771-782.indd 782

4/3/2015 10:58:28 AM

51 Breast Augmentation With Implants: Transaxillary Approach

B

Jean-Yin Lin

reast augmentation with implants can be quite different in Asian women compared with Western women. To best determine the size of the implant for Asian breast augmentation, the distance from the upper breast border to the nipple to the inframammary fold (IMF) is used. To limit the scar and to produce augmented breasts with a natural feel, surgeons have used the transaxillary submuscular approach, which has been popular for the past two decades. However, this preference has shifted to placing the implant in the subfascial plane to achieve better shape, cleavage, or even more natural movement of the augmented breasts, and maintaining the low capsular contracture rate in the process. In this chapter, I describe my current approach to breast augmentation, based on having performed more than 5000 breast augmentations over the past 10 years. I still perform breast augmentations with implants through the transaxillary incision, but I place the implant in the subfascial plane above the pectoralis major muscle. I describe the surgical techniques of transaxillary subfascial breast augmentation in detail. Th s chapter will also cover the advantages of this approach, the management of complications, and revision surgeries.

Specific Considerations for Asian Breast Augmentation The specific considerations for Asian women who request breast augmentation are shape, symmetry, size, and fl w.1 Women in Taiwan listed their order of importance for breast augmentation as (1) size enhancement, (2) fl w (cleavage, mobility), (3) shape, and (4) feel.

Sha pe

The ideal aesthetic breasts for Asians are similar to those in Westerners, with the “teardrop” or “bamboosprout” shape being preferred (Fig. 51-1). The ideal breast projects, with the nipple-areola complex at the point of maximal projection. There is adequate volume above and below the nipple. However, the curve above the nipple is concave, and the curve below the nipple is convex.2,3

783

784

Part VIII 

Plastic Surgery of the Breast

Fig. 51-1  Ideal aesthetic breast.

A

B

Fig. 51-2  A, Anteroposterior view of a candidate for breast augmentation. B, The preoperative examination should include having the patient raise her arms to disclose any asymmetry.

Symmetr y

Ideally, a woman’s breasts should be symmetrical; however, minor asymmetry is common. Augmentation can proportionally emphasize the difference, so any asymmetry should be pointed out to the patient before surgery to avoid postoperative dissatisfaction and complaints (Fig. 51-2).

Size

The breasts of Asian women differ greatly in size from those of Western women. Breast augmentation must be performed in proportion to the woman’s body frame. When the maximum breast projection is equal to the anteroposterior diameter of the chest, the breast size complements the woman’s figu e. In addition, Asian-style clothing is different from Western clothing. “Perkiness” or upper pole fullness is not evident with Asian clothing.

Fl ow

Breasts that look like coconut shells fixed to the chest wall are not appreciated by men or women. The ideal breasts should move when the woman moves or changes posture, and they should form cleavage when a proper bra is worn.

Chapter 51 

Breast Augmentation With Implants: Transaxillary Approach

Indications for Breast Augmentation In general, congenital or involutional hypoplasia in many Asians is regarded as the norm rather than an anomaly. Other indications for breast augmentation include asymmetry and a contour anomaly. Congenital or acquired asymmetry can be camouflaged through breast augmentation. A contour anomaly, such as Poland’s syndrome or tuberous breasts, may be improved through breast augmentation.

Preoperative Assessment A patient with a history of anemia, malnutrition, smoking, or uncontrolled hypertension should be properly managed before surgery.

Patient Expect atio ns

The reason for and size of a requested augmentation must be realistic. A woman who presents for breast augmentation because her husband is asking that she get a super-large cup size is not likely to be a happy patient. The preoperative consultation should include a discussion of the patient’s desired shape, symmetry, size, and fl w. The patient should list her preferences in order. If feel is the number one priority, a submuscular approach is advised. If an extra-large cup size is the aim, a subglandular pocket is better. If the patient insists on ample cleavage, the submuscular approach is not recommended. If she wants a natural fl w, the subfascial or subglandular approach would be better.

Ass ess ment of the Br ea st–S oft Tiss ue Envel ope

A nulliparous woman with a flat chest is the most difficult patient on whom to perform augmentation, because her skin is too tight. Augmentation in patients with involutional breast hypoplasia or signifi ant weight loss can also be difficult, because they have lost the supporting structure of the breast (Fig. 51-3). A

B

C

D

Fig. 51-3  It is easier to achieve a good result in a patient with a loose breast–soft tissue envelope. A and B, Patient with a tight envelope. C and D, Patient with a loose envelope.

785

786

Part VIII 

Plastic Surgery of the Breast

Fig. 51-4  The pinch test can help evaluate breast thickness.

Fig. 51-5  Ultrasonography can be used to measure breast thickness.

Fig. 51-6  The upper breast border and IMF defi e the breast footprint. Upper breast border

Breast footprint Inframammary fold

A pinch test can be used to assess the thickness of the breast–soft tissue envelope4 (Fig. 51-4); ultrasound can also be used to measure breast thickness (Fig. 51-5). Typically, thickness of less than 2 cm is considered a “flat chest.”

Mea sur ement s

Important measurements for augmentation include breast width, the upper breast border (Fig. 51-6), and the nipple-to-IMF distance. Asians are short in stature and have a wider breast width; thus the distance from the upper breast border to the nipple to the IMF is a better measurement for determining the base diameter of the implant in Asians (Fig. 51-7). Once the base diameter of the implant has been determined, the projection and volume can be selected, taking into consideration the soft tissue condition and the fi al cup size (see Fig. 51-7). A high profile implant may allow more volume and projection than a moderate profile implant with the same diameter.

Chapter 51 

Breast Augmentation With Implants: Transaxillary Approach

Fig. 51-7  Markings for projection and volume. (BB, Breast border; UBB, upper breast border.) A

B

Fig. 51-8  Two axillae after transaxillary breast augmentation. The scars are inconspicuous. Note that in A the area of the scar does not have or grow hair.

Incis io n Cho ices

Transaxillary, inframammary, periareolar or transareolar, and transumbilical incisions can be used for Asian breast augmentation.5 Asian women are somewhat conservative and do not wish to have any of the telltale signs of augmentation when their breasts are exposed. If the patient’s axillary skin is of good quality, the transaxillary approach provides a remote entry port with adequate exposure, enabling the surgeon to perform the pocket dissection and to place a breast implant without difficulty. Using an endoscope or lighted retractors, the surgeon can perform the axillary approach, which provides the most satisfactory results in Asian patients. I prefer the transaxillary approach for both submuscular or subfascial pockets for the following reasons: • The scar can be hidden in the axillary fold. • An endoscope can be used to aid in easy pocket dissection. • When using a saline implant, the surgeon should not have any difficulty with inserting a deflated prosthesis. • A 5 cm axillary incision can be used to accommodate a smooth silicone gel prosthesis up to 420 cc and a textured silicone gel prosthesis up to 350 cc.6 I use the axillary approach in approximately 90% of the procedures that I perform. In recent articles, the transaxillary approach is comparable to the inframammary approach among experienced surgeons. The data support the transaxillary approach by proving the integrity of the lymphatic drainage and the applicability of the detection of the sentinel lymph node after transaxillary breast augmentation (Fig. 51-8).

787

788

Part VIII 

Plastic Surgery of the Breast

The inframammary approach is reserved for women who can accept the postoperative scar, especially in the supine position. The inframammary approach is not recommended for an Asian woman who lacks volume of the lower pole and has no well-defined IMF or who has a tendency to produce keloid scars. The periareolar or transareolar approach is advocated by some surgeons in Asia. However, I am against the idea of transecting the breast tissue or ducts for breast augmentation. The transumbilical approach can only accommodate a saline implant. Th s approach can be technically challenging and is considered less feasible. The only benefit of this approach is that there is a remote scar. Table 51-1 compares the different types of incisions used for Asian breast augmentation.7

Lo ca tio n of Po cke t Cho ices

The different pocket choices that can be used for breast augmentation with implants through the transaxillary approach are subglandular, subfascial, submuscular, and dual plane. Table 51-2 outlines each of these pocket choices.8,9

Table 51-1  Comparison of Different Incisions Factor

Transaxillary

Inframammary

Periareolar or Transareolar

Transumbilical

Scar

Inconspicuous

Fair

Fair

Fair

Infection

Low

Low

Higher

Low

Exposure/Surgical Access

Poor

Good

Good

Poor

Capsular contracture rate

Average

Average

Higher

Higher

Morbidity

Higher

Lower

Lower

Higher

Feasible for revision

Difficult

Yes

Yes

No

From Pound EC III, Pound EC Jr. Transumbilical breast augmentation (TUBA): patient selection, technique, and clinical experience. Clin Plast Surg 28:597-605, 2001.

Table 51-2  Comparisons of Implant Placement Subglandular

Subfascial

Submuscular or Dual Plane

Shape

Yes

Yes

No

Flow

Yes

Yes

Cleavage

Yes

Yes

Capsular rate

Low

Infection

Increased

Feel

Shell or wave

Shell or wave

Pain

Low

Low

Severe pain

Differential aging

Yes

Animation deformity

Yes

Baywatch phenomenon

Yes

Yes

Data from Collis N, Sharpe DT. Recurrence of subglandular breast implant capsular contracture: anterior versus total capsulectomy. Plast Reconstr Surg 106:792-797, 2000; and Danino AM, Basamcioglu P, Saito S, et al. Comparison of the capsular response to the Biocell RTV and Mentor 1600 Siltex breast implant surface texturing: a scanning electron microscopic study. Plast Reconstr Surg 108:2047-2052, 2001.

Chapter 51 

Breast Augmentation With Implants: Transaxillary Approach

The subglandular pocket with a smooth implant is notorious for its capsular contracture. The submuscular plane was advocated to increase soft issue coverage and decrease capsular contracture. Therefore transaxillary submuscular breast augmentation has become very popular in Asia over the past two decades. However, I think that transaxillary submuscular breast augmentation has the following drawbacks in Asian patients: • Inadequate profile: the pectoralis muscle cannot accommodate the high profile prosthesis (Fig. 51-9) • Deviation of the prosthesis, usually upward and laterally (Fig. 51-10) • With postural change, the prosthesis moves in a direction not correlated with the nipple

Fig. 51-9  Asians are prone to hypertrophic pectoral muscles. A

B

C

Fig. 51-10  The prosthesis deviates upward and laterally. A, Before surgery. B, One year postoperatively. C, Ten years postoperatively.

789

790

Part VIII 

Plastic Surgery of the Breast

Fig. 51-11  Submuscular augmentation produces an athletic look. A

B

Fig. 51-12  A, Submuscular augmentation without any movement. B, Animation deformity with pectoralis movement. • The pectoralis muscle is also augmented, producing an athletic look (Fig. 51-11) • Animation deformity (Fig. 51-12) • The three elements that compose the feel of the breast—breast, muscle, and prosthesis—cannot unite in one piece, even if there is no capsular contracture • Postoperative pain • Differential effects of aging • Difficulty in forming cleavage (Fig. 51-13) • Exaggerated asymmetry (Fig. 51-14) For the typical Asian woman, I prefer to perform transaxillary breast augmentation, placing an implant in the subfascial pocket. Th s type of breast augmentation has a few distinct advantages: it produces a more natural appearance, submuscular distortion can be avoided, and it tends to have a more natural fl w with

Chapter 51 

Breast Augmentation With Implants: Transaxillary Approach

Fig. 51-13  Submuscular augmentation with inadequate cleavage.

Fig. 51-14  Asymmetry is exaggerated after submuscular augmentation.

cleavage. The range of implant volume in my practice is between 120 and 375 cc, with the average implant approximately 200 cc. I prefer the textured gel prosthesis, which consistently gives my patients satisfactory results.

Surgical Technique The markings for the transaxillary approach are made with the patient standing. The upper breast border is the upper border, and the inferior border is the IMF, or 1 cm below the IMF. The medial border is the midline or 1 cm lateral to the midline, and the lateral border is the anterior axillary line. After the markings are made and the distances from the upper breast border to the IMF and the nipple to the IMF are measured, the breast width is recorded. Any differences or asymmetries are pointed out to the patient before surgery. Intravenous anesthesia with propofol, midazolam, and fentanyl is used for the procedure, and local anesthesia is aided by tumescent infiltration with 20 ml of 2% lidocaine with 0.5 ml epinephrine 1 ml/1 mg, plus 1000 ml normal saline solution. The axillary incision is placed in the middle of the hairy axilla. A skin crease that will be well hidden in the armpit is chosen. After the skin incision is made, the subcutaneous tissue is dissected with electrocautery. With the aid of lighted retractors, the surgeon makes a subcutaneous tunnel to the pectoralis muscle. The lateral border of the pectoralis fascia is recognized by its fibrous nature, and the subfascial plane is created. Dissection is carried out under direct vision or with an endoscope.10,11

791

792

Part VIII 

Plastic Surgery of the Breast

A

B

C

D

E

F

Fig. 51-15  Transaxillary approach. A, The surgeon should open the fascia in the axillary area, where the fascia is thicker

than with an inframammary approach. B, The pocket is dissected, and its dimensions are checked. C, The prosthesis is squeezed through the axillary wound into the pocket. The location of the prosthesis should be checked closely, because the implant could be stuck in the upper portion of the pocket. D, The prosthesis must be positioned properly. E, The surgeon must confirm that the prosthesis is facing upward and that its edges are touching the preoperative markings. F, An incision up to 5 cm is made to accommodate a textured cohesive gel implant up to 350 cc.

In addition to the vascular branches from the medial, lower, and lateral aspects, the perforating branches from the pectoralis muscle can cause signifi ant bleeding. After ensuring hemostasis and adequate pocket dissection, the surgeon widens the axillary wound with Army-Navy retractors to create a path for insertion of the prosthesis. The incision’s width should be checked meticulously based on the surgeon’s experience. A 5 cm incision is large enough for most Asian women. The surgeon holds the prosthesis with his or her nondominant hand, maintaining constant pressure, and uses the thumb of the dominant hand to push the shell into the pocket. These actions are very similar to reducing an inguinal hernia into the peritoneal cavity. The prosthesis might be folded or deformed where it enters the pocket, in which case it must be unfolded and delivered again in the proper position. A Jackson-Pratt drain is routinely used for drainage. With the prosthesis being squeezed into the pocket, before wound closure the surgeon should confi m that the prosthesis is facing upward, there is no folding, and the edges of the prosthesis are touching the preoperative markings. Some surgeons check the result with the patient in the sitting position. Although I do not have the patient positioned upright, I am still able to get a satisfactory result (Fig. 51-15).

Chapter 51 

Breast Augmentation With Implants: Transaxillary Approach

Pectoralis major muscle

Pectoralis major muscle

Partial subpectoral placement

Subglandular placement

Fig. 51-16  Axillary subfascial augmentation. The prosthesis is above the muscle, where it has adequate muscle coverage. A

B

Fig. 51-17  A, The difference between the displacement that occurs from upright implants, and B, implants lying down on a flat surface.

Although it is subfascial, the implant is placed above the muscle, where it still has the benefit of muscle coverage12 (Fig. 51-16). Prosthetics are quite similar when lying flat but differ greatly when standing. Although saline solution is biocompatible, it acts as implant filling and has a deleterious effect in thinning and stretching the surrounding skin envelope (Fig. 51-17).

Postoperative Care After surgery, the breasts are dressed with a supportive bra, and an elastic strap on the upper breast is used for compression. Prophylactic antibiotics with cefazolin sodium and gentamicin are used 1 hour before surgery. After surgery, only acetaminophen/paracetamol (Panadol) is prescribed. Typically, the patient can leave the clinic 4 hours after surgery. I think that a “hand-in-glove” fit is benefic al to wound healing; that is, the prosthesis and the surrounding tissue should be in close contact. To avoid any fluid collection, the drain is removed only after ultrasonography clearance. The patient is followed with ultrasonography on postoperative days 7 and 14. If there is local fluid, it is drained through ultrasound guidance. Within 1 month after surgery, the patient should have follow-up surgery if ultrasonography detects generalized fluid in the pocket, there is clinical evidence of any asymmetry or malposition, or ultrasonography shows folding or wrinkling of the prosthesis.

793

794

Part VIII 

Plastic Surgery of the Breast

Fig. 51-18  A localized seroma can be drained under ultrasound guidance.

A

B

Fig. 51-19  Ultrasound. A, Effusion in the pocket. B, No effusion, no contracture, and mild wrinkles. A total of 1.2% of my patients required second look surgery within the fi st postoperative month. After the procedure, 1.5% of these patients were found to be lactating. They were treated with cabergoline (Dostinex). There were no additional complications in this group. After gel prosthetics became available in Taiwan, the textured cohesive gel began being used in axillary subfascial breast augmentation. After surgery, prosthetic displacement and massage should be avoided, and the breasts should have steady support for 3 months. Ultrasonography can be used preoperatively to screen for breast tumors and to determine the thickness of the patient’s soft tissue. Postoperatively, ultrasonography is helpful to gauge the amount of blood or seroma in the pocket. This technology can also serve as a guide to drain a localized seroma and to detect the malposition or even rupture of a prosthesis (Figs. 51-18 and 51-19).

Results In Taiwan, I used only normal saline implants before November 2008. After 2008, I used textured cohesive gel prostheses. In April 2012, a 3-year follow-up analysis was conducted for patients with gel implants. Th s analysis revealed the following: • Satisfaction: Among patients who received gel implants, 92% said they were happy about the size, shape, cleavage, and flow of their breasts, stating that their breasts felt “real” (Fig. 51-20). The other 8% said they were unhappy, because the feel of their breasts was not “real.” • Rupture rate: 0% • Capsular contracture rate: Baker grade III-IV or above, 4.2% • Revision rate: 2%

Chapter 51 

Breast Augmentation With Implants: Transaxillary Approach

795

Fig. 51-20 After receiving gel implants, this patient has breasts that feel “real” and can be manipulated.

A

B

C

D

Fig. 51-21 Th s 26-year-old woman was accompanied by her mother. They asked that she have breast augmentation to increase her feminine charm, with natural-looking breasts. She did not exercise regularly, but did have a strong pectoralis major muscle. The distance from the nipple to the IMF was short. Transaxillary subfascial augmentation with 150 cc round textured cohesive gel implants was performed. The surgery had a subtle but defin te result. The postoperative photographs were taken 1 year after the procedure.

K23345_Pu_c51_Transaxil Approach_r3_st_783-802.indd 795

4/3/2015 2:11:24 PM

796

Part VIII 

Plastic Surgery of the Breast

A

B

C

D

Fig. 51-22 Th s 35-year-old woman had given birth to two children. She was a diabetic who had a recent weight loss of 30 kg (66 pounds). The preoperative photos show a flat chest, a lowered upper breast border, and a loose breast pocket. The woman did not want a periareolar or inframammary scar, because she loved to go to the sauna and the hot spring bath. Therefore, a transaxillary subfascial augmentation with a 300 cc round textured cohesive gel prosthesis was performed. The postoperative photos were taken 1 year after the procedure. The oblique view shows how the prosthesis enhances the upper pole and camouflages the lowered upper breast border.

K23345_Pu_c51_Transaxil Approach_r3_st_783-802.indd 796

4/3/2015 2:11:25 PM

Chapter 51 

Breast Augmentation With Implants: Transaxillary Approach

A

B

C

D

797

Fig. 51-23 Th s 25-year-old woman was 163 cm (5 feet 3 inches) tall, and her body weight was only 43 kg (95 pounds). She also had a pigeon chest deformity. She requested a transaxillary incision. With this kind of thoracic cage, if a submuscular or dual plane were chosen, the prosthesis would likely deviate laterally and even posteriorly. Therefore a transaxillary subfascial augmentation with a 275 cc round textured cohesive gel prosthesis was performed. The postoperative photos were taken 1 year after the procedure. The woman is happy with the results, because the breasts are closer medially and form cleavage when she wears a bra.

K23345_Pu_c51_Transaxil Approach_r3_st_783-802.indd 797

4/3/2015 2:11:26 PM

798

Part VIII 

Plastic Surgery of the Breast

A

B

C

D

Fig. 51-24 This 43-year-old woman had two children. She sought larger breasts because of what she considered to be her male-type body frame, and because small breasts caused her distress in purchasing clothing. Her characterization of her upper body habitus was confi med by her hypertrophic pectoral muscle, short nipple-to-IMF distance, and low upper breast border. Augmentation was performed through a transaxillary subfascial approach using 350 cc round textured high profile cohesive gel implants. The postoperative photos were taken 1 year after the procedure was performed. Her breasts were enlarged and have a pleasing aesthetic contour without exaggerating her athletic build.

Management of Complications Infectio n If infection occurs, antibiotics should be used according to the results from the culture. There are several reports of nontuberculous mycobacterial granuloma (NTG), the source of which proved to be the endoscopic fiber. When the culture is negative for common bacteria, NTG should be suspected.13

Gal a ct or r hea

Galactorrhea is present in 1.5% of the female population. There are reports of postaugmentation lactorrhea thought to be caused by breast swelling and spinal reflex. Lactorrhea either preoperatively or postoperatively should be treated with bromcriptine mesylate or cabergoline.

Chapter 51 

Breast Augmentation With Implants: Transaxillary Approach

Fig. 51-25  Contracture of the axilla resolves after physical therapy.

Ruptur ed Saline Pr os thes is

After surgery, up to 90 to 120 ml of serous fluid could accumulate in one side of the pocket within 24 hours. A Jackson-Pratt drain is placed and removed only after ultrasonographic clearance. In patients with a textured prosthesis or in secondary cases, it takes more than 72 hours for the seroma to clear; thus follow-up ultrasonography on postoperative days 7 and 14 is very helpful. If detected, the seroma can be drained by intravenous catheter under ultrasonographic guidance. For ultrasound of a soft breast, the interface between the soft tissue and the prosthesis should be smooth. If there is a wrinkly or bumpy appearance that indicates awkward posture of the prosthesis, a second look in the operating room will ensure a better result. Obviously, a hematoma must be treated as soon as it is noticed, and the importance of blood pressure control cannot be overemphasized.

Muscle Contra ctur e

Pectoralis muscle contracture may develop after transaxillary submuscular breast augmentation, and the condition may last up to 6 months. The prosthesis can be pushed upward and laterally to limit the range of motion of the axilla. The condition usually resolves after physical therapy (Fig. 51-25).

Malp os itio n

Implant malposition in the immediate postoperative period may not be indicative of the eventual position.14 If the position of the implant has been checked before final closure, the malposition may be caused by muscle contracture, asymmetrical swelling, or something similar; therefore surgical intervention should be postponed. If a patient develops true implant malposition, performing an additional pocket dissection with capsulorrhaphy of unwanted space may solve the problem in some simple cases. However, for more complicated cases, a new pocket would add better control of the implant’s position and can be the key to success. If a portion of an implant becomes palpable or visible, autologous fat grafting to the localized area can be performed to camouflage such a soft tissue deficie cy.

799

800

Part VIII 

Plastic Surgery of the Breast

A

B

C

D

Fig. 51-26  Th s patient had previous breast augmentation through the transaxillary submuscular approach. Now she

wanted to improve the shape, cleavage, and flow and correct the animation deformity. She underwent revision through the transaxillary approach. The normal saline prostheses were removed. Subfascial placement was performed with 350 cc round textured cohesive gel prostheses. The patient was happy with the result 1 year after surgery.

Scar r ing

Although the axillary scar will usually heal well and is less noticeable in most Asian patients, the scar in this area can occasionally become a problem and may require aggressive massage or even future surgical revision.

Caps ul ar Contra ctur e

For patients with capsular contracture, an open capsulotomy can only be performed in some simple cases. In Baker grade IV classifi ation with a calcifi d thick capsule, biofilm formation may be the cause. After total or near-total capsulectomy, the creation of a new pocket—subglandular to submuscular, and submuscular to neopectoral—is suggested so that the implant can be placed in a fresh pocket15-19 (Figs. 51-26 and 51-27).

Chapter 51 

Breast Augmentation With Implants: Transaxillary Approach

A

B

C

D

801

Fig. 51-27  This patient presented with deformities resulting from bilateral capsular contracture. We decided to change

the submuscular position of her implants to the subfascial position. The patient had been operated on previously through a periareolar approach with submuscular augmentation. Now she wanted to improve the shape of her breasts. Revision was performed through the axillary approach. The prostheses were exchanged from submuscular normal saline implants to subfascial 175 cc round textured cohesive gel implants. The patient was happy with the result 1 year after surgery.

Pearls for Success • Breast augmentation through the transaxillary subfascial approach can be performed in Asians with satisfactory results. • The availability of a form-stable, textured gel prosthesis has signifi antly benefited the procedure. • The surgeon must communicate with the patient in the preoperative assessment and gain a thorough understanding of her expectations. • Careful and precise preoperative planning is crucial. • Exact dissection of the pocket and proper placement of the prosthesis are essential. • The appropriate management of postoperative complications is crucial.

Refer ences 1. Bostwick J III. Plastic and Reconstructive Breast Surgery, ed 2. St Louis: Quality Medical Publishing, 2000. 2. Hammond DC. Breast augmentation using anatomic implants. Oper Tech Plast Reconstr Surg 7:125-130, 2000. 3. Hedén P, Jernbeck J, Hober M. Breast augmentation with anatomical cohesive gel implants: the world’s largest current experience. Clin Plast Surg 28:531-552, 2001. 4. Tebbetts JB. Dual plane breast augmentation: optimizing implant-soft- issue relationships in a wide range of breast types. Plast Reconstr Surg 118(7 Suppl):815-985; discussion 995-1025, 2006.

K23345_Pu_c51_Transaxil Approach_r3_st_783-802.indd 801

4/3/2015 2:11:28 PM

802

Part VIII 

Plastic Surgery of the Breast

5. Hoechler H. Breast augmentation: the axillary approach. Br J Plast Surg 26:373-376, 1973. 6. Mladick R. Textured silicone breast implants. Plast Reconstr Surg 110:1201-1202, 2002. 7. Pound EC III, Pound EC Jr. Transumbilical breast augmentation (TUBA): patient selection, technique, and clinical experience. Clin Plast Surg 28:597-605, 2001. 8. Collis N, Sharpe DT. Recurrence of subglandular breast implant capsular contracture: anterior versus total capsulectomy. Plast Reconstr Surg 106:792-797, 2000. 9. Danino AM, Basamcioglu P, Saito S, et al. Comparison of the capsular response to the Biocell RTV and Mentor 1600 Siltex breast implant surface texturing: a scanning electron microscopic study. Plast Reconstr Surg 108:20472052, 2001. 10. Price CI, Eaves FF III, Nahai F, et al. Endoscopic transaxillary subpectoral breast augmentation. Plast Reconstr Surg 94:612-619, 1994. 11. Niechajev I. Mammary augmentation by cohesive silicone gel implants with anatomic shape: technical considerations. Aesthetic Plast Surg 25:397-403, 2001. 12. Elliott LF. Breast augmentation with round, smooth saline or gel implants: the pros and cons. Clin Plast Surg 28:523-529, 2001. 13. Nahabedian MY, Tsangaris T, Momen B, et al. Infectious complications following breast reconstruction with expanders and implants. Plast Reconstr Surg 112:467-476, 2003. 14. Diedwardo CA, Shestak KC. Implant malposition: prevention and correction. Oper Tech Plast Reconstr Surg 7:144-149, 2000. 15. Cairns TS, de Villiers W. Capsular contracture after breast augmentation—a comparison between gel- and salinefilled prostheses. S Afr Med J 57:951-953, 1980. 16. Ersek RA. Rate and incidence of capsular contracture: a comparison of smooth and textured silicone doublelumen breast prostheses. Plast Reconstr Surg 87:879-884, 1991. 17. Fagrell D, Berggren A, Tarpila E. Capsular contracture around saline-filled fi e textured and smooth mammary implants: a prospective 7.5-year follow-up. Plast Reconstr Surg 108:2108-2112; discussion 2113,2001. 18. Hakelius L, Ohlsén L. A clinical comparison of the tendency to capsular contracture between smooth and textured gel-filled silicone mammary implants. Plast Reconstr Surg 90:247-254, 1992. 19. Spear SL, Carter ME, Ganz JC. The correction of capsular contracture by conversion to “dual-plane” positioning: technique and outcomes. Plast Reconstr Surg 118(7 Suppl):103S-113S;discussion 114S, 2006.

K23345_Pu_c51_Transaxil Approach_r3_st_783-802.indd 802

4/3/2015 2:11:28 PM

52 Breast Augmentation With Implants: Inframammary Approach

C

Susumu Takayanagi

reating natural-looking breasts is an important goal of augmentation mammaplasty. To achieve this, the following factors should be considered: the thickness of the skin and fat tissue; the elasticity of the breasts, and the breast width, height, and projection; the position of the nipple-areola complex; the distance between the nipple and the clavicle; the distance between the nipple and the inframammary fold (IMF); any asymmetry of the nipple-areola complex or breast shape; the height and body weight of the patient; the age of the patient; and any deformity of the chest. In this chapter, I describe my preferred technique of augmentation mammaplasty with implants using the inframammary approach.

Advantages of the Inframammary Approach There are several approaches for augmentation mammaplasty: the transaxillary approach, periareolar approach, and inframammary approach. I prefer the inframammary approach for the following reasons: hemostasis is easy and accurate; undermining of the area is easy and accurate; placement of the implant is easy, and the direction of the implant can be checked visually and manually; and, if necessary, the IMF can easily be lowered.1 Some Asian women may be concerned about the visibility of the inframammary scar. As shown in Fig. 52-1, most of the scar will not be visible after 2 to 3 years; it is important to emphasize this fact to patients, and the discussion should be documented. However, the quality of the scar may vary, depending on the quality of the patient’s skin. Patients with skin that is oily or has a white or reddish tone are good candidates for the inframammary approach. Patients with atopic dermatitis or asthma have a tendency to develop a hypertrophic scar or pigmentation, and the surgeon must be careful when performing augmentation mammaplasty in these patients.

803

804

Part VIII 

Plastic Surgery of the Breast

If the patient has a scar anywhere on his or her body, it is important to evaluate the quality of the scar. If the scar has pigmentation or is a hypertrophic scar or keloid, the inframammary scar may ultimately have the same quality. Thus these patients are not good candidates for augmentation mammaplasty (Table 521). Even if we use a transaxillary or periareolar approach, the scar may be very visible in these patients.

A

B

C

D

Fig. 52-1  A, Inframammary scar 4 months after surgery. The scar is slightly red and visible. B, Eight months after sur-

gery, the redness of the scar has almost disappeared, but the scar is still visible. C, Th ee years and even D, 10 years after surgery, the scar cannot be detected.

Table 52-1  Considerations for the Inframammary Approach in Asian Patients Skin Condition

Appropriate for Inframammary Approach

Oily skin

X

White skin tone

X

Red skin tone

X

Scar May Become Visible

Atopic dermatitis

X

Asthma

X

Scar Will Become Visible

Pigmentation of previous scars

X

Hypertrophic scars

X

Keloid scarring

X

Chapter 52 

Breast Augmentation With Implants: Inframammary Approach

Patient Selection for Breast Augmentation • Patients should not have a keloid or visible hypertrophic scar anywhere on their body. • Augmentation is contraindicated in patients with breast cancer. Before surgery, an examination of the breast for any cancer must be performed. • If the patient’s breasts have a ptotic appearance, any of the following must be selected: ȤȤ Lowering the IMF ȤȤ Elevating the nipple-areola complex ȤȤ Performing simultaneous mastopexy • If the patient is very thin, subpectoral augmentation must be performed. Furthermore, injections of fat or hyaluronic acid may be required to cover the visible edge of the implant. • The patient must be over 18 years of age.

Preoperative Assessment Type of Impl ant Selectio n

When a round type of implant is used, the most projecting point of the implant is the center of the round implant, and this point should be placed just behind the nipple. The most projecting point of an anatomic implant is in the lower part of the implant and is not the center; and this point should be placed just behind the nipple2 (Fig. 52-2). I use a template, which has the same diameter as that of the implant, to mark the placement of the implant.

A

B

Round

Anatomic

Fig. 52-2  A, The most projecting point of a round implant is the center of the implant, and this point should be placed just behind the nipple. B, The most projecting point of an anatomic implant is in the lower half of the implant, and this point should be placed just behind the nipple.

805

806

Part VIII 

Plastic Surgery of the Breast

Fig. 52-3, A through H, shows the template markings indicating placement of a round implant, the preoperative view, and the postoperative result.

A

B

D

F

C

E

G

H

Fig. 52-3  A-C, Preoperative views of a 27-year-old woman. D, A template that has the same diameter as that of the

round implant to be used is placed on the surface of the breast. The center of the template is in the same position as the nipple. E, Th inner red line shows the placement of the round implant. The outer dotted red line shows the undermining area. The pectoralis major muscle was cut at the level of the inframammary crease to create a round lower half of the breast. F-H, Six months after surgery, the nipple is at the top of the breast mound.

Chapter 52 

Breast Augmentation With Implants: Inframammary Approach

An anatomic implant was used in the patient shown in Fig. 52-4, so the most projecting point was placed just behind the nipple.

A

B

C

F

G

D

E

Fig. 52-4  A-C, Preoperative views of a 47-year-old woman. D, Template markings showing placement of the anatomic

implant. The black line shows the future IMF. The incision should be placed in the black line. E, Frontal view showing the result with anatomic implants 10 months after surgery. F and G, Postoperative views show lowering of the IMF. The nipple is at the top of the breast mound.

807

808

Part VIII 

Plastic Surgery of the Breast

Some patients may have asymmetry of the breast or nipple-areola complex. In these patients, if the most projecting point of the implant is placed just behind the nipple, the asymmetry of the breast or nipple position may become visible. Thus sometimes it is better to correct the asymmetry of the breast and the nipple-areola complex (Fig. 52-5). If the patient has very elastic skin, which is rare, bottoming out of the breast implant may occur when there is subglandular or subpectoral augmentation with severing of the pectoralis major muscle at the IMF level. Thus when the breast skin elasticity test (described later) yields a result of more than 1.5, the most projecting point of the implant should be placed 1.0 to 1.5 cm superior to the nipple, depending on the volume of the implant and breast skin elasticity (Figs. 52-6 and 52-7). Bottoming out usually occurs within the fi st 12 to 18 months postoperatively, and after this period, breast shape does not change very much.

A

B

C

D

E

Fig. 52-5  A and B, Preoperative views of a 44-year-old woman. The nipple-areola complex is not symmetrical. C, Mark-

ings showing the placement of the round implant and lowering of the right nipple-areola complex. The crescent-shaped portion of the right periareolar skin was resected to obtain the symmetrical position of the nipple-areola complex. D and E, Seven months after surgery. The nipple-areola complex is in a symmetrical position.

Chapter 52 

Breast Augmentation With Implants: Inframammary Approach

A

809

B

C

D

E

F

G

Fig. 52-6  A and B, Preoperative views of a 37-year-old woman who had very elastic breast skin. C, The result of her

breast skin elasticity test was 1.5, which meant the skin was easily stretchable and future bottoming out would occur, because the pectoralis major muscle was severed at the level of the inframammary crease. The center of the round template was 1.5 cm superior to the nipple (X). D and E, Result 1 month after surgery. The implant was in a slightly high position. F, Lateral view 20 months after surgery. The implant has moved to a slightly inferior position, and the nipple is at the top of the breast mound, which looks quite natural. G, Result 20 months after surgery. Because the implant also moved caudally, the shape of the breast has a natural appearance.

K23345_Pu_c52_Br Aug Inframam_r2_cl_803-822.indd 809

4/3/2015 12:12:39 PM

810

Part VIII 

A

Plastic Surgery of the Breast

B

C

Fig. 52-7  A, Preoperative lateral view of a 30-year-old woman whose skin was very elastic. The skin elasticity test re-

sult was 1.6. B, Lateral view 1 month after surgery. The implant was placed 1.5 cm superior to what would be considered normal placement. C, View 18 months after surgery, after bottoming out of the implant. The shape of the breast is natural.

A

B

C

D

Fig. 52-8  A and B, Preoperative views showing the concave deformity of the upper half of the breast. C and D, Six months after surgery with a round implant, the upper poles of the patient’s breasts look youthful and natural.

There are mainly two breast implant shapes: anatomic and round. With a round implant, equal volume change is produced in the upper and lower halves of the breasts, whereas an anatomic implant creates more volume in the lower half of the breast. Because most of my patients want to have upper pole fullness, the round implant is better for them. If the patient has a concave deformity in the upper half of the breasts, round implants work well to create upper pole fullness (Fig. 52-8).

Chapter 52 

Breast Augmentation With Implants: Inframammary Approach

A

B

Fig. 52-9  A, Th s 48-year-old woman wanted large breasts, but she did not want too much volume in the upper poles. An anatomic implant was used. B, Lateral view 8 months after surgery. The breasts have an aesthetic contour without too much fullness in the upper pole.

A

B

Fig. 52-10  A, Several different sizers should be placed under the patient’s bra so the patient can see the postoperative shape and volume of the breast. B, It is important to have the patient look at her breasts, waist, and buttocks in the mirror.

Some middle-aged patients do not want to have upper pole fullness, because they think this fullness will make their breasts look too artific ally youthful. In these patients, anatomic implants are a better option (Fig. 52-9).

Determin atio n of Impl ant Vol ume

Patients must have realistic expectations regarding the postoperative results of mammaplasty. Thus the volume of the breast implant should be selected before surgery with the participation of the patient. To evaluate the appropriate volume of the breast implant, several different size templates or sizers should be placed under the patient’s bra. The patient should stand in front of a mirror and look at her breasts in relation to her waist and buttocks (Fig. 52-10). In doing so, the patient can identify the desired volume of the breast implants, and if her selection is unrealistic, the surgeon has the opportunity to demonstrate the appropriate volume for her body habitus.

811

812

Part VIII 

Plastic Surgery of the Breast

Impl ant Pl a cement

The subfascial technique has been described by Graf et al.3 I had used this technique in seven patients, but I decided not to use this technique any more. In one patient the edge of the round implant was visible in the upper pole. Undermining the superior part of the breast subfascially through the inframammary approach was time consuming and resulted in slightly more bleeding than with the other technique. I prefer to use either subglandular or subpectoral augmentation, because the postoperative pain is less and there is no unnatural movement of the breast. If the implant is placed beneath the muscle, the implant moves when the muscle shrinks, which looks strange, and some patients do not like it. However, if the patient’s original breasts are very small or flat, the skin is elastic and easily stretchable, and the skin and fatty tissue are also very thin, subpectoral augmentation is required to obtain a natural appearance. To select the technique for augmentation mammaplasty, assessment of the breasts is very important. Evaluation includes measuring skin elasticity and the pinch test. To measure the elasticity of the breast skin, the distance between the nipple and the IMF is measured. Then the same distance is stretched strongly upward and downward. The stretched length is divided by the original distance, which can range between 1.2 and 1.6 cm in Asian women. A measurement of 1.2 cm indicates that the skin is very fi m and not easily stretched. A measurement of 1.6 cm indicates that the skin is very elastic and can easily be stretched (Fig. 52-11). A

B

Fig. 52-11  A, The distance between the nipple and the IMF is measured. B, While the same distance is stretched strongly upward and downward, the length should be measured again. By dividing the stretched length by the original length, the skin’s elasticity can be evaluated.

Fig. 52-12  Pinch test of the skin and subcutaneous fat tissue. The lateral, medial, and superior parts of the breast should be measured. Measurements are then averaged for breast skin thickness.

Chapter 52 

813

Breast Augmentation With Implants: Inframammary Approach

To measure the thickness of the skin and fat tissue, a pinch test should be performed in the lateral, medial, and superior parts of the breast. After the measurements are taken, the mean can be calculated (Fig. 52-12). The decision regarding whether to perform subglandular or subpectoral augmentation is based on several factors (Table 52-2 and Figs. 52-13 through 52-15).

Table 52-2  Subglandular Versus Subpectoral Augmentation Pinch Test Results (cm)

Elasticity Results (cm)

Subpectoral

Flat, small-sized breasts   Normal; elastic

.2.0

.1.5

X

  Firm

,2.0

.1.3

X (Maximum volume should be 180 to 200 cc)

  Firm

,2.5

.1.3

X (Maximum volume should be 250 cc)

Small- or medium-sized breasts

.2.0 —

— —

Condition of Skin

A

B

C

D

X

Subglandular

X

Fig. 52-13  A and B, Preoperative views of a 38-year-old woman. The pinch test was 1.2 cm and the elasticity data measured 1.4. C and D, Postoperative views shown 1 year after subpectoral augmentation.

814

Part VIII 

Plastic Surgery of the Breast

A

B

C

D

Fig. 52-14  A, Preoperative lateral and B, oblique views of a 32-year-old woman. Her skin was very fi m. The elasticity data measured 1.3, and the pinch test measured 2.2 cm. Although the original breast is almost flat, subglandular augmentation can be performed, because the pinch test was thick and the skin was fi m. C, Lateral and D, oblique views 10 months after surgery. Subglandular augmentation was performed. The edge of the implant is neither visible nor palpable.

A

B

C

D

Fig. 52-15  A and B, Preoperative views of a 29-year-old woman. Subglandular augmentation mammaplasty was performed because the breast was medium sized. C and D, Postoperative views shown 10 months after surgery.

K23345_Pu_c52_Br Aug Inframam_r2_cl_803-822.indd 814

4/3/2015 12:12:51 PM

Chapter 52 

815

Breast Augmentation With Implants: Inframammary Approach

Surgical Technique In both subglandular and subpectoral augmentation mammaplasty, a 3.5 to 4 cm incision is made in the new IMF, which is marked with the template that has the same diameter as that of the implant. The undermining area should be about 1.0 cm wider in the lateral and medial sides and about 2.0 cm larger in the superior part of the breast than the template markings when implant size is less than 150 to 200 cc. If the implant volume is larger than 150 to 200 cc, the undermining area should be about 1.5 cm wider in the medial and lateral sides and about 3.0 cm larger in the superior part of the breast than the template markings. If subglandular augmentation is performed, after the incision is made, the vertical undermining is retained until the fascia is identifi d. The undermining should then be at the top of the fascia, and the area that will be undermined is just beneath the marking of the surface skin (Fig. 52-16).

A

C

B

D

E

Fig. 52-16  A, A template with the same diameter as that of the implant is used to mark the placement of the implant.

The center of the round implant should be just beneath the nipple position. B, The incision is marked as a blue dotted line, and the undermining area is marked as a green dotted line. In both subglandular and subpectoral augmentation, the undermining area should be the same. C, Just beneath the skin incision, the fascia at the top of the muscle should be identifi d in subglandular and subpectoral augmentation. D, When subpectoral augmentation mammaplasty is performed, the lateral edge of the pectoralis major muscle is identified (pressed point), and from this point the muscle is elevated and undermined. E, The lateral edge of the pectoralis major muscle is elevated.

Continued

816

Part VIII 

Plastic Surgery of the Breast

F

G

H

I

Fig. 52-16, cont’d  F, A fi ger is inserted from the lateral edge of the pectoralis major muscle, and the blunt dissec-

tion is performed only in the shaded area. Undermining of the marked area should be performed with bipolar forceps for hemostasis. G, Next, the pectoralis major muscle should be cut in the medial IMF, which is shown as a blue sheet. H, Th pectoralis major muscle is severed in the IMF area with bipolar forceps. I, The implant is inserted through the incision line.

If subpectoral augmentation is performed, undermining should be kept at the top of the fascia through the incision toward the axilla, about 4 to 6 cm. The lateral edge of the pectoralis major muscle should then be identifi d, and through this point blunt dissection can be extended beneath the pectoralis major muscle. The pectoralis major muscle is then divided at the new IMF level to provide enough space for the placement of the implant.4 The pocket is irrigated with saline solution fi st and then saline solution with antibiotics. To close an inframammary incision, 5-0 nylon sutures are used in the deep layer. For a subcutaneous closure, 6-0 or 5-0 nylon or PDS (resorbable) sutures are used. For a superfic al suture, 7-0 nylon is used. Also, a Penrose drain is placed in the incision site, which can be removed 1 to 3 days after surgery. After removal of the sutures, tape fi ation is used for 2 more weeks. Patients are also informed not to use an underwire bra for 3 months.

Postoperative Care In all patients drains are used for the fi st 1 to 3 days, and slight compression is provided by the bandage or the patient’s bra for 1 month after surgery. Stitches are removed 1 week after surgery. Because I tend to use textured-surface implants, I advise my patients not to massage the breasts for 3 months after surgery to avoid complications such as seroma.

Chapter 52 

Breast Augmentation With Implants: Inframammary Approach

817

Results All patients are asked to check their breast implants and breast tissue every year. Complications in my patients have included infection (0.2%), rippling of the implants (4.1%), and capsular contracture (Baker grades III and IV) (3.9%). All of the infected implants were removed (0.2%), and patients waited at least 6 months to have the implants reinserted (0.1%). In some patients in whom the implant rippled, fat injection was performed in one to three sessions to resolve this problem. To treat a capsular contracture, either open capsulotomy or position change (subpectoral to subglandular or subglandular to subpectoral) was performed.

A

B

C

D

Fig. 52-17 Th s 34-year-old woman requested breast augmentation. Because the patient’s skin was very firm, subglandular augmentation was performed. A 160 cc round cohesive silicone textured implant was used in this patient. The 14-month follow-up of this patient was uneventful, and the patient was satisfi d with the results.

K23345_Pu_c52_Br Aug Inframam_r2_cl_803-822.indd 817

4/3/2015 12:12:55 PM

818

Part VIII 

Plastic Surgery of the Breast

A

B

C

D

Fig. 52-18 Th s 29-year-old woman requested augmentation mammaplasty. Because the patient’s skin and fat tissue were thin, subpectoral augmentation with 175 cc round cohesive silicone textured implants was performed. Nine months after surgery, the patient showed good results without any complications.

K23345_Pu_c52_Br Aug Inframam_r2_cl_803-822.indd 818

4/3/2015 12:12:56 PM

Chapter 52 

Breast Augmentation With Implants: Inframammary Approach

A

B

C

D

819

Fig. 52-19 Th s 27-year-old woman wanted breast augmentation. Because the pinch test showed thick skin and fat tissue, subglandular augmentation was performed. A 200 cc round textured implant was used. Fifteen months after surgery, the patient was satisfi d with the results.

K23345_Pu_c52_Br Aug Inframam_r2_cl_803-822.indd 819

4/3/2015 12:12:57 PM

820

Part VIII 

Plastic Surgery of the Breast

A

B

C

D

Fig. 52-20 Th s 46-year-old woman requested augmentation mammaplasty. Because the pinch test showed that the skin was thick enough and fi m, subglandular augmentation mammaplasty with 175 cc round cohesive silicone textured implants was performed.

Discussion I started to use cohesive silicone gel implants instead of traditional saline implants because saline implants tend to develop a rippled appearance (Fig. 52-21). The rippling problem in saline implants may be resolved with the injection of more saline, but the implants become fi mer, which results in very fi m breasts. Palpable rippling may also occur with textured cohesive silicone gel implants. Even though the rippling is not visible, the patient should palpate their postoperative breasts very carefully. Some patients may request correction of the palpable rippling of the implant, although this is a very rare situation. To resolve this problem, I inject fat into the subcutaneous plane of the breasts. The fat may be harvested through the umbilicus. If one session is not enough, fat injection can be repeated 3 months from the time of the fi st injection. In my early series of augmentations, bottoming out of the implant was seen in some patients after a long follow-up. Th s phenomenon may occur only when subglandular augmentation is performed, or subglandular augmentation with cutting of the muscle at the inframammary level is done, and also only when the skin is very elastic and easily stretched.

Chapter 52 

Breast Augmentation With Implants: Inframammary Approach

Fig. 52-21  Rippling may be visible when saline implants are used. To avoid this phenomenon, more saline should be injected into the implant, which may result in fi m breasts.

To avoid bottoming out, the preoperative evaluation of the breasts is very important. If the skin is very soft and easily stretchable, the most projecting point of the implant should be placed 0.5 to 1.5 cm superior to the nipple position. We know that larger implants may move more because of gravity, and bottoming out may also become more visible when the skin is more elastic. One of the main complications of augmentation mammaplasty is capsular contracture. I prefer the textured cohesive silicone gel implant instead of a smooth implant because there are fewer cases of capsular contracture when textured implants are used, although this complication may still occur.5 It is clear that if a postoperative hematoma occurs, the rate of capsular contracture will be higher. Thus hemostasis during the surgery is very important, and I always keep drains in place for 1 to 3 days after the procedure. In addition, a very minor degree of infection may increase the possibility of capsular contracture. Disinfecting the operative fi ld is essential, and I always use a nipple-areola shield during surgery to prevent contamination through the nipple. If the capsular contracture becomes a problem for a patient, I prefer to change the location of implant placement from subglandular to subpectoral or subpectoral to subglandular. However, in some patients it is impossible to insert the implant into the subglandular space. The implant shape may be visible or palpable if the skin and fat tissue are very thin or the breast skin is very elastic. In these patients I perform multiple cutting of the superfic al capsule vertically and horizontally to enlarge the inner space for implant placement. Our patients are advised to check their breast tissue and breast implants every year. For patients with breast implants, I perform ultrasound examination and careful palpation of the breasts. Mammography is not recommended as a routine examination. In Japan at least two cases of implant rupture during mammography have been reported, and one patient sued the doctor. To avoid these problems, other types of examinations should be considered. If mammography is required, great care must be taken, and the patient should be informed that the implant may rupture during the examination. When good skin quality is confi med during the preoperative evaluation, and no hypertrophic scars or keloids are found, any scarring will fade gradually over several months. Patients should be informed that this will be a gradual process. Superfic al sutures should be removed within 1 week; then the wound should be protected by a taped dressing for 2 more weeks.

821

822

Part VIII 

Plastic Surgery of the Breast

If the inflammation of the scar is above the normal level or the scar has a tendency to become hypertrophic, steroid injections into the scar may then be started 1 month after surgery and repeated every 3 weeks. Also, sponge fix tion to the scar with a bandage to give slight pressure may be used until the redness of the scar disappears.

Pearls for Success • Careful evaluation of skin elasticity and thickness of the skin and fat tissue is essential. • Skin quality must be assessed to avoid a visible incision scar. • The volume and shape of the implant should be selected carefully, in consultation with the patient. • The surgeon must assess skin quality, thickness, and the patient’s body habitus to determine the location of implant placement: subglandular or subpectoral. • Careful hemostasis and sterile technique must be observed. • Incision closure and postoperative scar management may be necessary. • Management of complications and revision surgery should be performed as needed.

Refer ences 1. Mateo JM, Pérez MM. Innovative new concepts in augmentative breast surgery. Aesthetic Plast Surg 22:372-379, 1998. 2. Takayanagi S, Nakagawa C, Sugimoto Y. Augmentation mammaplasty: where should the implant be placed? Aesthetic Plast Surg 28:83-88, 2004. 3. Graf RM, Bernardes A, Ripple R, et al. Subfascial breast implant: a new procedure. Plast Reconstr Surg 111:904908, 2003. 4. Tebbetts JB. Dual plane breast augmentation: optimizing implant-soft- issue relationships in a wide range of breast types. Plast Reconstr Surg 107:1255-1272, 2001. 5. Coleman DJ, Foot IT, Sharpe DT. Textured or smooth implants for breast augmentation? A prospective control trial. Br J Plast Surg 44:444-448, 1991.

K23345_Pu_c52_Br Aug Inframam_r2_cl_803-822.indd 822

4/3/2015 12:12:59 PM

53

P

Endoscopic-Assisted Transaxillary Approach for Treatment of Capsular Contracture and Implant Malposition

A

En

Li Yu

ugmentation mammaplasty can be performed through various incisions: transaxillary, inframammary, circumareolar, and transumbilical. In Asia it is usually performed using an axillary approach. The incision is hidden inside the axillary hair and far from the breast area. For aesthetic reasons, most patients who undergo treatment for postaugmentation complications do not want an additional incision on the breast or elsewhere; thus the transaxillary incision is the only acceptable approach for these patients. Capsular contracture and implant malposition are common problems that require revision surgery after primary breast augmentation. Some authors think that the axillary approach does not allow optimal control during implant insertion, which is needed for consistent, predictable positioning. Th s increases the risk of implant damage. In my experience, a form-stable, anatomic implant can be inserted through an axillary incision and into a predissected pocket without damage. In this chapter I describe my experience in managing these complications through a transaxillary approach with the assistance of endoscopy.

CAPSULAR CONTRACTURE Pathophysiology Capsular contracture should not necessarily be considered a complication, but it should be regarded as an exaggeration of normal wound healing. The factors that directly cause capsular contracture are not well understood; therefore complete prevention is not possible. Clinically, bilateral capsular contracture is more common than unilateral contracture. Th s suggests that the response of patients to implants is an important factor in contracture formation. The discovery of the adhesion kinetics of myeloid-related protein 14 (MRP14, calprotectin) on the surface of silicone implants has advanced our understanding of contracture

823 K23345_Pu_c53_Endo Assist_r2_cl_823-836.indd 823

4/3/2015 12:16:15 PM

824

Part VIII 

Plastic Surgery of the Breast

formation. Th s protein (in a complex with MRP8) plays an important role in leukocyte recruitment, enhancing adhesion to circulating monocytes.1,2 Before this discovery, no defin tive evidence had been presented to show that an immune-mediated response to silicone or to breast implants played a role in the development of capsular contracture.3 After implants are inserted, the body initiates a local inflammatory response characterized by activation of polymorphonuclear leukocytes and mononuclear cells. After several days, the cells in the capsule are predominantly lymphocytes, fibroblasts, and monocytes. The monocytes differentiate into macrophages and foreign body giant cells.4 The fibroblasts proliferate and produce collagen (types I, III, and IV), which is found in higher concentrations in contracted capsules. It has been theorized that myofibroblasts may be critical to the process of capsular contraction, because they tighten and relax, similar to smooth muscle cells, thereby providing the force that contracts a capsule.3 As a capsule matures, it becomes a stable structure as fibroblasts deposit more fibrous tissue.5,6 Capsular thickness ranges from 0.25 to 4.0 mm, with an average thickness of approximately 1.3 to 1.4 mm.4 The textured surface structure reduces fibroblast proliferation and produces a random orientation of fibroblasts and collagen in the capsule that vectors the contractile forces into many directions.7 One theory attributes capsular contracture to a silicone bleed, which can generate a chronic inflammatory reaction that stimulates fibrosis and contributes to contracture.3 Th s stimulates the production of a barrier layer between the two silastomer layers in the implant shell. Cohesive gel is highly cross-linked and cannot migrate out of the shell, even if an implant ruptures. Subclinical infection and biofilm formation is a proven cause of capsular contracture after augmentation mammaplasty in an animal model. The risk of infection should be eliminated to prevent or reduce the incidence of capsular contracture.8

Classification of Capsular Contracture The most widely used system to quantify capsular contracture is the Baker classifi ation9,10 (Table 53-1). The criteria are subjective. An in-depth discussion is necessary with all patients to determine whether revision surgery is the best option.

Table 53-1  Baker System for Classifi ation of Capsular Contracture Classification (grade)

Breast Characteristic

1

The augmented breast feels as soft as a natural breast.

2

The breast is not naturally soft, but the shape is normal and the implant is not visible; however, the implant can be palpated. The patient is usually not concerned.

3

The breast is fi mer than normal, and the implant is visible and easy to palpate. Some breasts have a normal shape, but others are overly round and visibly distorted.

4

The breast is abnormally hard and in some cases, cold and tender. The implant is visible, and gross distortion is obvious.

From Baker JL Jr. Classifi ation of spherical contractures. Presented at the Symposium on Aesthetic Surgery of the Breast, Scotts­ dale, AZ, Nov 1975.

Chapter 53 

Endoscopic-Assisted Transaxillary Approach for Treatment of Capsular Contracture and Implant Malposition

825

Indications In general, it is unnecessary to treat patients who have mild degrees of capsular contracture (grades 1 and 2). Grade 2 capsular contracture is characterized by minor increased firmness, and surgical intervention usually does not provide predictable and reliable results or much softer breasts. The balance between the benefits and the risks and trade-offs of the surgery should be carefully evaluated and thoroughly discussed with every patient. Some nonsurgical therapies have been recommended, including high doses of oral vitamins A and E and the use of leukotriene receptor antagonists such as zafi lukast and montelukast; however, no strong experimental evidence supports the efficacy of these uses in the treatment of capsular contracture. Treatment is indicated for patients with Baker grades 3 and 4 capsular contracture. Patients with grade 4 contracture usually describe a feeling of pain or discomfort, such as tightness. Th s can be severe during arm movement. Surgical intervention is indicated for severe capsular contracture. The established surgical treatment strategies are capsular opening, implant replacement under the muscle, capsular scoring, and capsulectomy. Patients should be offered the option of having the implants removed without replacement. Explanation without implant replacement involves a partial or total capsulectomy. I recommend resection of the anterior and/or posterior capsule to prevent distortion of the breast contour and accumulation of fluid in the cavity, which can lead to late seroma formation. Most women with contracture will reject the option of explanation without replacement and prefer to have implants, despite problems or inconveniences. The procedure should be customized for each patient.

Preoperative Assessment The patient’s physical condition, clinical surgical history, previous surgical report, and MRI of the breast are carefully evaluated. Current preoperative clinical assessment and planning for transaxillary secondary breast augmentation, including the choice of pocket location, implant size, and new inframammary fold position, are based on methods of quantitative tissue assessment and implant selection for each patient. Surgical intervention is recommended no later than 6 months after the preoperative clinical assessment. The submuscular or dual-plane pocket is the only choice for Asian patients. The new inframammary fold position is created according to the size of the newly implanted breast prosthesis and the thickness of the soft tissue coverage of the breast. The potential drawback of insufficient tissue coverage should be discussed with patients who have undergone revision breast augmentation.

Surgical Technique Surgery is performed while the patient is under general anesthesia. The patient is placed in a supine position with the arms abducted to 80 degrees. A dilute solution of local anesthesia and a vasoconstrictor is infiltrated into the proposed incision area. The original incision—whether inframammary, periareolar, or transaxillary—is chosen for the revision surgical incision. The transaxillary approach and the use of the previous transaxillary scar are discussed in this chapter. The axillary incision is made no longer than the previous incision scar. The incision scar will be trimmed after the procedure is completed. Skin hooks or a toothed retractor is used to expose the subcutaneous fat and allow palpation of the lateral border of the pectoralis muscle. The surgeon makes an incision through the subcutaneous fat and the superfic al pectoral fascia overlying the lateral border of the pectoralis muscle in a superoinferior direction. The cephalad fascial incision should not be excessive over the lateral pectoralis muscle to prevent damage to the cutaneous branches of the posterior humeral circumflex rtery and vein, which course anteriorly over the lateral border of the pectoralis muscle.

K23345_Pu_c53_Endo Assist_r2_cl_823-836.indd 825

4/3/2015 12:16:16 PM

826

Part VIII 

Plastic Surgery of the Breast

The lateral fascial border of the pectoralis muscle is exposed with electrocautery. The surgeon can select either a subfascial or submammary dissection plane. A subpectoral pocket can be made by dissecting posterior to the pectoralis major muscle. To enter the subpectoral plane at an optimal angle, the surgeon aims inferior to the incision, approximately halfway between the nipple and the clavicle. Dissection directly medially from the incision is avoided, because this area usually contains more blood vessels, including branches of the posterior humeral circumflex rtery and vein, which course anteriorly, and branches of the thoracoacromial artery and vein on the posterior surface of the pectoralis superiorly, which can be identifi d endoscopically within a fat pad under the pectoralis major muscle. A double-ended retractor is inserted beneath the muscle to establish the subpectoral plane using monopolar electrocautery under direct vision. The entire upper half of the subpectoral pocket can be established by fi ger palpation or forceps dissection, creating a plane between pectoralis major and the pectoralis minor muscles. Blunt or sharp dissection with electrocautery is then carried to the outer surface of the fibrous capsule. An endoscopic elevator is used under endoscopic control to continue the dissection close to the outer surface of the capsule (Fig. 53-1, A). The thickness, color, and vascular morphology of the capsule vary from patient to patient (Fig. 53-1, B). To prevent leakage of the silicone gel, the cavity should not be penetrated. The dissection is performed as much as possible on the outer dome of the capsule. After dissection is completed, the fibrous capsule is opened with endoscopic monopolar electrocautery. The fibrous capsule is easily opened to reveal the implant (Fig. 53-1, C). In patients with silicone implants, the devices are carefully examined for leakage. With the use of external digital manipulation, the implant is extruded from the capsular cavity through the former insertion plane and the axillary incision. If gel leakage is found, every effort is made to extract as much gel as possible under endoscopic control using hand manipulation,

A

B

C

D

E

F

Fig. 53-1  A, The outer surface of the fibrous capsule is explored with an endoscopic elevator under endoscopic control. B, The thickness, color, and vascular morphology of the capsule vary among patients. C, The fibrous capsule is easily split, revealing the implant. D, Gel leakage is found. E, The dome of the capsule is collapsed. F, The dome of the fibrous capsule is excised.

Chapter 53 

Endoscopic-Assisted Transaxillary Approach for Treatment of Capsular Contracture and Implant Malposition

vacuum suction, and normal saline irrigation (Fig. 53-1, D). The endoscope is reinserted into the capsular cavity and the entire cavity is carefully assessed for bleeding and leakage. If neither is observed, an endoscopic monopolar dissector is introduced through an axillary approach, and the collapsed capsule is visualized (Fig. 53-1, E). The dome of the fibrous capsule is excised (Fig. 53-1, F). The bottom part of the capsule is preserved if a partial capsulectomy is planned. Capsular contracture is usually accompanied by an increased intermammary space and an elevated inframammary crease. To create an adequate pocket to hold the implant in the correct position, the origin of the pectoralis major muscle should be partially electrocauterized from the rib, with traction placed on the muscle by an endoscopic retractor. The internal insertion of the pectoralis major should not be dissected. Th s requires precise cauterization of the medial cavity if necessary and cauterization of only the plane of the capsule, preserving the muscle beneath it. After an adequate pocket is created and irrigated with an antibiotic solution, the prosthesis is implanted in the pocket with a no-touch technique. A silicone drainage tube is placed in the subpectoral pocket. The previous scar is trimmed, and the axillary incision is sutured closed around the tube.

Pos ter io r Caps ulect omy

A posterior capsulectomy is indicated for patients with a thick and stiff capsule. It is recommended if a silicone gel implant has been broken and the patient desires maximal removal of silicone. Silicone may have leaked from the implant and escaped from the disrupted shell. However, the risks and benefits need to be thoroughly discussed with each patient. If the capsule is so adhered to the rib and external intercostal muscle that it is completely immobil, it cannot be separated from the periosteum, perichondrium, and intercostal muscle, then a posterior capsulectomy is absolutely contraindicated. Replacement of a textured or smooth-surface device with a textured implant is not a typical indication for posterior capsulectomy; however, a textured implant that is placed in a cavity in which a capsulectomy was performed with a fresh tissue surface may develop better adherence. Some authors suggest removal of the entire capsule around a leaking implant. However, the posterior capsule can become densely adhered to the chest wall, increasing the risk of penetration through the intercostal region, with resultant pneumothorax. Therefore a partial capsulectomy of the anterior capsule is usually performed, and leaked gel is thoroughly removed. The posterior capsule is preserved. The safety of a complete capsulectomy is directly related to the surgeon’s patience, experience, and technical skills using endoscopic instrumentation.

Postoperative Care The drain is maintained until the total drainage amount is less than 40 ml in a 24-hour period. Patients are typically discharged on postoperative day 3. The sutures are removed on postoperative day 7.

Results Patients treated endoscopically for implant contracture are followed for approximately 6 months. Results are generally favorable. No additional scars are made, and no scars are left on the breast. Patients are generally satisfi d with the softer feel and natural contour of their breasts.

827

828

Part VIII 

Plastic Surgery of the Breast

Fig. 53-2 Th s 45-year-old woman had Baker grade 3 capsular contracture bilaterally. Preoperative MRI showed that the implants had broken and leaked. This was confirmed intraoperatively. A total capsulectomy was performed on left side and a partial capsulectomy on the right side. She was seen for follow-up 7 months after surgery.

K23345_Pu_c53_Endo Assist_r2_cl_823-836.indd 828

4/3/2015 12:16:17 PM

Chapter 53 

Endoscopic-Assisted Transaxillary Approach for Treatment of Capsular Contracture and Implant Malposition

Before treatment

Tissues removed

After treatment

Fig. 53-3 Th s 33-year-old woman had Baker grade 4 capsular contracture in her left breast and Baker grade 4 contracture in her right breast. The dome capsulectomy was performed in a transaxillary manner with endoscopic assistance on both breasts. The implant was renewed and placed subpectorally. The excised capsule shows the signifi ant difference in tissue thickness. Six months after surgery, the patient was very happy with the result and her natural breast shape.

Discussion A complete capsulectomy is preferable to a partial capsulectomy for many reasons. However, after removal of an implant in patients with capsular contracture, a plastic surgeon has to determine whether to perform a complete or partial capsulectomy or to leave the fibrous capsule in place. Some authors advocate a capsulectomy (total or partial) in conjunction with extraction in some patients, including those with grade 3 or 4 capsular contracture and/or a calcifi d or thick capsule, those who require removal of a ruptured implant or implants, and those who will undergo exchange of an existing implant with a new one in a different tissue plane.11 A partial capsulectomy of the submuscular capsular portions is recommended because of the higher risk of injuring the muscle and causing a pneumothorax. It is emphasized that if a textured implant is inserted, the pocket should be lined with fresh tissue (not mature scar tissue). A capsulectomy should usually be performed to allow the textured implant surface to interact with a fresh tissue surface. With a subpectoral implant placement, contracture is corrected with a partial capsulectomy in which the entire anterior capsule is removed.12 When a surgery is performed to treat contracture, it is reasonable to use either saline- or gel-filled implants, depending on local anatomic considerations and the patient’s preference. If the remaining tissue is thin, either from compression atrophy or tissue removal during the capsulectomy, a gel-filled implant may provide a more natural texture and appearance. If a textured implant is inserted, the pocket should be newly formed with fresh tissue, showing textured morphology (as opposed to mature capsule). Most experts report that if surface texturing is to be effective, it is necessary for a textured capsule to form adjacent to the shell.13 Textured implants have been associated with a higher incidence of waviness or rippling of the overlying skin, and this disadvantage must be weighed against the potential benefic al effect on recurrent contracture.

829

830

Part VIII 

Plastic Surgery of the Breast

IMPLANT MALPOSITION Implant malposition describes breast distortion caused by an implant that is not properly centered behind the nipple. Malpositioned implants can be too high, too medial, too low, or too lateral. The cause of malposition is incorrect placement of the breast implant at the time of augmentation or displacement over time.

Classification and Selection for Management of Implant Malposition Impl ant To o High

An implant that is too high has its center above the nipple, and the upper pole of the breast is too full (Fig. 53-4). Malposition immediately after the operation is from inadequate detachment of the inferior border of the pectoralis major muscle, inadequate dissection of the inferior pocket and improper placement of an anatomic implant during implantation. Capsular contracture is the most common cause of delayed superior displacement. Appropriate correction relies on identifi ation of the cause of malposition. If malposition results from an inframammary crease that is too high, the new implant pocket should be dissected at a lower level. If malposition occurs because of capsular contracture, the cause of contracture needs to be understood. These include the location of the implant, the surface of the implant, subclinical infection and biofilm, and hematoma formation. If the implant is placed subglandularly, it should be removed with a partial or total capsulectomy and placed submuscularly. If the implant is submuscular, the most likely cause is inadequate detachment of the inferior border of the pectoralis major muscle. Treatment includes dissection and lowering of the inferior border.

Impl ant To o Med ial

Development of an implant pocket too far medially can result in synmastia (Fig. 53-5). Th s severe malposition is characterized by confluence of the breasts in the midline and loss of normal cleavage. The nipple is not at the apex of the breast, and the soft tissues detach from the sternum in severe cases. If the implants are in the submammary position, one solution is to remove the implants and replace them in the subpectoral position. Preservation of the entire medial attachment of the pectoral muscle will prevent the implant from shifting too close to the midline. The medial pectoral muscle should not be dissected too far medially.

Fig. 53-4  An example of implants that are too high.

Chapter 53 

Endoscopic-Assisted Transaxillary Approach for Treatment of Capsular Contracture and Implant Malposition

Fig. 53-5  An example of implants that are too medial.

Fig. 53-6  An example of implants that are uneven. The implant on the left side is too low.

If the implants are in the submuscular position, a total or subtotal capsulectomy can be performed if the capsule is thick enough and the medial portion of the pocket can be obliterated by placing sutures between the anterior skin flap and the chest wall. Th s can be technically difficult through the axillary approach, because the skin flap in this area is usually quite thin, and sutures may be close to the epidermis, causing visible skin depressions, which may last several months. Placement of sutures can be more challenging on the thin periosteum of the sternum, because such sutures can easily be torn off. It is usually possible to place a few tacking sutures to obliterate the space medially. If the capsule is thick enough, a partial medial capsulectomy can be performed to create a tonguelike capsular flap directed upward that can be pulled laterally to overlap the sutures on the remaining capsule. The implant should be replaced with a textured device. Artifi ial dermis (such as AlloDerm) can be used as a barrier and sutured to the dome and bottom of the capsular cavity, along the medial border of the cavity, to block the medial portion of the pocket from the medial movement of the implant.

Impl ant To o Low

If an implant is too low, the center of the breast mound is below the nipple (Fig. 53-6). The causes include improper preoperative design and placement of the inframammary crease, aggressive dissection of inferior border of pectoralis major muscle, and inadequate tissue support.

831

832

Part VIII 

Plastic Surgery of the Breast

Fig. 53-7  An example of implants that are too lateral on both breasts.

A crease that is too low cannot be repositioned upward postoperatively with tape or a bra if the implant is on the crease line. Regardless of the incision location used in the primary augmentation, an inframammary or periareolar incision is generally required for the revision procedure. Correction through an axillary incision can be performed in patients who do not want an additional scar on their breast, but it is a time-consuming procedure. If the capsule is thick enough to be pulled upward to support the implant, the simplest treatment is to go through the inframammary fold incision to plicate the existing capsule with nonabsorbable sutures to close the inferior portion. An additional procedure in which the dermis is sutured to a rib through a transaxillary approach is recommended in severe and recurrent cases. However, some dimpling can last several months. The fi al option is removal of the implant.

Impl ant To o Lateral

When the pocket has been enlarged too far laterally and/or the medial dissection is inadequate, an implant that is too wide can easily become displaced beyond the anterior axillary line, causing flatness of the breast in the parasternal region and more fullness laterally when the patient stands (Fig. 53-7). If the cause is excessive cavity dissection laterally, correction requires reduction of the dimensions of the pocket by capsulorrhaphy and appropriate placement of the implant. The procedure should be performed under direct visualization. The appropriate segment of the capsule is resected, and the cut edges are approximated and sutured to one another to obliterate the lateral extension of the pocket. If an implant is too far lateral because it is too small and dissection in the medial cavity is insuffici t, the medial cavity should be properly dissected and an appropriate-sized implant placed.

Results Most patients who undergo endoscopic-assisted correction of implant malposition are satisfi d with their results. Two patients had dimpling from the sutures after correction of implants that were too low and too medial. Th s can last several months. No revisions were performed.

Chapter 53 

Endoscopic-Assisted Transaxillary Approach for Treatment of Capsular Contracture and Implant Malposition

833

Fig. 53-8 Th s 24-year-old woman had upper pole fullness of both breasts. An endoscopic-assisted procedure was performed to lower her inframammary folds. Her 225 cc round implants were replaced with 245 cc Con­ tour Profile Gel 321 implants.

K23345_Pu_c53_Endo Assist_r2_cl_823-836.indd 833

4/3/2015 12:16:19 PM

834

Part VIII 

Plastic Surgery of the Breast

Fig. 53-9 Th s 35-year-old woman had implant malposition with a wide intermammary distance. An endoscopic procedure was performed through an axillary incision. The medial aspect of the cavity was suffici tly dissected, while the medial part of the pectoralis major muscle was protected. On the left breast, her 135 cc saline implant was replaced with a 215 cc McGhan 410 mm implant. On the right breast, her 148 cc saline implant was exchanged for a 225 cc McGhan 410 mm implant.

Discussion Implant malposition is one of the most common complications of augmentation mammaplasty. The causes are multifactorial, including improper presurgical evaluation for implant size or base diameter because patient and tissue variables were not considered, selection of an unsuitable surgical technique, and inappropriate postsurgical care. The best way to prevent such complications is to customize treatment for each patient. Th s requires suffici t knowledge of a patient’s anatomic variations. Successful treatment and an ideal result require the correct diagnosis of the cause of malposition and selection of an appropriate sur-

K23345_Pu_c53_Endo Assist_r2_cl_823-836.indd 834

4/3/2015 12:16:19 PM

Chapter 53 

Endoscopic-Assisted Transaxillary Approach for Treatment of Capsular Contracture and Implant Malposition

835

gical technique. Endoscopy-assisted treatment of implant malposition through an axillary approach has several advantages: The former axillary approach is used without an additional incision having to be made, dissection of the layers is precise, and bleeding can be well controlled. The disadvantages are related to the surgeon having to learn how to use new endoscopic instruments. Training is needed to obtain the necessary technical skills. Results with endoscopic assistance should be equal to or better than those obtained with traditional approaches.

Pearls for Success • The implant position and status should be carefully evaluated preoperatively. • Skillful endoscopic control is required. • Careful dissection is performed close to the outer surface of the fibrous capsule with an endoscopic elevator under endoscopic control. • The outer surface of the capsule should be suffici tly explored without penetrating the capsule. • The selection of a surgical technique depends on the desired result. • Explantation is often a last choice for difficult and recurrent cases.

Refer ences 1. Backovic A, Wolfram D, Del-Frari B, et al. Simultaneous analysis of multiple serum proteins adhering to the surface of medical grade polydimethylsiloxane elastomers. J Immunol Methods 328:118-127, 2007. 2. Bouma G, Lam-Tse WK, Wierenga-Wolf AF, et al. Increased serum levels of MRP-8/14 in type 1 diabetes induce an increased expression of CD11b and an enhanced adhesion of circulating monocytes to fibronectin. Diabetes 53:1979-1986, 2004. 3. Young VL, Watson ME, Atagi TA. Secondary breast augmentation. In Mathes SJ, ed. Plastic Surgery: Trunk and Lower Extremity, vol 6. Philadelphia: Elsevier, 2006. 4. Yu L, Wang J, Zhang B, et al. Endoscopic transaxillary capsulectomy. Aesthetic Plast Surg 30:282-285, 2006. 5. Loss C, Hansson HA. Peptide growth factors and myofibroblasts in capsules around human breast implants. Plast Reconstr Surg 91:1277-1286, 1993. 6. Rudolph R, Abraham J, Vecchione T, et al. Myofibroblasts and free silicon around breast implants. Plast Reconstr Surg 62:185-196, 1978. 7. Van Kooten TG, Whitesides JF, von Recum AF. Influence of silicone (PDMS) surface texture on human skin fibroblast proliferation as determined by cell cycle analysis. J Biomed Mater Res 43:1-14, 1998. 8. Tamboto H, Vickery K, Deva AK. Subclinical (biofilm) infection causes capsular contracture in a porcine model following augmentation mammaplasty. Plast Reconstr Surg 126:835-842, 2010. 9. Little G, Baker JL Jr. Results of closed compression capsulotomy for treatment of contracted breast implant capsules. Plast Reconstr Surg 63:30-33, 1980. 10. Baker JL Jr. Classifi ation of spherical contractures. Presented at the Symposium on Aesthetic Surgery of the Breast, Scottsdale, AZ, Nov 1975. 11. Young VL. Guidelines and indications for breast implant capsulectomy. Plast Reconstr Surg 102:884-891, 1998. 12. Handel N. Managing local implant-related problems. In Spear SL, ed. Surgery of the Breast: Principles and Art. Philadelphia: Lippincott-Raven, 1998. 13. Mathes SJ, Hentz VR, eds. Plastic Surgery, ed 2. Philadelphia: Saunders-Elsevier, 2006.

K23345_Pu_c53_Endo Assist_r2_cl_823-836.indd 835

4/3/2015 12:16:19 PM

K23345_Pu_c53_Endo Assist_r2_cl_823-836.indd 836

4/3/2015 12:16:19 PM

54 Breast Augmentation With Conventional Fat Grafting

C

Qingfeng Li, Lee L.Q. Pu

onventional fat grafting to enlarge the breasts can be performed for cosmetic reasons, for correction of asymmetry, and for reconstruction of a deformity. The absence of an autoimmune response, the ease in accessing donor fat, and the minimal complications associated with fat transfer make autologous fat a virtually perfect material for augmenting breasts. Successful transplantation requires a delicate and less traumatic technique, from fat harvesting and refinement to the injection procedure and even postoperative care. The fi st reported use of fat grafts to the breast dates from the end of the nineteenth century, when Czerny transplanted a lipoma to reconstruct a breast defect.1,2 But because of the significant fat necro­sis that resulted, this technique was not revisited for many years. Bircoll3 initiated a brief revival of breast fat transplantation in the early 1980s following the maturation of liposuction techniques, but this effort was short-lived, because the techniques for fat refi ement had not yet matured. Some clinical teams, including Li’s team in China,4,5 began to research methods for refini g harvested fat and other improvements in fat survival. Centrifugation can be used to purify fat for transplantation. Li’s team proposed that centrifugation at 1000 rpm for 2 minutes can provide not only high purity of fat but also more viable adipocytes within the fat grafts 4 The glucose transport test (GTET), established by our group, can be used to evaluate the viability of fat grafts before their in vivo transplantation.4,5 With ever-increasing knowledge of the biologic behavior of adipose tissue, methods of fat transfer will continue to be refi ed, and this autologous material will undoubtedly continue to be used increasingly for reconstruction of breast soft tissue defects.

Anatomy Safe and effective fat grafting relies not only on a clear understanding of the blood supply, but also on detailed knowledge of the anatomy of the fascia and fat layers. The breast gland is contained within the superfic al fascia. The superfic al layer of the superfic al fascia, which is the outer covering of the parenchyma, is

837

838

Part VIII 

Plastic Surgery of the Breast

Gland lobules Cooper’s ligaments Superficial fascia Fat lobules Lactiferous duct Ampulla

Fig. 54-1  Fasciae and ligaments act as septa within the fat tissue of the breast.

situated close to the dermis. The deep layer of the superfic al fascia can be identifi d on the posterior deep surface of the breast. The superfic al layer of the deep muscular fascia covers the pectoralis major, the upper portion of the rectus abdominis, the medial serratus anterior, and the external oblique muscle in the lower central breast. Cooper’s ligaments run from the deep muscle fascia through the breast parenchyma, to the dermis of the overlying skin. Fasciae and ligaments act as septa within the fat tissue (Fig. 54-1). Fat grafts are transplanted around these septa.

Indications Breast augmentation with conventional fat grafting is indicated under the following circumstances: • Augmentation of the breasts in patients with micromastia, tuberous breasts, or Poland syndrome but the patient refuses an artific al implant • Correction of contour deformities of the breast or asymmetry after removal of silicone implants, or a breast lumpectomy, or after reconstructive surgery • Creation of a thick envelope of breast tissue after placement of a silicone implant

Preoperative Assessment A thorough medical history is essential, including specific questioning about any family history of breast or ovarian cancer. A routine physical examination should be performed, with particular attention to breast masses. It is recommended that women over age 35 have a preoperative mammogram and that women under 35 undergo a breast ultrasound examination. Patient education is vital during consultation, because fat grafts have a variable and unpredictable survival rate. Especially during the initial consultation, it is important to listen to the patient to determine her expectations for the outcome of the procedure. In addition, the surgeon must defi e the limits of possible surgical improvements. All potential complications should be discussed, particularly fat necrosis and cyst formation. The potential need for additional procedures to refi e the result should also be mentioned.

Chapter 54 

Breast Augmentation With Conventional Fat Grafting

Surgical Technique Fat Har ves ting

The most common donor sites for fat harvest are the abdomen, the outer thigh, and the inner thigh. With the patient standing, the harvest sites are marked immediately before the operation. The procedure is performed with the patient under general anesthesia. A local anesthetic solution is injected, consisting of 0.9% saline 500 ml, 2% lidocaine 20 ml, epinephrine 1:1000 1 ml, and 3% sodium bicarbonate 5 ml. Liposuction may begin after 15 minutes, when the solution has taken effect and there is good bleeding control. A two-holed blunt-tipped harvesting cannula (3 mm in inner diameter) is connected to a vacuum pump (Fig. 54-2). The fat grafts are aspirated at low negative pressure (20.5 atm). The lipoaspirate is washed with 0.9% normal saline solution. Then the collection syringes are sealed and centrifuged at 1000 rpm (72 g) for 2 minutes.4,6 After centrifugation, the lipoaspirate will have separated into three layers: the upper layer is composed of oil from the destruction of fat fragments, the second layer is composed of adipose tissue, and the third layer mainly contains the anesthetic solution and blood cell debris. Only adipose tissue from the middle layer is used for fat grafting. In most techniques currently used for fat grafting, centrifugation is performed to purify fat for transplantation. In Coleman’s technique, centrifugation at 3000 rpm for 3 minutes is a standard way to process the harvested fat.7 However, our studies have demonstrated that adipocytes within fat grafts had less viability when the speed of centrifugation was more than 1000 rpm; the reduction of viability is directly related to the speed of centrifugation when the speed is higher than 1000 rpm. 5 The same conclusion was reported by Piasecki et al,8 who used a trypan blue viability assay. Centrifugation at 1000 rpm for 2 minutes is therefore what we recommend. After centrifugation, when the oil fraction is above the fat and the bloody fraction is at the bottom, we use a 2 cc or 5 cc syringe to collect fat below the oil fraction.4,5

A

C

B

Fig. 54-2  A, Vacuum pump for harvesting fat. B, Blunt-tipped harvesting cannulas. C, Centrifuge.

839

840

Part VIII 

Plastic Surgery of the Breast

Fat Graft Injectio n

The cannula for fat infiltration is a one-holed blunt-tipped cannula with a 3 mm diameter nozzle. It is connected to the 5 cc syringe for fat infiltration. Two small incisions are made in the breast (Fig. 54-3). Th ough a periareolar incision, the fat grafts are infiltrated into the subcutaneous tissue of the inner half of the breast. Th ough an inframammary incision, the fat grafts are infiltrated into the subglandular tissue and the subcutaneous tissue of the lateral half of the breast. As the syringe is withdrawn, the fat graft should be injected in small quantities in one place each time, radially from distal to proximal. Blunt-tipped cannulas allow greater dispersion of the grafted tissue in aliquots smaller than 2 mm3 and reduce the chance of intravascular injection. The volume of fat to be transferred to the patient should be overestimated to account for the approximate 30% fat reabsorption after injection. However, it is counterproductive to continue injection when injected fat is coming out from the incision, which could lead to the development of fat necrosis. After fat grafting, the skin is sutured with nonabsorbable suture material; the site is then gently massaged to evenly distribute the injected tissue. In our experience, approximately 60 to 120 cc (101 cc average) of fat can be injected into the subcutaneous tissue of the breast, and 60 to 90 cc can be injected into the subglandular tissue of the breast. If necessary, fat grafting can be repeated after at least 3 months. In patients with a signifi ant breast contour deformity, two or three repeat procedures may be required.

A

Periareolar incision and injection direction above glandular tissue

Inframammary incision and injection direction below glandular tissue

B Periareolar incision

Inframammary incision

Fig. 54-3  Through a periareolar incision, the fat grafts are infiltrated into the subcutaneous tissue of the inner half of

the breast. Th ough an inframammary incision, the fat grafts are infiltrated into the subglandular and subcutaneous tissue of the lateral half of the breast. A, Breast markings and arrows indicating direction in which fat injections are fanned outward. B, A periareolar incision and inframammary incision are made.

Chapter 54 

Breast Augmentation With Conventional Fat Grafting

841

Postoperative Care We recommend that the patient wear a supportive surgical bra day and night for 7 days after breast augmentation with fat grafting. In our experience, it is important that for these 7 days the breast should remain in a supported, fi ed position with the bra to avoid local accumulation of grafted fat caused by the movement of the pectoralis major muscle. Oral antibiotics are administered for 3 days postoperatively. For donor site care of the abdomen or thigh, the patient should wear a compression garment for 1 month.

Results

Fig. 54-4 Th s 24-year-old woman underwent one autologous fat grafting procedure for breast augmentation. The amount of fat transplanted was 180 cc in each breast. She is shown 13 months postoperatively. She was very pleased with the result.

K23345_Pu_c54 55_Br Aug Fat Graft_r4_cl_837-848.indd 841

4/6/2015 7:28:20 AM

842

Part VIII 

Plastic Surgery of the Breast

Fig. 54-5 Th s 27-year-old woman underwent autologous fat grafting twice to increase her breast volume after silicone implants were removed. She had had silicone gel breast implants placed twice; both times the implants had failed and required removal because of capsular contractures. For aesthetic enhancement, she requested augmentation with fat grafting. The amount of fat grafted was 202 cc in each breast for the fi st injection, and 170 cc for the left breast and 190 cc for the right breast in the second procedure. The results are shown 22 months after the second procedure. The patient was very pleased with the result.

K23345_Pu_c54 55_Br Aug Fat Graft_r4_cl_837-848.indd 842

4/6/2015 7:28:21 AM

Chapter 54 

Breast Augmentation With Conventional Fat Grafting

843

Fig. 54-6 Th s 23-year-old woman underwent autologous fat grafting twice for breast augmentation. The amount of fat transplanted was 120 cc in each breast in the fi st procedure and 140 cc in each breast in the second procedure. She is shown 12 months after the second procedure. Her breast contour has been improved signifi antly. The patient was very pleased with the result.

K23345_Pu_c54 55_Br Aug Fat Graft_r4_cl_837-848.indd 843

4/6/2015 7:28:23 AM

844

Part VIII 

Plastic Surgery of the Breast

Fig. 54-7 Th s 31-year-old woman underwent one autologous fat grafting procedure to increase her breast volume after the removal of silicone implants. The implants had to be removed because of a bottoming-out complication. Th s removal created a deformity in the left reast. The total amount of fat transplanted was 202 cc in each breast. She is shown 12 months postoperatively. The patient was very pleased with the result.

K23345_Pu_c54 55_Br Aug Fat Graft_r4_cl_837-848.indd 844

4/6/2015 7:28:24 AM

Chapter 54 

Breast Augmentation With Conventional Fat Grafting

Discussion Cyst Forma tio n

A cyst, whether thin-walled or thick-walled, is a common histologic type of fat necrosis. Most liponecrotic cysts can be diagnosed accurately based on their characteristics: the timing of cyst formation, its layers, and benign calcifi ations as identifi d through mammography (Table 54-1). Mammographic fi dings of a liponecrotic cyst appear as an entirely radiolucent round or ellipsoid mass surrounded by a thin or thick fibrous membrane, with or without calcifi ations. Usually these calcifi ations appear to have typical benign features. The exact pathogenesis of a liponecrotic cyst after fat grafting to the breast is poorly understood. It is thought to be the result of an inflammatory response of the host tissue to the fat grafts that have degenerated from an inadequate blood supply. Most liponecrotic cysts are found in the subglandular layer of the breast. It is possible that fat necrosis is caused by injecting too much fat into one area or by the accumulation of injected fat in one area resulting from movement of the pectoralis major muscle. Grafted fat should be placed in small aliquots with each pass to maximize the surface area of contact between the grafted fat and the recipient tissue. A large surface area of contact between the host tissues with their capillaries and newly grafted tissue promotes nutrition and reduces the number of liponecrotic cysts. We usually try to inject a very small volume (0.2 cc) of fat at each injection point. As previously mentioned, for approximately 7 days postoperatively, the breast should be maintained in a fi ed position with a surgical bra to avoid the local accumulation of grafted fat resulting from the movement of the pectoralis major muscle. Postoperative management of liponecrotic cysts in the breast can be done through needle aspiration or surgical extirpation. If breast sonography identifies a cyst that has occurred 1 month postoperatively, and its volume has remained constant in the follow-up period, this may indicate the formation of a cyst secondary to necrotic fat and warrants needle aspiration in the early postoperative period. Open extirpation of the cyst can also be a good option. During the operation the capsule of the cyst can be found and excised, including the calcifi ations within the capsule. Most calcifi ations are found within the cyst capsule through the evidence of mammography and histologic evaluation (Fig. 54-8).

Table 54-1  Comparison of Fat Necrosis and Breast Cancer Characteristics 

Fat Necrosis

Breast Cancer

Time of occurrence

Most necrotic cysts occur 1 to 3 months after surgery

Does not appear at a fi ed time after fat grafting

Layer

Usually develops in the subcutaneous or subglandular plane, seldom in the glandular layer

Develops in the glandular layer, not the fatty layer

Mammography

Typical cysts have an entirely radiolucent inside with a thin or thick high-density fibrous membrane; calcifi ations identifi d as benign

Clusters of pleomorphic microcalcifi ations

Sonography

Are seen as lumps in the subcutaneous or subglandular plane, seldom in the glandular layer; cysts have a hypoechoic inside and equal-echo outside

Seen in the glandular layer

845

846

Part VIII 

Plastic Surgery of the Breast

A

B

D

C

E

Fig. 54-8  A, In this patient, a mammogram 49 months after autologous fat transplantation showed multiple masses in the subglandular layer of her left breast. B, During surgical exploration, a cyst was found and removed completely. C, Histologic evaluation confi med the clinical fi dings and showed a collagen capsule. D, All cysts were removed from the left reast (positions shown). E, A mammogram 1 year after removal of the cysts showed no further calcifications. (From Zheng DN, Li QF, Lei H, Zheng SW, Xie YZ, Xu QH, Yun X, Pu LL. Autologous fat grafting to the breast for cosmetic enhancement: experience in 66 patients with long-term follow up. J Plast Reconstr Aesthet Surg 61:792-798, 2008.)

Patient Dissa tis f a ctio n With Aes the tic Res ul t s

Autologous fat grafting to the breast is a useful procedure for cosmetic enhancement in many patients who desire such a procedure. However, no standardized rating scales are available to evaluate outcome. Sometimes, because of graft resorption or necrosis, the clinical results are not satisfactory to the patient. Other complications affecting the aesthetic result include the formation of calcifi d and noncalcifi d masses. Before the operation, the surgeon must explain clearly what the patient can expect from the procedure and must not create unrealistic expectations. The patient should be advised that additional procedures may be required to achieve the desired breast contour.

K23345_Pu_c54 55_Br Aug Fat Graft_r4_cl_837-848.indd 846

4/6/2015 7:28:25 AM

Chapter 54 

Breast Augmentation With Conventional Fat Grafting

847

Pearls for Success • Consideration of high-risk patients and baseline mammography should guide patient selection for autologous fat augmention. • Sterile technique must be strictly followed. • Fat must be harvested at low negative pressure. • Fat grafts should be processed with low-speed centrifugation and injected into the recipient areas with low volume for each pass through multiple tunnels, multiple planes, and multiple points. • After surgery, the patient should wear a supportive surgical bra 24 hours a day for 7 days to reduce the relative movements between the gland and the pectoralis major muscle as much as possible.

Refer ences 1. Czerny V. Plastic replacement of the breast with a lipoma. Chir Kong Verhandl 2:21, 1895. 2. Illouz YG. Body contouring by lipolysis: a 5-year experience with over 3000 cases. Plast Reconstr Surg 72:591-597, 1983. 3. Bircoll M. Cosmetic breast augmentation utilizing autologous fat and liposuction techniques. Plast Reconstr Surg 79:267, 1987. 4. Zheng DN, Li QF, Lei H, Zheng SW, Xie YZ, Xu QH, Yun X, Pu LL. Autologous fat grafting to the breast for cosmetic enhancement: experience in 66 patients with long-term follow up. J Plast Reconstr Aesthet Surg 61:792-798, 2008. 5. Xie Y, Zheng D, Li Q, et al. The effect of centrifugation on viability of fat grafts: n evaluation with the glucose transport test. J Plast Reconstr Aesthet Surg 63:482-487, 2010. 6. Xie Y, Zheng DN, Li QF, Gu B, Liu K, Shen GX, Pu LL. An integrated fat grafting technique for cosmetic facial contouring. J Plast Reconstr Aesthet Surg 63:270-276, 2010. 7. Coleman SR, Saboeiro AP. Fat grafting to the breast revisited: safety and efficacy. Plast Reconstr Surg 119:775-785, 2007. 8. Piasecki JH, Gutowski KA, Lahvis GP, et al. An experimental model for improving fat graft iability and purity. Plast Reconstr Surg 119:1571-1583, 2007.

K23345_Pu_c54 55_Br Aug Fat Graft_r4_cl_837-848.indd 847

4/6/2015 7:28:25 AM

K23345_Pu_c54 55_Br Aug Fat Graft_r4_cl_837-848.indd 848

4/6/2015 7:28:25 AM

55 Breast Augmentation With Cell-Assisted Lipotransfer

A

Kotaro Yoshimura, Noriyuki Aoi, Yuko Asano

utologous fat transplantation is one of the promising procedures for soft issue augmentation or reconstruction and facial rejuvenation because of its minimal incisional scars and lack of complications associated with foreign materials. However, certain problems remain with autologous fat transplantation such as its unpredictability and its low rate of graft urvival because of partial necrosis. Implantation of prostheses has been the benchmark procedure for breast augmentation, but complications with artific al materials, such as capsular contracture and implant palpability, still need to be resolved. Recently, autologous fat injection has been reevaluated as a potential alternative to artific al implants for breast augmentation1; this development refl cts recent advances in the surgical techniques of autologous fat transfer and the radiologic detection of breast cancer. Adipose tissue has many types of cells other than adipocytes, which can be extracted as a cell pellet called stromal vascular fraction (SVF) through the collagenase digestion of aspirated adipose tissue (Fig. 55-1). SVF contains adipose stromal (progenitor) cells (ASCs), vascular endothelial cells, pericytes, adiposeresident macrophages, and so on.2 Now regarded as a potent tool for cell-based therapies, ASCs are comparable to bone marrow–derived mesenchymal stem cells, because they have comparable proliferation/ differentiation potential and can be obtained in a large amount through a less invasive approach. We have found that aspirated fat tissue contains only half the number of ASCs compared with intact fat tissue.3 Th s low ASC/adipocyte ratio may lead to long-term atrophy of transplanted adipose tissue, because ASCs in the graft contribute to adipose tissue regeneration after fat grafting by replacing old adipocytes with next-generation adipocytes.4 Thus we designed a novel strategy called cell-assisted lipotransfer (CAL), in which progenitor-poor adipose tissue was converted to progenitor-normal adipose tissue by supplementing SVF containing ASCs freshly isolated from the extra volume of lipoaspirate.3,5 In this chapter, we describe CAL in detail for cosmetic breast augmentation and other related procedures.

849

850

Plastic Surgery of the Breast

Granulocytes Monocytes Lymphocytes

CD34

Part VIII 

Liposuction

CD45

Collagenase digestion

Other cells CD31

Endothelial cells ASCs

SVF Liposuction aspirate

CD34

Fig. 55-1  From liposuction to isolation of adipose stem/progenitor cells, SVF can be obtained through collagenase digestion of the lipoaspirate. SVF contains many blood-derived cells (CD451) and adipose-derived cells (CD452). The adipose-derived cells (CD452) are further divided into CD311/CD341 endothelial cells, CD312/CD341 ASCs, and CD312/CD342 other cells. (CD, Cluster of differentiation.)

Indications Many factors affect the clinical result of lipoinjection into the breasts, including the following: • Skin redundancy of the breasts • Age • BMI • Quality of fat tissue • Adhesive scars • Breast implant and its capsule • Systemic disease such as autoimmune disease, oral corticosteroid, and smoking history Good candidates for lipoinjection have suffici t fat tissue at the donor sites and a redundant breast skin envelope, with healthy vascularity and no scars. For CAL, which needs additional adipose tissue for SVF isolation, additional donor tissue is required. Thus fat patients (with a BMI greater than 22) with redundant skin, such as women with ptotic breasts, are good candidates for this technique.

K23345_Pu_c55_Breast Aug with Cell_r4_cl_849-864.indd 850

4/3/2015 12:18:03 PM

Chapter 55 

851

Breast Augmentation With Cell-Assisted Lipotransfer

Lipoinjection can be performed in patients from their teens to their seventies, but patients with a low BMI (less than 19) are not good candidates because of the difficulty in harvesting a suffici t volume of fat tissue without producing severe morbidity. In thin patients who want to avoid aggressive liposuction of the donor site, conventional autologous fat grafting or mini-CAL can be performed. In mini-CAL, we do not obtain additional lipoaspirates, and only the waste fluid portion is processed for SVF isolation. In full-CAL, either the adipose portion or both the adipose and waste fluid portions are processed (Fig. 55-2). In thin patients with tight breast skin, implant augmentation with possible delayed replacement with fat grafting is another option (Fig. 55-3). The implants can be replaced with adipose tissue after 1 year if patients have fattier tissue, because the breast skin will be suffici tly expanded before implant removal. For these patients, using an oral contraceptive is frequently helpful to produce more adipose tissue and a feminine body contour.

CELL-ASSISTED LIPOTRANSFER (CAL)

Adipose

Conventional Centrifuged fat

Thin patients

Adipose

Centrifuged fat Mini-CAL SVF

Fatty patients

Adipose

Centrifuged fat

Full-CAL Adipose SVF

Fig. 55-2  Conventional lipoinjection and the two types of CAL. In conventional lipoinjection, the adipose portion (yel-

low) of the liposuction aspirate is centrifuged and used as injection material. In mini-CAL, the fluid portion (pink) of the liposuction aspirates is used to isolate SVF containing ASCs. In full-CAL, another volume of liposuction aspirates is additionally harvested for SVF isolation. Freshly isolated SVFs are used for the supplementation of ASCs to the graft materials.

852

Part VIII 

Implant

Plastic Surgery of the Breast

Skin

Fat

100-150 cc fat injection Expansion

150-200 cc implant

1 year later 250 cc fat injection

Expansion

Fig. 55-3  Breast augmentation for a thin Asian patient. A large volume (250 to 350 cc) cannot be injected into the breasts

of thin patients, because thin patients have less donor fat tissue available and a tight breast skin envelope. The skin is not easily expanded even by repeated fat grafting, although it can be easily expanded by implants or tissue expanders. Thus a reasonable strategy for thin patients is temporary placement of an implant, followed by replacement with fat grafting or a combination of both implant and fat grafting (see the Discussion section later in this chapter).

Patients who want a large-volume (250 to 400 cc) augmentation are not good candidates for lipoinjection, because augmentation volume achieved by a single session of lipoinjection is limited (100 to 200 cc). Some patients are concerned about complications derived from foreign bodies and about possible surgical removal or replacement of implants in the future. Others do not want their history of breast surgery to be recognized. These patients want to avoid breast implants and do not usually persist in requiring a particular size of breast augmentation; therefore they are good candidates for this procedure.

Preoperative Assessment Physical measurements (maximum and deepest-layer breast circumferences, and so on), mammogram, MRI, ultrasound echogram, photographs, and videography are performed as part of the preoperative evaluation (Table 55-1). We start injection with the deep layer just above the rib, into the muscle and between the muscle and the gland, and we fin sh with the subcutaneous layer. In addition, we adopted a threedimensional measurement system that enables a volumetric evaluation of the breast mound in a standing position6 (Fig. 55-4). Donor sites are usually the thighs alone or the thighs and the abdomen or flanks in Asian females; the specific s te is determined according to the patient’s preference and her BMI, although the abdomen and flanks may provide suffici t fat tissue in very fatty patients. Preoperatively, it is very important for the surgeon to accurately estimate how much fat tissue can safely be harvested from the donor sites and how much fat tissue can be maximally injected into each breast. From the estimated injection volume, the surgeon can plan the operative parameters such as how much fat tissue needs to be harvested, what areas should be used as the donor sites, which part and how much of the liposuction aspirates should be used for SVF isolation, and so on.

Chapter 55 

853

Breast Augmentation With Cell-Assisted Lipotransfer

Table 55-1  Schedule of Preoperative and Postoperative Patient Assessments Preoperative

1 mo

3 mo

6 mo

1 yr

2 yr

3 yr

4 yr

5 yr

Photographs/videos

3

3

3

3

3

3

3

3

3

Ultrasonography

3

3

3

3

3

3

3

3

3

3D-VM

3

3

3

3

3

3

3

3

Mammogram

3

3

3

3

3

3

3

MRI

3

3

3D-VM, Th ee-dimensional volume measurement.

Fig. 55-4  A three-dimensional system for measuring breast volume shows a quantitative analysis of volume change. Two cameras take photographs with striped light projected on the breasts. Software calculates the volume over the standard plane, which is defi ed by plotting three points. Thus the volume of the breasts that extends beyond the standard plane is calculated. Using this system, breast volume can be measured while the patient is in a standing position.

Surgical Technique Each key operative procedure—liposuction, storage, preparation, and injection—is rate limiting and should be optimized to produce the best possible clinical outcomes, and excellent preoperative and postoperative care are essential. Each procedure is not yet standardized, and new techniques and devices are being developed. Aspirated adipose tissue is not vascularized and is being damaged in the surgical fi ld; therefore harvested adipose tissue should be injected as quickly as possible after appropriate preparation.

Pr eo pera tive Man a gement

No specific patient preparation is needed preoperatively. For breast reconstruction patients with adhesive scars, an external negative-pressure device can be helpful to expand and soften the recipient tissue if the tissue has not been irradiated.

K23345_Pu_c55_Breast Aug with Cell_r4_cl_849-864.indd 853

4/3/2015 12:18:06 PM

854

Part VIII 

Plastic Surgery of the Breast

Lipos uctio n

After a general anesthetic is administered, the liposuction site is infiltrated with saline solution with epinephrine 0.001%. Adipose tissue is suctioned using a cannula with a 2 to 3 mm inner diameter and a conventional liposuction machine. After suction, 0.5% lidocaine (40 ml per thigh) is injected into the suctioned cavity for postoperative overnight sedation.

Stromal Vascular Fraction Isolation If some extra fat tissue is available, the lipoaspirate is used for SVF isolation, although only the infranatant watery fluid portion is used. The SVF isolated from the adipose portion (lipoaspirate) is called the processed lipoaspirate (PLA) cells, whereas the SVF from the fluid portion is called the liposuction aspirate fluid (LAF) cells2 (Fig. 55-5). PLA cells contain many more functional ASCs than LAF cells do. Either PLA cells alone or both PLA and LAF cells combined are used in full-CAL, although only LAF cells are used in mini-CAL for thin patients (see Fig. 55-2). For PLA cells, suctioned fat tissue is digested with 0.075% collagenase in phosphate buffered saline and centrifuged for 30 minutes at 37° C. After centrifugation at 800 g for 10 minutes, mature adipocytes and connective tissues (fl ating tissue) are discarded. The cell pellets are resuspended in Dulbecco’s modifi d Eagle’s medium and passed through a 100 mm mesh filter. To eliminate the remaining collagenase, the cells pellets are repeatedly washed with resuspension in Dulbecco’s modifi d Eagle’s medium and washed after centrifugation at least three times. The whole process takes approximately 80 minutes. For LAF cells, the suctioned fluid is centrifuged at 400 g for 10 minutes, and the pellets are resuspended in distilled water for 30 seconds for erythrocyte lysis, followed by osmic normalization by adding 10% volume of 103 phosphate-buffered saline or 9% NaCl solution. After centrifugation and filtration, cell pellets are obtained as SVF; the process takes approximately 20 minutes. For both PLA and LAF cells, cell counting for erythrocytes and nucleated cells is performed using a cell counter (hemocytometer) that is generally used for blood tests; the process takes approximately 1 minute. The normal viable nucleate PLA cell number is 300,000:1,000,000 per cubic centimeter of adipose tissue.

PLA cells (processed lipoaspirate cells)

LAF cells (liposuction aspirate fluid cells)

Fig. 55-5  The adipose and fluid portions of the liposuction aspirates. SVF can be isolated both from the fl ating adi-

pose portion (lipoaspirates) and the infranatant fluid portion, although the infranatant portion contains signifi antly fewer ASCs. PLA cells are the SVF obtained from the upper portion through collagenase digestion, whereas LAF cells are the SVF obtained from the lower fluid by means of hypotonic processing. PLA cells contain many more adipose tissue– derived cells such as ASCs and vascular endothelial cells, whereas LAF cells include all hemorrhagic tissue and thus many more leukocytes.

Chapter 55 

855

Breast Augmentation With Cell-Assisted Lipotransfer

Pr o cess ing and St ora ge of Graft Mater ial

Aspirated adipose tissue used for lipoinjection (graft material) is centrifuged for 3 minutes at 700 3 g. Because the centrifugation reduces the adipose volume by 25% to 35%, the volume reduction should be taken into account in tissue harvesting7 (Fig. 55-6). Centrifugal force can be calculated by the following formula: RCF (Relative centrifugal force [g]) 5 1118 3 (Centrifugal speed [rpm]) 2 3 (Radius [cm]) 3 10–8 For example, if the fat tissue is centrifuged at 1000 rpm in a centrifuge with a radius of 10 cm, the centrifugal force is 111.83 g. After centrifugation, the oil on the top and the infranatant fluid are discarded, and the graft materials are kept cool (4° C) until injection.

Lipoinjectio n

Before injection, the freshly isolated SVF was added to the centrifuged fat tissue by repeated decanting, followed by gentle mixing and incubation of 5 to 10 minutes to achieve appropriate cell adhesion to the centrifuged fat tissue (Fig. 55-7). A Luer-Lok syringe with a screw type of threaded plunger allows precise control and avoids the need for a flushing injection (Fig. 55-8).

Improve ASC/Adipocyte ratio Oil

Water

Before

After

Before

1200 g

Centrifugation

Fig. 55-6  The effects of centrifugation on aspirated adipose tissue. The adipose portion is condensed into 71% of the

original volume after centrifugation for 3 minutes at 1200 3 g. The volume of the fluid and oil portions increases by the centrifugation, but the number of ASCs contained in the adipose portion has not changed significantly. Thus centrifugation at 1200 3 g theoretically led to condensation of the number of cells per volume of adipocytes and ASCs by 25% and 43%, respectively, and improved the ASC (adipocyte ratio) by 14%.

856

Part VIII 

Plastic Surgery of the Breast

TIME COURSE OF SURGERY Operating room

Liposuction (right thigh)

Liposuction (left thigh)

Centrifugation (implant removal)

Lipoinjection

Isolated cells

Lipoaspirate Cellprocessing room

Collagenase digestion Cell isolation 1 hr

2 hr

3 hr

4 hr

Fig. 55-7  Time course for CAL surgery. The operation begins with the harvesting of fat tissue for the isolation of SVF cells. While the cell isolation process is performed in a cell-processing room, liposuction and centrifugation for graft material are performed in the operating room. After adding isolated SVF to the centrifuged fat tissue, the surgeon injects the mixture into the breast. The entire procedure takes approximately 31∕2 to 4 hours.

Fig. 55-8  A 20 cc screw injector with an original syringe. A high-pressure injection can be performed with a disposable syringe with a threaded plunger. A 150 mm 16- or 18-gauge needle is attached to the syringe with a connecting tube threaded at both ends. The injection needle is rigidly manipulated by an operator while an assistant rotates the plunger according to the operator’s instruction.

To reduce the procedure time, two syringes are used; while one syringe is being used, the other is filled with the graft material in preparation for the next injection. A 16- or 18-gauge sharp needle (150 mm long) is used for lipoinjection and inserted subcutaneously from the inframammary fold (IMF) or areolar margin. To avoid causing a pneumothorax, the surgeon takes care to insert and place the needle horizontally (parallel to the body). The needle is inserted in several layers and directions and is continuously and gradually retracted while the plunger is advanced (Fig. 55-9). Each pass of the injection is like inserting a 10 cm thin noodle with a volume of 1 cc. This technique is used to obtain a diffuse distribution of the graft material. The grafts are placed into the fatty layers on, around, and under the mammary glands (but not into the mammary glands), and also into the pectoralis muscles. After training, the surgeon should be able to recognize that the mammary gland or pectoralis fascia is a harder tissue than the fat or muscle tissue. The injection is discontinued when the skin tension becomes tense; the injection volume is usually 200 to 300 cc for each breast, depending on the redundancy of the skin envelope.

Chapter 55 

Breast Augmentation With Cell-Assisted Lipotransfer

For patients with implants, lipoinjection can be performed concomitant with implant removal.6 Breast implants are removed through a periareolar incision, which is placed at the caudal third of the areola margin. During the injection, the surgeon can insert his or her fi gers into the implant capsule to identify the location of the injection needle (see Fig. 55-9). Injection into the mammary glands or into the capsular cavity is not performed. Finally, the capsular cavity is irrigated with saline solution to remove any fat tissue injected, and then the periareolar incision is closed.

A

B

C

Fig. 55-9  Injection method for implant replacement. A, The needle is inserted either through a periareolar incision

or at one of several points on the IMF. The needle is aimed in various directions and into different planes to achieve a diffuse distribution. A small amount of fat tissue is injected as thin strings (1 cc fat corresponds to a 10 cm string) with a long needle; the tissue is injected while the needle is continuously withdrawn. B, Using a long needle attached to a syringe with a threaded plunger, the surgeon injects the fat tissue into layers other than the mammary gland and capsular cavity. C, To determine the location of the needle tip, the surgeon inserts his or her fi gers through a periareolar skin incision into the implant capsule while injecting the fat tissue.

857

858

Part VIII 

Plastic Surgery of the Breast

Postoperative Care After surgery, patients are instructed to wear a correctly sized bra at all times. Patients can take a shower on the next day, and the stitches are removed 1 week after surgery. Massage of the breasts is prohibited during the fi st 3 months, because immobilization of the grafts is critical for better graft take. Regular exercise is allowed at 1 month. Patients return for follow-up at 1 week, 1 month, 3 months, 6 months, 12 months, and annually up to 5 years. After surgery, an echogram can be performed at every visit and is sensitive enough to detect abnormalities such as small (2 mm in diameter) fat necrosis. For up to 5 years, an annual follow-up with a mammogram is recommended to detect abnormal signs, such as calcifi ations, because calcifi ations usually develop between 1 and 5 years.

Results Bruising is usually seen during the fi st 2 weeks in both the donor and the recipient sites. At 1 month, the breasts generally look very good with tight skin tension, but the breast size and the skin tension are gradually reduced until 3 months postoperatively. At 1 month any oil drops (necrotized fat) can be detected as hypoechoic round lesions by ultrasonography. Small oil drops (less than 5 mm) usually disappear by 12 months, whereas large ones (more than 10 mm) remain as oil cysts after reducing in size until 12 months. The cyst wall is formed by 12 months, and the size of the cyst does not change after 12 months, although the cyst wall gradually calcifies until 5 years. It is possible that the breast size changes until 12 months, because many of the small oil drops remaining at 3 months are absorbed between 3 and 12 months. Calcifi ations usually appear between 6 and 12 months and can further develop up to 4 years; however, most of the calcifi ations just look like small stones or sands and are easily discriminated by a radiologist. The clinical outcomes of our 550 breast patients have been satisfactory and appear to be superior to our patients treated with conventional fat grafting, although the fi al volume retention varies among patients from between 40% and 80% of the injected volume. It is recommended that more than 100 cc of adipose tissue be processed for isolating SVF in breast patients, although the ideal volume to process may be the same as the injected fat volume. Too much volume processing seems wasteful in thin patients; thus further investigation is needed.

K23345_Pu_c55_Breast Aug with Cell_r4_cl_849-864.indd 858

4/3/2015 12:18:08 PM

Chapter 55 

Breast Augmentation With Cell-Assisted Lipotransfer

Fig. 55-10 Th s 30-year-old woman underwent breast augmentation with full-CAL (310 cc in each breast) (Fig. 55‑10). Her breasts were dramatically augmented, with an increase in breast circumference of 8.0 cm at 24 months. The breast mounds were soft ith no subcutaneous indurations. The original IMF on the left reast is slightly visible, but injection scars are not visible.

859

860

Part VIII 

Plastic Surgery of the Breast

Fig. 55-11 Th s 34-year-old woman underwent breast augmentation with full-CAL (270 cc in each breast) (Fig. 55‑11). Her breasts were augmented well without any subcutaneous lumps or scars, and the look and feel of the breasts were natural at 12 months after surgery.

Chapter 55 

Breast Augmentation With Cell-Assisted Lipotransfer

Fig. 55-12 Th s 33-year-old woman underwent implant removal and breast augmentation with full-CAL (Fig. 55-12). The patient had 210 cc implants removed, and they were replaced with 260 cc of fat tissue, which was transplanted into the subcutaneous and muscular layers of each breast. Clinical views before surgery show capsular contracture and upward displacement of the left implant. Twelve months after surgery, the breasts had a natural and symmetrical appearance.

861

862

Part VIII 

Plastic Surgery of the Breast

Discussion Key Fa ct ors fo r the Pr epara tio n of Graft Mater ials

For the preparation of adipose grafts, here are two key influential factors for optimizing the graft etention rate. The fi st is to improve the viable cell number per volume. The needed components, such as viable adipocytes, ASCs, and other cellular components, need to be condensed, and the unneeded components, such as water, oil (ruptured dead adipocytes), and erythrocytes, need to be discarded. Th s is usually performed through gravity sedimentation, filtration (with or without vacuum), or centrifugation. Centrifugation concentrates the cellular components and separates the water and oil with varying degrees depending on the centrifugation force and time.7 The second influential factor is to improve the cellular quality of the graft. In other words, the progenitor (ASCs) or adipocyte ratio needs to be normalized. Aspirated adipose tissue is suggested to have a lower ratio than intact adipose tissue.3 In general, stem or progenitor cells and activating signals are crucial factors for tissue regeneration. In fat grafting, there are many signals to activate stem or progenitor cells, such as tissue injury or bleeding; however, dying adipocytes seem to be crucial signals to induce ASC differentiation into adipogenic lineage.8,9 If the adipose graft did ot contain enough stem or progenitor cells,3 the tissue regeneration would not be effici t. On the other hand, if only stem or progenitor cells are transplanted, stem cells would not be either activated or differentiated in the expected direction. The relative deficie cy of ASCs in aspirated fat tissue may lead to long-term atrophy of the grafts, nd supplementation of vascular stromal fraction containing ASCs may boost the efficacy and safety of lipoinjection into the breasts.3 Thus, if the number of stem cells is deficie t in the graft tissue, it would be reasonable to normalize stem cell density in the tissue by supplementing the stem or progenitor cells, as performed in the CAL strategy (see Fig. 55-3), or by reducing the adipocyte number. Centrifugation can relatively reduce the viable adipocyte number without losing ASCs7 (see Fig. 55-7).

Key Fa ct ors t o Optimize Fat Graft Sur viv al and Iss ues fo r Subs eq uent Fat Grafting

The surviving fat volume varies substantially among patients, and multiple factors likely affect the clinical results. Patient factors include skin redundancy of the breast, scarring (history of surgery and irradiation), and the availability of donor fat, and surgeons need to improve the quality of fat graft (such as their viability and progenitor richness) and infiltration techniques. Skin envelope redundancy can be achieved by preoperative skin expansion through the temporary placement of a breast implant or a tissue expander, or external expansion with the Brava. Scarring and ligamentous structures in the breast limit the skin elevation and contouring of the breasts. These structures can be partly released by the so-called Rigottomy, which entails subcutaneous multiple cutting with a sharp needle while suspending the skin with a hook. Irradiated tissue is ischemic and fibrous, but it has recently been reported that repeated fat injections can improve the tissue texture and vascularity as well as the quality of the overlying skin. The second fat injection can be performed between 4 and 6 months, although it is ideal to perform it after 1 year when the injection volume is large.

Man a gement of Complica tio ns

If injection was performed inappropriately, problems derived from fat necrosis—cyst formation, calcifi ation, and no augmentation effects—would be seen. Large fat necrosis (more than 8 mm) can form nodular cysts between 4 and 12 months. Cyst formation can be avoided only by careful and diffuse distribution of fat grafts, uch as making a thin noodle (0.1 cc/cm; 3.6 mm in diameter) of fat, although the injection method does not guarantee volume retention. Formed cysts are not easy to treat, and excision may be required if they are palpable through the skin.

Chapter 55 

Breast Augmentation With Cell-Assisted Lipotransfer

863

Small calcifi ations can occur 1 year after surgery and can continue to develop, although their features are distinguishable from those of malignant ones. To avoid inframammary calcifications, fat should not be injected into the mammary glands. Pneumothorax is possible as a result of mechanical damage to the pleura. Larger-volume liposuction could induce postoperative donor site problems, such as irregularity or seroma, especially in lean patients; therefore, with liposuction, patient selection and careful performance of procedures are important.

Combinatio n Pr o ced ur es With Impl ant s

If patients want very large breasts, a combination of fat grafting and implant augmentation is an option. Th s strategy is one of the standards for breast reconstruction after total mastectomy. For cosmetic breast augmentation, fat grafting over the mammary glands thickens the tissue coverage for a subglandular implant. Th s makes the breast contour and softness more natural and reduces the risk of implant-associated complications such as capsular contracture, sagging breasts, and rippling. Fat grafting over the mammary glands provides benefits for both the implant and the fat, and it is an attractive option for thin patients.

Pearls for Success • Thin patients with tight breast skin are not good candidates for breast augmentation with fat grafting; therefore implant augmentation with possible delayed replacement with fat grafting may be recommended. • Moderate augmentation (100 to 200 cc) of the breast is successfully achieved by CAL without major complications. • Preoperatively, it is very important to accurately estimate how much fat tissue can safely be harvested from the donor sites and how much fat tissue can be maximally injected into each breast. • Aspirated fat tissue should be appropriately harvested and stored, and quickly processed and infiltrated with proper devices to avoid degradation of the graft tissues and to place aliquots of fat grafts as diffusely as possible. • It is very helpful to use an echogram for postoperative follow-up. An echogram is easy to perform at every patient’s visit without any additional cost or ionizing irradiation, and it is sensitive enough to detect abnormalities such as small (2 mm in diameter) fat necrosis.

Refer ences 1. Coleman SR, Saboeiro AP. Fat grafting to the breast revisited: safety and efficacy. Plast Reconstr Surg 119:775-785; discussion 786-787, 2007. 2. Yoshimura K, Shigeura T, Matsumoto D, et al. Characterization of freshly isolated and cultured cells derived from the fatty and fluid portions of liposuction aspirates. J Cell Physiol 208:64-76, 2006. 3. Matsumoto D, Sato K, Gonda K, Takaki Y, Shigeura T, Sato T, Aiba-Kojima E, Iizuka F, Inoue K, Suga H, Yoshimura K. Cell-assisted lipotransfer: supportive use of human adipose-derived cells for soft tissue augmentation with lipoinjection. Tissue Eng 12:3375-3382, 2006. 4. Eto H, Kato H, Suga H, Aoi N, Doi K, Kuno S, Yoshimura K. The fate of adipocytes after nonvascularized fat grafting: evidence of early death and replacement of adipocytes. Plast Reconstr Surg 129:1081-1092, 2012. 5. Yoshimura K, Sato K, Aoi N, Kurita M, Hirohi T, Harii K. Cell-assisted lipotransfer for cosmetic breast augmentation: supportive use of adipose-derived stem/stromal cells. Aesthetic Plast Surg 32:48-55; discussion 56-57, 2008. 6. Yoshimura K, Asano Y, Aoi N, et al. Progenitor-enriched adipose tissue transplantation as rescue for breast implant complications. Breast J 16:169-175, 2010.

K23345_Pu_c55_Breast Aug with Cell_r4_cl_849-864.indd 863

4/3/2015 12:18:11 PM

864

Part VIII 

Plastic Surgery of the Breast

7. Kurita M, Matsumoto D, Shigeura T, Sato K, Gonda K, Harii K, Yoshimura K. Influences of centrifugation on cells and tissues in liposuction aspirates: optimized centrifugation for lipotransfer and cell isolation. Plast Reconstr Surg 121:1033-1041; discussion 1042-1043, 2008. 8. Yoshimura K, Suga H, Eto H. Adipose-derived stem/progenitor cells: roles in adipose tissue remodeling and potential use for soft tissue augmentation. Regen Med 4:265-273, 2009. 9. Yoshimura K, Eto H, Kato H, Doi K, Aoi N. In vivo manipulation of stem cells for adipose tissue repair/reconstruction. Regen Med 6(6 Suppl):33-41, 2011.

K23345_Pu_c55_Breast Aug with Cell_r4_cl_849-864.indd 864

4/3/2015 12:18:11 PM

56 Mastopexy

T

Mihye Choi, Emily C. Cleveland, David S. Kung, Lee L.Q. Pu

he   goal of mastopexy is to lift and reshape the breast. The nipple-areola complex (NAC) is repositioned and upper pole fullness is restored to create a more youthful and aesthetically pleasing appearance. Although often discussed in the context of reduction mammaplasty, mastopexy reshapes the breast without substantially changing breast volume. Th s is particularly true when ptosis is corrected in women with small to medium-sized breasts. Unlike reduction mammaplasty, mastopexy can be a purely cosmetic procedure. As such, scarring is less well tolerated. Periareolar or vertical techniques are preferred whenever possible, particularly in Asian women and others prone to hypertrophic or equally unacceptable scarring. In women who want an increase in their breast size, in addition to correction of minimal ptosis, augmentation alone or in conjunction with mastopexy can address both of these issues. In modern mastopexy, restoration of upper pole fullness with possible parenchymal rearrangement can be an essential part of the procedure, even without implant augmentation.

Anatomy and Pathophysiology In 1976 Regnault1 developed the most common grading system for breast ptosis (Fig. 56-1). In a breast with grade 1 ptosis, the NAC has dropped to the level of the inframammary fold (IMF). In a breast with grade 2 ptosis, the NAC falls below the IMF. In grade 3 or severe ptosis, the NAC is the most dependent aspect of the breast. Pseudoptosis occurs when glandular tissue of the inferior pole of the breast falls below the level of the IMF, creating the illusion of ptosis despite the NAC remaining in a normal position (above the IMF). The shape of the breast parenchyma is defi ed by a ligamentous sling that emerges from the thoracic wall as a condensation of Cooper’s ligaments. Ptosis occurs as these ligaments lose their strength, allowing the breast to drop and flatten. Although some degree of breast ptosis occurs with normal aging, multiparity, signifi ant weight loss, and smoking predispose women to developing more signifi ant ptosis.2 Successful mastopexy repositions the NAC to an aesthetically correct position above the IMF and restores upper pole fullness.

865

866

Part VIII 

Fig. 56-1  Regnault’s classifi ation for three grades of ptosis.

Plastic Surgery of the Breast

Minimal ptosis

Moderate ptosis Severe ptosis

Breast anatomy has been well described previously.3 The arterial supply to the breast and subdermal NAC is provided by vessels off of the lateral thoracic, thoracoacromial, internal thoracic, and anterior intercostal arteries. Preservation of adequate vascularity is essential in any procedure that repositions the nipple. Any of these four blood supplies can provide suffici t infl w to safely transpose the NAC, allowing the surgeon to choose between a lateral, superior, medial, or inferior pedicle. However, because mastopexy requires little or no parenchymal resection, it is not always necessary to develop a true dermoglandular pedicle under the NAC. Nevertheless, familiarity with these vascular pedicles is necessary when performing mastopexy techniques that rely on reshaping the breast by means of parenchymal pillars.

Indication and Selection of a Procedure Per iar eo l ar Ma st opex y

Women with minor skin redundancy and mild ptosis often achieve excellent results with periareolar mastopexy. Periareolar mastopexy is a useful technique when the nipple needs to be elevated less than 2 to 3 cm (Fig. 56-2). The main advantage of this technique is scar location, which can be well hidden around the areola. Th s technique tends to flatten the breast anteriorly from a more conical breast shape and can also cause skin pleating around the incision. Benelli’s “round block” technique can improve breast projection. However, if too much skin is resected through this technique, the areola will stretch, even if a permanent periareolar suture is placed. Most patients who qualify for this technique want augmentation, which can also correct pseudoptosis but may avoid a mastopexy.

Ver tical Ma st opex y

Vertical mastopexy is often preferred for women with moderate ptosis and moderate-sized breasts (Fig. 56-3). The real advantage of this technique is the ability to move and shape breast parenchyma. Vertical mastopexy allows the surgeon to narrow the breast diameter and increase the projection. Medial, lateral, or superior pedicles can be incorporated with this incision for a more extensive mastopexy procedure; the specific technique depends on the degree of ptosis and the absolute distance the NAC must be elevated. We prefer the superior pedicle technique when the NAC needs elevation of only 3 to 4 cm, and we use the Hall-Findlay medial pedicle technique4 if the NAC needs more substantial elevation.

Chapter 56 

Mastopexy

Inver ted-T Ma st opex y

For the rare Asian woman with severe ptosis or for a patient with extremely poor skin quality especially from massive weight loss, inverted-T incisions may be required (Fig. 56-4). Th s is a relatively easier technique for reducing and reshaping the breast if the patient is willing to accept the scars. The advantage is the ease of the technique and the ability to lift and shape signifi antly ptotic breasts. In patients with a long sternal notch-to-nipple distance (greater than 30 cm) and a short nipple-to-IMF distance, we prefer to use an inferior pedicle. Th s allows a shorter pedicle length and better venous drainage. In most patients who require inverted-T incisions, we prefer to use a medial pedicle, as described later. The pedicle is extremely reliable and easily dissected, and thus the operation can be completed safely and effici tly.

Fig. 56-2  A typical candidate for a periareolar mastopexy.

Fig. 56-3  A typical candidate for a vertical mastopexy.

Fig. 56-4  A typical candidate for an inverted-T mastopexy.

867

868

Part VIII 

Plastic Surgery of the Breast

Fig. 56-5  A typical candidate for a no vertical scar mastopexy.

No Ver tical Scar Ma st opex y

Another option for Asian women with moderate to severe ptosis who want less scarring is the no vertical scar mastopexy (Fig. 56-5). Th s procedure can be used to reduce and reshape the breast as an inverted-T mastopexy without the vertical scar. For a patient with grade 2 or 3 breast ptosis without excessive base width, this technique produces excellent results with less scarring than with the inverted-T mastopexy. The technique uses a superiorly based skin flap overlying a medial, lateral, inferior, or superior NAC pedicle. There is much flex bility in pedicle positioning and shaping. Natural, rounded breasts can also be formed with lateral subcutaneous tissue recontouring, which avoids the boxy appearance that can be inherent in this technique. Although this technique is ideal for larger, more pendulous breasts, smaller breasts can also be lifted. The one caveat is that the patient must be comfortable with leaving some areolar tissue in the IMF as a trade-off for avoiding the vertical scar. Many Asian women prefer this minimal scar technique, because it can deliver a mastopexy with minimal visible scars in the frontal view.

Preoperative Assessment To determine the ideal procedure to correct the ptosis, the surgeon must have an in-depth conversation with the patient regarding her goals and concerns, along with a careful physical examination. Any personal and/or family history of breast diseases and recent mammogram results are essential to discuss and document. Bra size, childbirths, and breast-feeding history are documented. In general, the degree of ptosis and the patient’s desire for any change in breast volume dictate the indicated procedure. Parenchymal ptosis, nipple-areola position, breast volume, skin elasticity, and any asymmetries must be examined and addressed in the formulation of the surgical plan. Any previous scars and chest wall deformity need careful examination. Tuberous breasts or asymmetry must be measured and incorporated into the surgical planning. A patient with spinal scoliosis with signifi ant breast asymmetry will need mastopexy with two different techniques. Other concerns include the patient’s inherent scar-forming tendencies and comorbidities that may compromise postoperative outcomes, particularly smoking. We require any woman who smokes to stop smoking at least 4 weeks before surgery, and she is strongly encouraged to abstain for a minimum of 4 weeks after surgery to avoid wound healing complications. Most Asian women seeking mastopexy have smaller breasts with mild to moderate ptosis. The rates of hypertrophic scarring and keloid formation are higher in this population than in whites, which further underscore the need to minimize the length of the incisions and to plan carefully to ensure that scars are as hidden as possible. In addition to scarring, the surgeon must discuss and inform patients regarding the potential loss or alteration in nipple sensation, the inability or difficulty to breast-feed, postoperative asymmetry, recurrent ptosis, and potential nipple necrosis.

Chapter 56 

869

Mastopexy

Surgical Technique Per iar eo l ar Ma st opex y Markings

The patient is marked in the standing position. It is crucial to pay careful attention to preoperative marking, particularly in women who tend to have poor scarring. The midline is marked fi st, followed by the breast meridians. These are drawn along the volumetric center of each breast, starting from a point on the clavicle 5 to 6 cm lateral to the midline. In many women this line travels through the NAC. However, it may fall medial or lateral to the nipple if the ptotic breast has drifted laterally or medially. Next, the new nipple position is marked by placing the index fi ger at the IMF and the thumb over the breast mound. A point 2 cm above the new nipple position is marked for the new superior areolar border, and the skin for excision is marked next as an eccentric ellipse that includes both the original NAC and the new nipple position. Th s outside diameter should not exceed 7 to 8 cm to prevent flattening of the breast parenchyma resulting from the overresection of skin. The new superior border of the NAC should not be more than 2 cm superior to its preoperative location (Fig. 56-6, A). In general, the ratio of the outside diameter of the skin resection to the inside diameter (areolar border) should not exceed 2:1.5

Technique The patient is placed in the supine position on the operating table with the arms abducted. The arms are secured with a Kerlix gauze wrapping to ensure that they do not fall when the table is fle ed intraoperatively to place the patient in an upright sitting position. General anesthesia is induced either with a laryngeal mask airway or an endotracheal tube. The skin is prepared from the neck to the umbilicus with chlorhexidine, and the planned incisions are then injected with 40 ml of a solution containing equal parts of 1% lidocaine and injectable normal saline solution, which is mixed with epinephrine diluted to 1:200,000. Care is taken not to infiltrate the parenchyma underlying the NAC, which may compromise the surgeon’s ability to assess nipple viability intraoperatively. The skin is then prepared again with a second chlorhexidine preparation stick, and the patient is draped, leaving the breasts, clavicles, axillas, and epigastric area exposed. Gentle circumferential pressure is used to put the areola under tension, and the periareolar incision is marked with a 38 to 45 mm cookie cutter, depending on the desired diameter of the areola. The surgeon should err on the side of placing the periareolar incision just within the areola rather than allowing it to fall even a fraction of a millimeter beyond the border. Th s is particularly important for patients with darkly pigmented areolas. If any of the surrounding lighter skin is incorporated into the NAC and transposed, a “double-ring” scar can result, effectively highlighting rather than hiding the periareolar scar.

A

Fig. 56-6  A, Pattern for periareolar mastopexy.

Continued

870

Part VIII 

B

Plastic Surgery of the Breast

C

12

9

3

6

Fig. 56-6, cont’d  B, The extent of surgical dissection. C, A round clock technique for periareolar closure.

An incision is made along the periareolar and elliptical circumareolar lines, and the intervening skin is deepithelialized. The deepithelialized dermis is incised to create a sewing edge to oppose to the areolar border (Fig. 56-6, B). To close, a 3-0 purse-string Gore-Tex or 3-0 Mersilene suture is run along the circumference of the outside ellipse in the deep dermis; this is then tightened to bring this skin in to meet the edge of the areolar border (Fig. 56-6, C). A cookie cutter can facilitate this process, making the outer circumference match the areola circumference. The skin is closed with interrupted 3-0 Vicryl sutures followed by a running 4-0 Monocryl subcuticular suture.

Ver tical Ma st opex y Markings

The patient is marked in the upright position. First, the midline is identified with a line from the suprasternal notch to the xiphoid. The breast meridian is then drawn from a point on the clavicle 5 to 6 cm lateral to the midline, extending down to the NAC. Th s is transposed down onto the chest wall, and the preoperative IMF is also marked. The new nipple position is identifi d by transposing the level of the IMF anteriorly onto the meridian line on each breast. The sternal notch-to-nipple distance is confi med to be symmetrical and is adjusted as needed. The design of the circumareolar incision depends on the preoperative location and size of the patient’s NAC. It can be designed to elevate the nipple, reduce areolar size, or both.6 In most patients the upper border of the circumareolar incision, which becomes the nipple-areolar position, should be marked approximately 2 cm above the new nipple position on the breast meridian. To mark the medial and lateral limbs, the breast is gently displaced laterally and medially. Two vertical lines are drawn in the lower pole of the breast lining up with the breast meridian line drawn on the chest wall. Gently curving lines are then drawn from the medial and lateral limbs, bringing them to meet inferiorly approximately 1 to 3 cm above the preoperative IMF (Fig. 56-7, A). These vertical limbs should not extend beyond 1 to 3 cm above the preoperative IMF, because the new IMF will fall 1 to 3 cm above the old IMF depending on the degree of elevation needed for the breast mound. Postoperatively the IMF rises; if the vertical scar is extended down to the preoperative IMF, it will ultimately end up on the chest wall. A gentle dome is drawn around the new nipple position starting from the nipple-areolar border and connecting with the medial and lateral limbs.

Chapter 56 

871

Mastopexy

A

B

C

Fig. 56-7  A, Pattern for a vertical mastopexy. B, Intraoperative markings for vertical mastopexy. C, Note the excess tissue in the bottom portion of the vertical closure.

Technique The patient is positioned, anesthesia is induced, the skin is prepared, and the incision is injected as previously described. The surgeon must be careful to avoid injecting the parenchyma that will form the NAC pedicle. The skin is prepared again, and the patient is draped in the standard fashion. The periareolar incision is marked with a 42 mm cookie cutter while the NAC is held in gentle stretch (Fig. 56-7, B). Frequently the excess tissue at the bottom of the vertical incision must be properly managed to achieve an optimal contour (Fig. 56-7, C). Techniques for the use of the skin-only and medial pedicle procedures will be described, because they are the ones we most commonly use. Skin-Only Reshaping Technique  Once the new nipple position and the skin marking of a vertical pattern are decided, the NAC is outlined with a cookie cutter. Incisions are made along the periareolar circle and the marked circumvertical incision. The skin within the vertical pattern is deepithelialized and the breast skin elevated accordingly along the circumvertical incision for a tension-free closure. The proposed NAC skin circle is approximated with a 3-0 PDS suture, and the NAC is then moved to the new location and approximated with a 3-0 Monocryl suture in an interrupted fashion for deep dermal closure. New vertical closure is initially approximated with skin staples and then closed with interrupted 3-0 PDS sutures for deep dermal closure. The NAC skin closure is then performed with a 5-0 chromic suture in a simple running fashion. The vertical skin closure is performed with a 4-0 Monocryl suture in running subcuticular fashion. The excess tissue in the lower pole of the breast, if any, can be marked and defatted first with scissors. Th s is followed by placement of a 3-0 Monocryl purse string suture to evenly fold the excess skin together.

872

Part VIII 

Plastic Surgery of the Breast

Medial Pedicle  For women who require a more extensive lift, a medial NAC pedicle is used, as described by Hall-Findlay.7 Th s is marked as a 6 to 7 cm wide pedicle with half of its base falling in the areolar opening and the other half underlying the vertical limb of the medial skin incision. Th s allows the pedicle to rotate superiorly during inset of the NAC into its new position. Periareolar and circumvertical incisions are made, and the intervening skin is deepithelialized. The pedicle is then divided from the surrounding breast parenchyma and carried down to the pectoral fascia. Care is taken to dissect along the pectoral fascia only as far medially as necessary to allow easy rotation of the NAC while still preserving sensory nerves entering the breast medially through the pectoralis muscle. The pedicle is then rotated up into the new position and tacked in place to secure the new areolar position. Care is taken to thin the inferior flaps to minimize the need for horizontal excision. The lateral border of the pedicle becomes the medial pillar; this is closed to the lateral pillar, which is drawn medially, thereby narrowing the breast base. The skin is redraped and closed with staples, symmetry is confi med and adjusted with the patient sitting, and skin closure proceeds as previously described.

Inver ted-T Ma st opex y Markings

Incisions for an inverted-T mastopexy are similar to those described by McKissock8 for a reduction mammaplasty. The patient is marked in the upright position, identifying the midline and breast meridians, as described previously. The meridian is transposed and extended down onto the chest wall on each side, and the preoperative IMF is marked. The new nipple position is identifi d on the meridian at or just above the level of the IMF depending on the patient’s anatomy and goals of surgery. A keyhole incision is then designed around the new nipple location, which is centered along the meridian line. The angle of divergence for the vertical limbs varies from 45 to 90 degrees depending on the size of the breast, degree of ptosis, and amount of skin laxity. The larger the breast and greater the skin laxity, the wider the angle will need to be (Fig. 56-8, A). The vertical limbs should be 7 cm long for most patients, but longer limbs may be needed in patients who want larger breast sizes (cup size D or above). The vertical limbs and their medial and lateral extensions are confi med and adjusted as needed after the patient is supine on the operating table. The inferior incision is also drawn with the patient on the table.

Technique The patient is positioned, prepared, and draped as previously described. Again, care is taken not to infiltrate the planned pedicle with the solution of local anesthetic and epinephrine. After the vertical limbs and their medial and lateral extensions are confi med, the inferior incision is marked. Postoperatively the IMF will rise; therefore this lower incision should be placed on the breast mound 1 to 2 cm above the preoperative IMF. In addition, we often create a small inverted V at the meridian on the inferior incision to minimize tension at this point. The chosen pedicle is drawn on the skin, and the periareolar incision is marked as previously described. Again, care should be taken to ensure that this incision falls just within the more darkly pigmented areola, so that no lighter skin is incorporated into the transposed NAC. An incision is made around the areola and keyhole incisions, and the skin overlying the pedicle is deepithelialized. The pedicle is then divided from the remaining breast parenchyma down to the pectoral fascia.

Chapter 56 

Mastopexy

A

New nipple position

B

Fig. 56-8  A, Pattern for an inverted-T mastopexy. B, An inverted-T mastopexy after closure.

The use of a medial pedicle can be combined with autologous augmentation. To accomplish this, the surgeon should dissect an inferior parenchymal pillar at least 5 cm in width. Th s parenchyma can then be transposed superiorly and tacked to the pectoral fascia. The NAC pedicle is then draped over this parenchyma and tacked in place. The keyhole areolar incision is secured to the periareolar dermis at four points around its circumference. The medial and lateral pillars are closed over the inferior pillar and secured in place, creating a parenchymal sling for the NAC pedicle. The skin is then redraped over the newly projecting breast mound. We prefer to use skin staples to close from outside toward the central T point to avoid a dog-ear formation; excess skin can then be safely resected as needed. The patient is repositioned into an upright sitting position to evaluate symmetry, as described previously. The skin is closed with 3-0 Vicryl dermal sutures and a running 3-0 Monocryl subcuticular suture. A 4-0 Monocryl suture is used around the areola (Fig. 56-8, B).

No Ver tical Scar Ma st opex y Markings

In essence, a no vertical scar mastopexy is an inverted-T mastopexy without the vertical scar (Fig. 56-9, A). The patient is marked in the upright position, identifying the midline and breast meridians as previously described. The preoperative IMF is marked as the meridian is extended onto the chest wall bilaterally. The new nipple position is identifi d on the meridian at or just above the level of the IMF. Alternatively, the new nipple-areolar position can be determined by a set distance from the sternal notch, ranging from 19 to 21 cm. The inferior incision is demarcated 5 to 6 cm below the new nipple-areolar position, sweeping superiorly in its medial and lateral extent.

873

874

Part VIII 

A

Plastic Surgery of the Breast

B

2.5-3 cm 5-6 cm

4-5 cm

Fig. 56-9  A, Pattern for a no vertical scar mastopexy. B, The intraoperative plan for surgical resection.

Technique The patient is positioned, prepared, and draped, as previously described. Again, one must avoid infiltrating the planned pedicle with the solution of local anesthetic and epinephrine, although tumescent solution is helpful for hemostasis. The chosen pedicle is drawn on the skin, and the periareolar incision is marked with a circular stent. The areola is then incised, and the skin overlying the pedicle is deepithelialized (Fig. 56-9, B). The pedicle is then divided from the remaining breast parenchyma down to the pectoral fascia. Th s parenchyma can then be shaped, transposed, and tacked to the pectoral fascia. The NAC pedicle is then draped over this parenchyma and tacked in place. A superiorly based skin flap 1 to 2 cm in thickness is developed and redraped over the newly projecting breast mound. The inframammary incision is closed in a layered fashion with deep and subcuticular 3-0 Monocryl sutures. The patient is repositioned into an upright sitting position to evaluate symmetry and nipple-areolar position, as described previously. The native NAC is then transposed to the flap surface with 3-0 and 4-0 Monocryl sutures.

Results The clinical outcomes in patients undergoing mastopexy who have had the appropriate preoperative evaluation and detailed operative planning have been excellent. In fact, these patients are often some of the most satisfi d clients who walk through a plastic surgeon’s offic door. Although the scar can occasionally be an issue, most patients are happy about the new shape of their breasts, and the scar can also be minimized with several methods. In some patients, minor revisions, especially for a widened periareolar scar, may be needed to improve the outcome.

Chapter 56 

Mastopexy

875

Per iar eo l ar Ma st opex y

Fig. 56-10 This 27-year-old Asian patient with grade 1 ptosis and minimal upper pole fullness with breast involution wanted to lift er breasts. She wanted no vertical scar after her mastopexy. She underwent a periareolar concentric mastopexy. A Gore-Tex suture was used to control the areolar circle and prevent spreading. At 10-month follow-up, she had symmetrical breasts with improved shape and contour match.

K23345_Pu_c56_Mastopexy_r3_cl_865-880.indd 875

4/3/2015 12:23:25 PM

876

Part VIII 

Plastic Surgery of the Breast

Ver tical Ma st opex y

Fig. 56-11 Th s 40-year-old Asian patient with grade 2 ptosis and minimal upper pole fullness wanted to improve the shape of her breasts. She underwent bilateral vertical mastopexy with the skin-only reshaping technique. Only the excess skin was removed from each side of the breasts. She did well after surgery and did not have any problems. All of her incisions healed primarily. At 4-month follow-up, a pleasing breast shape was achieved and well maintained. Scarring after vertical mastopexy was not an issue for this patient.

K23345_Pu_c56_Mastopexy_r3_cl_865-880.indd 876

4/3/2015 12:23:26 PM

Chapter 56 

Mastopexy

877

Inver ted-T Ma st opex y

Fig. 56-12 Th s 49-year-old Asian patient with grade 3 ptosis associated with pendulous breasts wanted to have her breasts lifted. She also wanted abdominal recontouring. She underwent an inverted-T mastopexy with a concurrent abdominoplasty. Fifteen months after surgery, she is extremely pleased with the elevation and shape of her breasts.

K23345_Pu_c56_Mastopexy_r3_cl_865-880.indd 877

4/3/2015 12:23:28 PM

878

Part VIII 

Plastic Surgery of the Breast

No Ver tical Scar Ma st opex y

Fig. 56-13 This 33-year-old Asian patient with grade 2 ptosis and minimal upper pole fullness wanted to improve the shape of her breasts and areolas. She underwent bilateral no vertical scar mastopexy with skin and parenchymal reshaping. Her postoperative course was uneventful. All incisions healed well. At 6-month followup, she had a pleasing shape of the breast mound and areolas with minimal scarring.

K23345_Pu_c56_Mastopexy_r3_cl_865-880.indd 878

4/3/2015 12:23:30 PM

Chapter 56 

Mastopexy

Discussion During the past 50 years, mastopexy has evolved from skin-only resections to the addition of parenchymal remodeling. There have been signifi ant improvements in both aesthetic outcomes and durable correction of ptosis. Several postoperative considerations merit further discussion, because they can pose challenges for plastic surgeons and their patients.

Ches t Wall Ir r egul ar ities and Asymmetr y

It is crucial to pay careful attention to preoperative asymmetries to ensure the ultimate success of the mastopexy. Many women have slight discrepancies in breast volume, the degree of ptosis, and the positioning of their IMFs and NACs. Often patients are unaware of these differences; however, most women will be substantially more perceptive and thus more critical of asymmetries after surgery. All of these differences must be considered when patients are marked preoperatively and on the operating room table. Care should be taken not to extend the incisions either too close to the IMF or too near the midline to avoid postoperative scarring in unacceptable areas. Rather than extending the incisions to correct dog-ear deformities, the corners can be modestly defatted subdermally to reduce contour irregularities. Sitting the patient upright intraoperatively is the key to ensuring that the breasts appear symmetrical when the effects of gravity alter the positioning of breast parenchyma on the chest wall. A symmetrical NAC position relative to the sternal notch and midline should be confi med before fi al inset. Th s can easily be accomplished with a length of suture with a clamp on either end. In some patients postoperative asymmetries may require operative revisions. However, most revisions can be avoided with careful preoperative planning and intraoperative correction.

Scar r ing

The use of silicone sheeting or gel is routinely recommended to patients, because these decrease hypertrophic scarring in Asian patients.9 If the patient experiences undesirable scar formation, a dilute solution of triamcinolone (5 mg/ml) can be injected intradermally as early as the fourth postoperative week. Steroid injections can be repeated every 3 months if the scarring persists or does not suffici tly improve. In our experience, little improvement is seen after more than three injections. However, the steroid concentration can be increased to as much as 20 mg/ml if the response to the initial injection is poor. Th s is in contrast to white patients, in whom high-dose injections often result in dermal thinning and depigmentation. The recalcitrant hypertrophic scar may require more than three injections.

Recur r ent Pt os is

After mastopexy there is an inevitable settling of the breast parenchyma as postoperative healing occurs. A certain degree of relaxation of both the skin envelope and underlying parenchyma must be expected and planned for in the weeks after surgery. Care must be taken during preoperative planning and marking not to reposition the NAC into too superior a position, because postoperative settling of the parenchyma can result in high-riding nipples. Bottoming out of the breast mound can be mitigated by both autologous augmentation of the superior pole as previously described and by tacking the repositioned breast tissue to the underlying pectoral fascia. A supportive bra should be worn at all times for 4 weeks after surgery to help maintain the desired breast shape and projection. Modest overcorrection of ptosis during mastopexy procedures can minimize postoperative bottoming out. However, all patients must be counseled before surgery that breast ptosis will inevitably recur to some degree as the patient ages in the years after mastopexy.

879

880

Part VIII 

Plastic Surgery of the Breast

Pearls for Success • The periareolar incision must lie within the dark areolar border to avoid the creation of a doublering scar. • The patient should be positioned upright before the surgery is completed to assess volume, shape, symmetry, and NAC position. • The stent used to mark the native NAC should be larger than the one used to mark the new NAC position. • In the periareolar technique, a permanent suture is used for the periareolar purse-string closure. • In the vertical technique, the excess tissue in the lower pole is defatted to minimize dog-ear formation and to improve the breast shape. • In the inverted-T technique, the surgeon uses an inverted-V closure for the three-point suture to minimize tension and skin loss. • In the no vertical scar technique, lateral pole debulking of the breasts can often improve breast shape.

Refer ences 1. Regnault P. Breast ptosis: defin tion and treatment. Clin Plast Surg 3:193-203, 1976. 2. Rinker B, Veneracion M, Walsh CP. Breast ptosis: causes and cure. Ann Plast Surg 64:579-584, 2010. 3. Skandalakis JE. Embryology and anatomy of the breast. In Shifman MA, ed. Breast Augmentation: Principles and Practice. Heidelberg: Springer-Verlag, 2009. 4. Hall-Findlay EJ. Pedicles in vertical breast reduction and mastopexy. Clin Plast Surg 29:379-391, 2002. 5. Spear SL, Giese SY, Ducic I. Concentric mastopexy revisited. Plast Reconstr Surg 107:1294-1299; discussion 1300, 2001. 6. Hidalgo DA, Spector JA. Mastopexy. Plast Reconstr Surg 132:642e-656e, 2013. 7. Hall-Findlay EJ. Vertical breast reduction using the superomedial pedicle. In Spear SL, ed. Surgery of the Breast: Principles and Art, vol 2, ed 2. Philadelphia: Lippincott-Raven, 2006. 8. McKissock PK. Reduction mammoplasty. Ann Plast Surg 2:321-331, 1979. 9. Kim S, Choi TH, Liu W, et al. Update on scar management: guidelines for treating Asian patients. Plast Reconstr Surg 132:1580-1589, 2013.

K23345_Pu_c56_Mastopexy_r3_cl_865-880.indd 880

4/3/2015 12:23:30 PM

57 Medial Pedicle Breast Reduction

B

Lee L.Q. Pu, Jeng-Yee Lin

reast reduction surgery can be performed for either functional or cosmetic reasons. Besides several functional improvements for back, neck, and shoulder pain and to eliminate skin rashes under the breast, four primary goals to achieve optimal size, shape, symmetry, and scarring should be applied to each type of breast reduction. The size of the breasts after breast reduction should be in proportion to the patient’s body habit. The shape after breast reduction should be cosmetically pleasing and long lasting. Although exact symmetry may be hard to achieve, most women desire more symmetrical breasts after reduction. It is also quite desirable to have minimal scarring after any type of breast reduction. Asian women are particularly conscious of whether scars will be visible on their breasts. The classic inverted-T inferior pedicle technique is still the most commonly performed breast reduction procedure for women worldwide. However, there are a number of long-term sequelae associated with this type of breast reduction, such as an unsightly scar and the potential for bottoming-out of the breast. Therefore plastic surgeons have made great efforts to develop a better breast reduction technique to improve overall long-term outcome after breast reduction with less visible scars for women with macromastia. Vertical breast reduction was advocated by Lejour1; the procedure has been popularized by Hall-Findlay.2,3 However, the medial pedicle vertical breast reduction has been criticized by many plastic surgeons, especially in North America, for its inconsistent cosmetic outcome and higher revision rate.4-7 In addition, the learning curve for medial pedicle vertical breast reduction appears to be longer, because many intraoperative adjustments must be done by the surgeon to produce a cosmetically acceptable fi al result. Since most Asian women have relatively smaller breasts with less stretched skin than Western women, the medial pedicle vertical breast reduction can be the procedure of choice for this unique group of patients. In this chapter, we introduce our preferred technique for medial pedicle vertical breast reduction, emphasizing patient selection and several technical refi ements.

Anatomy The breast is an ectodermal structure contained in a superfic al fascial system. It is formed by approximately 20 to 25 individual lobules that connect to the nipple. The blood supply comes in from several directions. The main blood supply to the breast is based on medial branches of the internal mammary artery. These branches supply the medially based pedicle. The medial pedicle receives its blood supply from the

881

882

Part VIII 

Plastic Surgery of the Breast

Fig. 57-1  The blood supply to the medial pedicle.

perforators of the internal mammary vessels. These perforators in general provide a robust blood supply to the pedicle, so necrosis of the nipple-areola complex is rare after breast reduction, as long as an adequate pedicle width is maintained (Fig. 57-1). In addition, the lower medial branch of the internal mammary artery penetrates the pectoralis fascia just about 2 to 4 cm above the inframammary fold (IMF) in the breast meridian. Th s vessel can supply an inferiorly or centrally based pedicle. The higher medial branch of the internal mammary artery runs superfic al to the breast on either side of the breast meridian. It can supply the superiorly based pedicle. Laterally, the breast receives its blood supply from the branches of the lateral thoracic artery, which also enter the breast superfic ally and may supply a laterally based pedicle. The veins of the breast rarely accompany the arteries. Much of the breast is drained by a superfic al venous system that lies just under the dermis. Because Asians typically have a thicker dermal layer, these veins can appear less conspicuous in Asian women. Innervation of the breast is based on the medial and lateral branches of the second to sixth intercostal nerves. These branches enter the breast superiorly through the pectoralis major muscle. The nipple is primarily innervated by the medial and lateral branches of the fourth intercostal nerve. However, the third and fi h intercostal nerves contribute as well.8

Indications and Patient Selection As in any other plastic surgical procedure, patient selection is critical to the success of the medial pedicle vertical breast reduction. Th s procedure is not indicated for all patients9; in general, younger women with good breast skin quality (no stretch marks) and reasonably round breast shape are good candidates for this type of breast reduction (Fig. 57-2). The overall amount of breast tissue reduction may not be the critical issue, although the average weight of this type of breast reduction is usually between 300 and 500 g. The distance between the nipples to the IMF of the breast should be less than 10 cm for such a breast reduction to be successful. Box 57-1summarizes the general indications for the medial pedicle vertical breast reduction.

Chapter 57 

Medial Pedicle Breast Reduction

Fig. 57-2  Th s Asian woman is a good candidate for a medial pedicle vertical breast reduction. In general, patients should be relatively young with good breast skin quality and a reasonably rounded breast shape.

Box 57-1  Good Candidates for Medial Pedicle Breast Reduction • Younger, healthy women (less than 35 years old) • Good breast skin quality (no stretch marks) • Reasonably round breast shape (no grade 3 ptosis) • Moderate-sized breast reduction (less than 500 g) • Relatively short distance from nipple to IMF (less than 10 cm)

Preoperative Assessment and Special Considerations Unlike the classic inverted-T inferior pedicle technique, the medial pedicle vertical breast reduction procedure requires some special considerations and more intraoperative adjustments. For example, the new nipple position should be placed lower during preoperative marking. In the vertical technique there is a general tendency to place the nipple too high and to produce more upper pole fullness. Therefore the surgeon should be careful to avoid creating high-riding nipples and to inform the patient that she may temporarily have upper pole fullness postoperatively. The new IMF should be placed higher than the actual IMF so that the distance between the nipple and the IMF can be shortened. This distance can be shortened further by a running subcuticular closure. However, the distance between the nipple and the new IMF will never be 5 to 6 cm, as after the classic inverted-T inferior pedicle breast reduction. Very often it will be about 7 to 8 cm so that an optimal breast shape can be maintained after reduction. The management of the excess tissue in the lower pole of the breast can be critical to the success of the medial pedicle vertical procedure. The surgeon should pay attention to this important issue and develop a strategy or technique to properly remove the extra tissue in this part of the breast (Box 57-2).

883

884

Part VIII 

Plastic Surgery of the Breast

Box 57-2  Special Considerations for Medial Pedicle Breast Reduction • Place new nipple position low • Create a new but higher IMF • Make appropriate intraoperative adjustments • Shorten the vertical distance during closure • Manage excess tissue in the lower pole • Inform the patient that she may have temporary upper pole fullness

New nipple position 1 to 2 cm below actual inframammary fold

Fig. 57-3  Preoperative marking of the medial pedicle vertical

breast reduction with the patient upright. Note that the new nipple position should be 1 to 2 cm below the level of the IMF, depending on the amount of reduction required.

Preoperative and Intraoperative Markings The marking of the patient’s breasts for a medial pedicle vertical breast reduction has two essential components: the patient is marked in an upright position preoperatively and in a supine position on the operating table, usually under general anesthesia. The new nipple position should be determined fi st. However, unlike the inverted-T inferior pedicle breast reduction, the new nipple position should be set at a level at least 1 to 2 cm below the level of the IMF to avoid a high-riding nipple position after breast reduction. In addition, if the patient has good upper pole fullness, the new nipple position should be marked lower than intended to avoid a high-riding nipple. The circle around the new nipple position is marked with a Wise-pattern marker. Th s would make the diameter of the circle about 42 mm. The level of the new IMF is determined to be about 2 cm above the actual IMF. After this, the medial and lateral borders of the resection are marked by rotating the breast both medially and laterally in reference to the midline of the breast (Fig. 57-3). While the patient is in the supine position, the nipple-areola complex is marked with either a 38 or 42 mm cookie cutter. The pedicle is then designed with the pedicle width between 6 and 8 cm, depending on the breast size the surgeon wants to achieve after breast reduction. It is important to leave at least 1 cm of breast tissue away from the proposed upper border of the nipple-areola complex to avoid cutting into it. Ideally, the width of the pedicle should be marked in such a way that half of it is within the areolar opening and the other half within the area bounded by medial and lateral pillars (Fig. 57-4). After the pedicle is marked, the new circle of the proposed nipple-areola complex and the medial and lateral markings of the proposed resected area in the breast are tested for easy approximation without tension. We have observed that there is a higher proportion of pliable fat component and less fi m glandular component in the

Chapter 57 

Medial Pedicle Breast Reduction

6-8 cm 1 cm

New inframammary fold position marked 1 to 2 cm above actual fold

Fig. 57-4  Intraoperative marking of the pedicle and the new level of the IMF with the patient in the supine position. The new level should be 1 to 2 cm above the actual level of the present IMF, depending on the amount of reduction required.

Fig. 57-5  Intraoperative view showing completion of deepithelialization over the pedicle.

breasts of Asian women, as well as a thicker dermis layer. Therefore the design of skin resection between the medial and lateral pillars should be more conservative initially and can be adjusted for resection later at the time of wound closure.

Surgical Technique For medial pedicle vertical breast reduction, the area of deepithelialization over the pedicle is much smaller than for the classic inverted-T inferior pedicle breast reduction. Therefore deepithelialization can be quickly performed over the pedicle with either a knife or scissors, depending on surgeon preference (Fig. 57-5). The lower portion of the breast tissue below the pedicle and the skin are resected fi st. Resection can be performed quickly down to the base of the breast, in close proximity to the pectoral fascia, but it should not include the fascia to better preserve nipple sensation. Caution must be exercised to preserve ample tissue in the medial aspect of the breast. The superior portion of the breast tissue above the pedicle along with the skin is excised accordingly, and the medial pedicle can then be elevated. The surgeon should ensure that the pedicle has adequate bulk of breast tissue in terms of width and thickness so that an adequate blood supply can be maintained to the nipple-areola complex. Additional resections of the breast tissue should be performed both laterally to remove excess breast tissues and superiorly to remove some deep breast tissue, so that the pedicle can be rotated into the new position without too much tension (Fig. 57- 6). Frequently the pedicle can be debulked further to make its inset easier. Compared with the inverted-T inferior pedicle technique, the resection of breast tissue can be performed relatively fast.

885

886

Part VIII 

Plastic Surgery of the Breast

Fig. 57-6  Intraoperative view showing completion of right breast resection before pedicle inset and vertical closure.

Fig. 57-7  Intraoperative view showing temporary completion of

pedicle inset and vertical closure. In this breast, the new IMF position has been determined and the excess tissue in the lower pole of the breast is outlined. Excess tissue

New inframammary fold position

Closure of the breast after inset of the pedicle can also be performed quickly. Once the periphery of the new nipple-areola complex is approximated with 2-0 PDS suture, the pedicle can be rotated into the new position and the nipple-areola complex can be approximated to the adjacent breast skin with skin staples. The medial and lateral pillar closure is then performed with 2-0 PDS sutures in an interrupted fashion, starting from the base of the pedicle. In general, only three sutures are needed to approximate the medial and lateral pillars. After both medial and lateral pillars are closed, the skin can be approximated with skin staples. At this point, the position of the new IMF can be determined. The excess breast tissue in the lower pole of the breast located at the lower end of the vertical incision is identifi d and marked (Fig. 57-7). The patient is moved to an upright position, and both breasts are assessed for their symmetry, size, shape, and projection. We prefer to aggressively defat the tissue marked in the lower pole down to just a few millimeters of subcutaneous fat. We place a purse-string suture with 3-0 Monocryl to evenly fold excess skin together9 (Fig. 57-8). A few simple interrupted approximations with 5-0 chromic suture can also be added to create a smoother closure. Liposuction may be required to remove excess fat in the lateral area of the breast, especially in an obese patient. The vertical incision is usually closed in two layers: the deep dermal layer is approximated with several simple interrupted 3-0 Monocryl sutures, and the final skin closure is performed with 3-0 Monocryl sutures in the subcuticular fashion. During vertical skin closure, some additional shortening can be achieved for the vertical distance (Fig. 57-9). The fi al closure after medial pedicle vertical breast reduction has to look good on the operating table. If for some reason there is more excess tissue in the lower pole of the breast, and the closure in the lower pole of the breast after aggressive defatting and a purse-string suture does not appear to be satisfactory,

Chapter 57 

Medial Pedicle Breast Reduction

887

Fig. 57-8  Completion of the closure. Note that the excess subcutaneous tissue in the lower pole of the breast has been removed by defatting and the excess skin has been approximated with a purse-string suture. The contour of the lower pole after surgery appears to be satisfactory.

Fig. 57-9  Immediate results after bilateral medial pedicle vertical breast reductions in the same patient. The contour of the lower pole for both breasts appears to be satisfactory on the operating table.

an L-shaped or a short inverted-T skin incision can be added at this point to improve the appearance of the closure in the lower pole of the breast, since more lower pole excess tissue can be removed in this way. However, adding an L-shaped or inverted-T incision may only be indicated for larger breast reduction or when one side of the breast is much larger than the other side.

Postoperative Care After surgery, sterile strips are placed tightly at the lower pole of the breasts to flatten the closure in this area. The rest of the incision is also covered with sterile strips, and a surgical bra is put on the patient. She will wear a supportive surgical bra for 2 to 3 weeks until the incision has healed and will then convert to a new bra with no underwires. We do not use drains for this type of breast reduction. Th s is in contrast to an inferior pedicle breast reduction, where drains are routinely placed for 24 hours. We frequently perform medial pedicle vertical breast reduction procedures in an outpatient setting.

Results Both functional and cosmetic improvement can be achieved with a medial pedicle breast reduction. The total healing time is quicker and problems related to wound healing occur less frequently. The scar is usually well tolerated by Asian patients. The overall patient satisfaction is high, and the need for minor revision has occurred in about 5% in our series.

K23345_Pu_c57_Med Ped Breast_r4_cl_881-894.indd 887

4/3/2015 12:42:05 PM

888

Part VIII 

Plastic Surgery of the Breast

Fig. 57-10 Th s 36-year-old woman of Korean descent desired breast reduction for symptomatic macromastia. Because of her good skin quality and the favorable shape of her breasts, she was offered a medial pedicle vertical breast reduction. Her surgery went well, and the total amount of breast tissue removed from her right breast was 305 g and from the left breast 320 g. She is shown preoperatively and 4 months postoperatively. Her postoperative course was uneventful; all incisions healed primarily and no hypertrophic scars developed. The patient is quite happy with the overall cosmetic appearance and functional improvement of her breast reduction.

K23345_Pu_c57_Med Ped Breast_r4_cl_881-894.indd 888

4/3/2015 12:42:06 PM

Chapter 57 

Medial Pedicle Breast Reduction

889

Fig. 57-11 Th s 32-year-old woman of Chinese descent had macromastia with breast ptosis that was exacerbated after she gave birth. Although stretch marks and moderate laxity of her breast skin was noticeable, a medial pedicle vertical breast reduction was planned because she requested a shorter scar. The amount of breast tissue removed from her right breast was 420 g and from her left breast was 425 g. Her postoperative recovery was quite uneventful. One year postoperatively, she has a good aesthetic outcome and breast symmetry.

K23345_Pu_c57_Med Ped Breast_r4_cl_881-894.indd 889

4/3/2015 12:42:07 PM

890

Part VIII 

Plastic Surgery of the Breast

Fig. 57-12 Th s 20-year-old woman of Chinese decent requested reduction mammaplasty with the shortest possible surgical incision, because she had developed hypertrophic scars elsewhere on her body and felt this would be the case with her breast scars as well. Preoperatively her left breast was noticeably more ptotic that her right breast. A medial pedicle vertical breast reduction was performed; the amount of breast tissue removed from her right breast was 415 g and from her left reast 445 g. Satisfactory contour and good symmetry were achieved, as seen 6 months postoperatively.

K23345_Pu_c57_Med Ped Breast_r4_cl_881-894.indd 890

4/3/2015 12:42:07 PM

Chapter 57 

Medial Pedicle Breast Reduction

891

Fig. 57-13 Th s 36-year-old woman of Chinese descent was diagnosed with a phylloid tumor of the left breast and had undergone a resection earlier. Because of progressive macromastia, she presented requesting substantial reduction of her breasts to relieve her back pain. She has good skin quality and mild skin laxity. A medial pedicle vertical breast reduction was performed; the amount of breast tissue removed from her right breast was 425 g and from her left reast was 415 g. The follow-up photos at 10 months show good healing after her breast reduction, with an optimal aesthetic outcome.

K23345_Pu_c57_Med Ped Breast_r4_cl_881-894.indd 891

4/3/2015 12:42:08 PM

892

Part VIII 

Plastic Surgery of the Breast

Management of Complications Management of complications is critical to ensure an optimal outcome after a medial pedicle vertical breast reduction.6,10 In our practice, delayed wound healing in the skin purse-string closure area may occur in about 20% of patients. Management of these minor wounds requires reassurance of the patient and prolonged local wound care. In general, such a wound will heal within 2 to 3 weeks, and no further scarring in the area is observed. Obviously if a prominent scar develops in this area or the contour of the lower breast appears to be less satisfactory to the patient or the surgeon, revision surgery can easily be performed in the offic under local anesthesia. However, this kind of revision surgery has been very rare in our practice. In general, complications after this type of breast reduction are much less common. Depending on the patient’s healing potential and the degree of defatting that was performed, some skin necrosis may develop in the area. Th s can usually be managed with prolonged local wound care and office isits with proper dressing changes. No reoperation is ever required. Occasionally the patient may develop a hematoma or seroma, just as in any type of breast reduction surgery. These complications can be managed accordingly with evacuation of the hematoma or seroma either in the offic or in the operating room. In a medial pedicle vertical breast reduction, the breast is “coned” once the medial and lateral pillars are approximated. Therefore the breast tends to be overprojected immediately after surgery. We have found that with time, the fi al breast shape with more fullness in the lower pole will be achieved and better aesthetic contour seen after the overall breast parenchyma gradually settles down. However, it may take longer in Asian patients to allow the breast parenchyma to settle down because of the thicker skin of Asians. Revision surgery to improve the breast shape should be postponed for 4 to 6 months until the fi al contour of the breast is established. Medial pedicle breast reduction is a parenchymal resection and reshaping operation. The skin gradually adapts to the new breast shape, in contrast to the inverted-T technique in which the skin tries to hold the previous breast shape. The breast shape after a medial pedicle reduction stands the test of time and can be satisfactory in both the short term and long term. In addition, inset of the medial pedicle is easy and adds rotation and coning to the breast tissue, resulting in better projection. Furthermore, the scarring is much less with this procedure and thus there is less need for scar revision, which can be more gratifying in Asian women, who tend to have a higher incidence of hypertrophic scars. The need for surgical revision to excise additional excess tissue and to improve the contour in the lower pole of the breast has been rare in our experience, since the excess tissue in the lower pole of the breast has been managed with aggressive defatting and purse-string skin closure in the operating room. In general, the purse-string closure site heals quite well and the scar will become flatter and less visible over longterm follow-up.

Discussion A medial pedicle breast reduction, if performed properly with good patient selection and the use of refi ed surgical techniques, especially for the management of excess tissue in the lower pole, can provide the patient with a very satisfactory outcome both functionally and cosmetically.3-6 Clearly, the medial pedicle vertical breast reduction may not be the appropriate procedure for every patient.4,10,11 We fi d that patient selection is the fi st critical element to ensure the success of such an operation. In contrast to what some authors maintain,1-3,12,13 we think that the medial pedicle vertical breast reduction technique is best employed for patients who are relatively young and have breasts with good skin quality.9 Although these patients may also have enlarged breasts, the shape of their breasts is basically

Chapter 57 

Medial Pedicle Breast Reduction

maintained with no skin stretch marks. The distance between the nipple and the IMF should be less than 10 cm, and their BMI should be near the normal range. For patients who are relatively older with poor skin quality and elongated breasts, the classic inverted-T inferior pedicle breast reduction is more likely to provide predictable results, although an extended scar and bottoming-out of the lower pole can still result after this type of breast reduction. We agree with others that there is a learning curve to perform the medial pedicle vertical breast reduction.4,5 The surgeon must fi st master one technique of breast reduction and then gradually evolve to performing the medial pedicle vertical breast reduction. A number of intraoperative decisions by the surgeon can be critical to ensure an optimal outcome. It is important to be able to remove excess breast tissue in the lower pole right below the new IMF. The excess amount of tissue should be identifi d fi st, and careful defatting can be performed to remove subcutaneous tissue in this location. A purse-string suture can then be placed to fold the skin into the new IMF. If the amount of excess tissue below the new IMF is more extensive, an L-shaped skin incision or a short inverted-T skin extension can be added to remove more excess tissue in this location to provide an aesthetically pleasing contour of the lower pole after vertical skin closure.4,11,14 Conventional liposuction can also be performed in the area under the new IMF to remove excess adipose tissues under the skin, as proposed by Hall-Findlay3 and others.7 We start skin closure from the lowest part of the wound so that scar length is more easily managed and can be adjusted intraoperatively.

Pearls for Success • Proper patient selection is critical to the success of a medial pedicle breast reduction. • There is a learning curve before one can master the procedure. • Good pedicle design is essential to ensure adequate blood supply to the pedicle. • The new nipple position is placed lower than the level of the IMF. • The new IMF is placed higher than the actual level of the IMF. • The surgeon should be prepared to perform more intraoperative adjustments than he or she would perform in the inverted-T reduction procedure. • The vertical distance may need to be shortened during closure. • The excess tissue in the lower pole of the breast must be effectively managed. • The patient should be advised to expect temporary upper pole fullness of the breast after surgery.

Refer ences 1. Lejour M, Abboud M. Vertical mammaplasty and liposuction of the breast. Plast Reconstr Surg 94:100-114, 1994. 2. Hall-Findlay E. A simplifi d vertical reduction mammaplasty: shortening the learning curve. Plast Reconstr Surg 104:748-759, 1999. 3. Hall-Findlay E. Vertical breast reduction with a medially-based pedicle. Aesthet Surg J 22:185-194, 2002. 4. Karp N. Medial pedicle/vertical breast reduction made easy: the importance of complete inferior glandular resection. Ann Plast Surg 52:458-464, 2004. 5. Chen C, White C, Warren S, et al. Simplifying the vertical reduction mammaplasty. Plast Reconstr Surg 113:162172, 2004. 6. Spector J, Kleinerman R, Culliford A, Karp N. The vertical reduction mammaplasty: a prospective analysis of patient outcomes. Plast Reconstr Surg 117:374-381, 2006. 7. Akyurek M. Contouring the inferior pole of the breast in vertical mammaplasty: suction-assisted lipectomy versus direct defatting. Plast Reconstr Surg 127:1314-1322, 2011.

893

894

Part VIII 

Plastic Surgery of the Breast

8. Hall-Findlay EJ. Reduction mammaplasty. In Nahai F, ed. The Art of Aesthetic Surgery: Principles & Techniques. St Louis: Quality Medical Publishing, 2005. 9. Pu LL. Achieving an optimal outcome for medial pedicle vertical breast reduction. Ann Plast Surg 73(Suppl 1):S57-S62, 2014. 10. Adham M, Sawan K, Lovelace C, et al. Unfavorable outcomes with vertical reduction mammaplasty: part II. Aesthet Surg J 31:40-46, 2011. 11. Rinker B. Lowering revision rates in medial pedicle breast reduction by the selective addition of “inverted-T” technique. Aesthetic Plast Surg 37:341-348, 2013. 12. Lista F, Ahmad J. Vertical scar reduction mammaplasty: a 15-year experience including a review of 250 consecutive cases. Plast Reconstr Surg 117:2152-2165, 2006. 13. Neaman K, Armstrong S, Mendonca S, et al. Vertical reduction mammaplasty utilizing the superomedial pedicle: is it really for everyone? Aesthet Surg J 32:718-725, 2012. 14. Kuran I, Tumerdem B. Vertical reduction mammaplasty: preventing skin redundancy at the vertical scar in women with large breasts or poor skin elasticity. Aesthet Surg J 27:336-341, 2007.

K23345_Pu_c57_Med Ped Breast_r4_cl_881-894.indd 894

4/3/2015 12:42:08 PM

58 Correction of Common Nipple Deformities

A

Kai Liu, Qingfeng Li

nomaly of the nipple encompasses many different types of malformations. Nipple hypertrophy and nipple inversion, two of the more frequently seen deformities, are more commonly found in women than in men. Both can cause psychological distress and physical discomfort, such as nipple irritation, chafi g, and ulceration. In this chapter we will describe the ideal nipple in Asian women, the two most common nipple deformities, and surgical techniques for their correction.

The Ideal Nipple The ideal nipple size for Asian women is approximately 10 mm in height and 8 to 10 mm in diameter. Nipples with height and diameter exceeding the normal size by more than 50% are considered hypertrophic, which qualifie them for surgical correction. However, when determining whether the patient has a hypertrophic nipple, the surgeon should consider the nipple’s proportion to the size of the breast and areola. A nipple can be divided into three subunits: the domed top (measuring 3 mm), the cylindrical middle (measuring 5 mm), and the curve-sloped base (measuring 2 mm) (Fig. 58-1). Almost all women consider their nipples to be an important element of their breasts. Undoubtedly, deformed nipples can ruin the image of aesthetically good-looking breasts.

3 mm 5 mm 2 mm 8-10 mm

Fig. 58-1  The ideal nipple measurements should be 8 to 10 mm in width, with a 3 mm domed top, 5 mm cylindrical middle, and 2 mm sloped base.

895

896

Part VIII 

Plastic Surgery of the Breast

NIPPLE HYPERTROPHY Nipple hypertrophy (excessive nipple projection), also known as macrothelia, is a frequent condition that occurs more commonly in Asian women than in Western women.1 Patients often try to conceal this condition by avoiding tight or light clothing. Because there is no exact definition of this condition, the epidemiology remains obscure. However, among all women, breast-feeding and hereditary factors are considered possible causes.2 Despite its frequent occurrence, nipple hypertrophy has received much less attention than macromastia. Over the years, surgeons worldwide have proposed many surgical techniques for correcting nipple hypertrophy, and each procedure has its own advantage and disadvantages. A successful surgical correction should avoid a compromise in the ability to lactate and should achieve a favorable cosmetic outcome.

Classification Nipple hypertrophy can normally be classifi d into the following three types1: 1. Type I: Nipple diameter exceeding 10 mm 2. Type II: Nipple height exceeding 10 mm 3. Type III: Both nipple diameter and height exceeding 10 mm

Surgical Techniques: Nipple Hypertrophy Over the years, surgeons worldwide have introduced many different surgical approaches to correct nipple hypertrophy. The techniques can be classifi d into two categories: preservation of the nipple dome and removal of the nipple dome.

Pr es er vatio n of the Nipple Dome

The domed top of the nipple is important for both function and aesthetic appearance. Preservation of the nipple dome has the advantage of maintaining the natural shape, sensation of the nipple, and central lactiferous duct. However, maintaining the nipple dome is procedurally challenging, because it is difficult to preserve circulation, and the erectile function of the nipple is often compromised. Th s method is frequently used for types I and II nipple hypertrophy. Several dome-preserving methods are discussed in the following section.

Circumcision Method The circumcision method was fi st introduced by Jin and Lee1 and is appropriate for type II nipple hypertrophy. The goal of this procedure is to correct excessive nipple projection. The postoperative size of the nipple can also be decided according to the patients’ needs. Zigzag incisions are made at the bottom and top around the nipple. The surgeon meticulously dissects the extra skin into a very thin cutaneous flap that is then excised. The new nipple is fi ed to its base by placing 4-0 or 5-0 sutures on the four corners (superior, inferior, medial, and lateral), invaginating the naked section. The rest of the wound is sutured with 6-0 or 5-0 PDS sutures (Fig. 58-2).

Expended Circumcision Method The expended circumcision method was also introduced by Jin and Lee1 and is mainly used for type III nipple hypertrophy (Fig. 58-3). The surgeon determines the desired diameter of the neonipple and then

Chapter 58 

A

897

Correction of Common Nipple Deformities

B

C

8 mm

2 mm

Fig. 58-2  The circumcision method. A, Zigzag incisions are made at the bottom and top around the nipple. B, The excessive skin tissue is excised. C, The wound is sutured.

A

C

B

D

8 mm

10 mm

Fig. 58-3  The expended circumcision method. A, The desired diameter of the neonipple is determined, and the excess

width is divided by 2. B, Two small wedges (measuring 2 to 5 mm) are marked on the inferior and superior surfaces opposite each other. C, The excessive skin is excised. D, The wound is sutured.

A

B

Fig. 58-4  A, An ill-shaped, overprojecting nipple before surgery. B, After nipple reduction and breast augmentation.

divides the excess width in two. Two small wedges (measuring 2 to 5 mm) are marked on the inferior and superior surfaces opposite each other. Next, two transverse (approximately 2 to 3 mm) incision lines are marked on both sides at the top of each wedge just below the dome. These two incisions allow the advancement of flaps that will close each wedge defect and narrow the neonipple. The two wedges are excised as very thin skin pieces by superfic al dissection. Two incisions are made on both sides of the superior limit of each bare wedge. The surgeon should make a subcutaneous dissection a minimum of about 2 to 3 mm bilaterally to raise the two advancing flaps that are approximated with inverted sutures. Two small triangles, measuring 2 to 5 mm in width, are marked and excised at the inferior and superior midline of the base incision to narrow the circular defects in the areola. Finally, the exposed areas are sutured. A representative case example is presented in Fig. 58-4. The patient is shown 2 weeks after nipple correction and a breast augmentation. No additional care was required after suture removal.

898

Part VIII 

A

Plastic Surgery of the Breast

C

B

Fig. 58-5  Double-triangle flap method. A, Two V-shaped incisions are made opposite each other on the sides of the nipple. B, A wedge-shaped area is removed. C, The wound is sutured.

B A

C

Fig. 58-6  A, The patient’s hypertrophic nipple is seen preoperatively. B, The sutured nipple and excised tissue. C, Th result 6 months after the procedure.

Removal of the Dome

Methods that remove the dome of the nipple are mainly designed to correct type I nipple hypertrophy. Although the nipple dome is essential for both function and aesthetic appearance, techniques that remove the dome are less challenging and can better preserve the nipple’s erectile function. However, nipple sensation and the central lactiferous duct are often damaged, which can lead to complete loss of the ability to lactate. Several dome-removing techniques are introduced in the following section.

Double-Triangle Flap Method The double-triangle flap method (Fig. 58-5), which was introduced by Wang,3,4 is mainly suited for type II nipple hypertrophy. Two V-shaped incisions are made opposite each other on the sides of the nipple. A wedge-shaped area is removed. Part or the entire center portion of the nipple is excised, depending on need. The two triangular flaps are sutured with 5-0 or 6-0 PDS sutures. A representative case example is presented in Fig. 58-6. The patient is shown 6 months after the procedure. No additional special care was needed after the stitches were removed.

Chapter 58 

A

Correction of Common Nipple Deformities

B

C

Fig. 58-7  The triple-flap technique. A, Th ee symmetrical triangular Y flaps are designed equidistant from each other. The core of the nipple is then excised. B, Next, the nipple is resected. C, The Y-shaped area.

A

B

Fig. 58-8  Removal of the dome. A, Preoperative markings on a nipple with excessive projection. B, After the tripleflap technique with breast augmentation.

Triple-Flap Method The triple-flap method (Fig. 58-7), introduced by Basile and Chang,2 is mainly used for correction of type III nipple hypertrophy. Th ee symmetrical triangular flaps equidistant from each other are designed in a Y fashion. The core of the nipple must be excised when diameter reduction is performed. The top of the nipple is excised in oblique triangular flaps to reduce excess height. The surgeon should suture the flaps toward the center with absorbable 5-0 sutures to reduce the nipple diameter. If the nipple only needs height reduction, the core does not need to be excised when the symmetrical triangular flaps are created. Fig. 58-8 shows the preoperative markings and postoperative result of the same breast 2 weeks after nipple reduction and breast augmentation. No special postoperative care was needed. The nipples retained the designed shape and volume, and the patient was satisfi d with the results. Some patients note a partial loss of sensation on the nipple tip; this possibility was discussed with the patient during the preoperative consultation.

899

900

Part VIII 

Plastic Surgery of the Breast

NIPPLE INVERSION In an inverted nipple, the nipple is retracted into the breast on a plane lower than the areola rather than bulging forward, which causes the so-called volcano-like deformity (Fig. 58-9).5 In mild cases, the nipple can temporarily protrude when pulled or stimulated, but in severe cases, it can only be corrected surgically.

Etiologic Factors An inverted nipple is usually congenital6; however, it can also be acquired from carcinoma, inflammation, or trauma. Approximately 10% of all women have this condition.7 About 87% of the cases are bilateral, and 13% are unilateral. It can affect women between the ages of 18 and 50 years. About 10% to 20% of all women are born with this deformity. The most common causes of a congenital inverted nipple are a short milk duct ligament and wide areolar muscle sphincter. Other common causes of nipple inversion are summarized in Box 58-1.

A

B

Retracted

Fig. 58-9  Comparison of a normal nipple with an inverted nipple. A, Normally protruding nipple with a normal lactiferous duct ligament. B, Retracted nipple with a shortened lactiferous duct ligament.

Normal nipple

Inverted nipple

Box 58-1  Common Causes of Nipple Inversion • Breast-feeding • Pregnancy • Trauma caused by fat necrosis, scars, a surgical complication, and so on • Breast ptosis • Cancer and cancer of the breast, inflammatory breast cancer • Paget disease • Repeated irritation or inflammation, such as mammary duct ectasia, a breast abscess, or mastitis • Genetic variant of nipple shape, such as Weaver syndrome, Fryns-Aftimos syndrome, chromosome 2q deletion syndrome, a congenital disorder of glycosylation type 1A and 1L, or Kennerknecht-Sorgo-Oberhoffer syndrome • Gynecomastia • Holoprosencephaly, recurrent infections, or monocytosis • Tuberculosis

Chapter 58 

Correction of Common Nipple Deformities

Grading System In 1999 Han and Hong7 introduced a grading system to classify the degree of nipple inversion. In their system, the nipple is classifi d into three grades according to how easily it may be protracted, the degree of fibrosis existing in the breast, and the damage caused to the milk ducts.

Grad e I

Grade I is referred to by many health professionals as the “shy nipple,” because it can be easily pulled out by hand or any other means (Fig. 58-10). A grade I inverted nipple maintains its projection and rarely retracts. Often the nipple protrudes without any manipulation or stimulation. Lactiferous ducts are normally uncompromised without any retraction, and breast-feeding is possible. Fibrosis is often absent or minimal. There is no soft tissue deficie cy of the nipples.

Grad e II

In grade II, the nipple can be pulled out but is buried deeper than a grade I inverted nipple (Fig. 58-11). The nipple often retracts when not manipulated. Breast-feeding is often very difficult, although it may still be possible. The degree of fibrosis is moderate. The lactiferous ducts are mildly retracted but do not need to be cut to release the fibrosis. Histologic examination often reveals nipples with rich collagenous stromata with numerous bundles of smooth muscle.

Fig. 58-10  A grade I inverted nipple can be pulled out by hand.

Fig. 58-11  A grade II nipple is buried deeper than a grade I nipple but can still be reached and pulled out.

901

902

Part VIII 

Plastic Surgery of the Breast

Grad e III

A grade III nipple is severely retracted and can rarely be pulled out (Fig. 58-12). Surgical correction is required. The milk ducts are often constricted, and breast-feeding is impossible. Because the nipples are severely retracted, it is difficult to maintain nipple hygiene, and infections or rashes occur. The fibrosis is severe, and the lactiferous ducts are short and severely retracted. Soft tissue is often insuffici t. Histologic examination may reveal atrophic terminal duct lobular units and severe fibrosis.

Nonsur gical Techniq ues

There are several treatment options to correct an inverted nipple, depending on the severity of the condition. Nonsurgical approaches such as a breast pump or other types of suction devices can be used in mild cases. In severe cases, plastic surgery may be the only option. A suction device is the easiest and most commonly used nonsurgical treatment for nipple inversion. In some circumstances, such as grade I or mild grade II nipple inversion, the nipple can be drawn out with a medical or off-the-shelf suction device (Fig. 58-13). Although this method has been effective in some cases, a relapse may occur when the patient stops using the device or the condition changes.

Fig. 58-12  A grade III nipple is severely retracted and can rarely be reached or pulled out.

A

B

Fig. 58-13  A simple suction device can be used for nonsurgical correction in patients with mild nipple retrusion although relapse may occur, requiring the suction technique to be repeated.

Chapter 58 

Correction of Common Nipple Deformities

Sur gical Techniq ues

In severe cases of grade III nipple inversion, in which the nipples cannot be pulled out physically, surgical treatment is the last resort. Over the years, surgical treatments have evolved into the following main categories: incision release, suture, skin flaps, and grafts.

Release and Suture The incision release method involves dissection of shortened fibrous bands and lactiferous ducts pulling the nipples inward through a periareolar incision. Th s method is effective but is not recommended for women planning to breast feed, because it significantly damages the lactiferous ducts. To resolve this problem, Chen et al8 introduced an endoscopic technique. Rather than blindly dissecting the shortened fibrous bands and lactiferous ducts and thus risking damage to normal lactiferous ducts, nerves, and blood vessels, this technique allows surgeons to visually and precisely locate and dissect the abnormal tissues, increasing the chances of preserving normal lactiferous ducts. The authors reported that 82% of the corrected nipples maintained eversion, and 27% of patients were able to lactate successfully.

U-Shaped Double Suture The U-shaped double suture was developed by Quan et al9 (Fig. 58-14). A traction suture is placed to protract the nipple above the areola level. Eight holes with a diameter of 1 mm equidistant from each other are punctured on the base nipple. The suture was performed with a 7-0 silk string. The needle enters through a hole made on the base of the nipple, advances downward, takes a small bite of the mammary gland, and then exits through the opposite hole. The needle reenters the exited hole, advances subcutaneously for about 5 mm, and then exits the hole on the same side. Again, the needle reenters the exited hole, advances downward carrying a small bite of the mammary gland, exits through the opposite hole, reenters the exited hole, travels subcutaneously for 5 mm, and then exits the hole fi st entered, thereby completing the cycle. The process is repeated to form two U-shaped sutures perpendicular to each other. The vertical forces push the nipple upward, thus improving nipple projection.

Fig. 58-14  Two U-shaped double sutures buried subcutaneously overlap each other at the base of the nipple.

903

904

Part VIII 

A

Plastic Surgery of the Breast

B

C

D

Fig. 58-15  The Broadbent and Woolf method. A, A vertical incision is made from the top down to the base of the nipple.

B, The surgeon bluntly dissects and releases the retracting fiber bands or lactiferous ducts. The gland tissue is dissected beneath the nipple, and two gland tissue flaps are created. C and D, Two gland tissue flaps are then pulled toward the center and fi ed with sutures to fill the space beneath the nipple.

A

B

Fig. 58-16  A, A grade III inverted nipple. B, Result 10 days after the Broadbent and Woolf suture technique was performed.

Broadbent and Woolf Incision and Suture Method The incision and suture method was developed by Broadbent and Woolf 10 (Fig. 58-15). A vertical incision is made from the top down to the base of the nipple. The surgeon bluntly dissects and releases the retracting fiber bands or lactiferous ducts. The gland tissue is dissected beneath the nipple, and two gland tissue flaps are created. These two flaps are then pulled toward the center and affixed with sutures to fill the space beneath the nipple, preventing recurrent retraction. The wound is closed with 5-0 or 6-0 sutures. A representative case example is presented in Fig. 58-16. The postoperative photo was taken 10 days after the procedure.

Lunar-Shaped Skin Flap The lunar-shaped skin flap method was developed by Wang3 (Fig. 58-17). The nipple is pulled out with a traction suture. A 0.6 to 1 cm by 1 to 2 cm lunar-shaped skin flap is designed on the inner lower quadrant, depending on the size of the nipple. The incision is made on the lower margin of the nipple, and retraction fiber pulling the nipple downward was excised. If the nipple is still inverted, the surgeon should dissect some or most lactiferous ducts to help release the retraction. A 0.6 to 1 cm by 1.5 cm mammary gland tissue flap is designed and placed under the nipple for filling purposes. A purse-string suture is placed on the nipple base to help stabilize the tissue flap and prevent herniation. The lunar-shaped skin flap is affixed to the incision on the nipple base, and the wound is closed.

Chapter 58 

Correction of Common Nipple Deformities

A

B

C

D

E

Fig. 58-17  Lunar-shaped skin flap. A, A traction suture is placed on the nipple tip. B, A lunar-shaped skin flap is de-

signed on the inner lower quadrant of the areola. C, The incision is made and the flap is raised. D, The underlying fibrosis is dissected. E, The wound is closed.

A

B D

C B A

C

D A

C B

D

Fig. 58-18  Bilateral rhomboid deepithelialized subcutaneous pedicle skin flaps. A, Two rhombic-shaped incisions are designed on two sides of the nipple opposite each other, and the skin tissue is excised. B, The two rhombic flaps are placed under the nipple and overlap each other. C, The wound is sutured. D, The fi al result.

Bilateral Rhomboid Deepithelialized Subcutaneous Pedicle Skin Flaps The bilateral rhomboid pedicle skin flap nipple revision procedure was developed by Zhang and Yang11 (Fig. 58-18). Two rhombic-shaped incisions are designed on two sides of the nipple opposite each other. The lengths of side AB and AD, which are equal to each other (10 to 15 mm), are equal to the height of the nipple after surgery. The widths of the rhombic-shaped incisions are designed according to the severity of the condition. The widths must not be too wide to affect suturing and blood supply (approximately 8 mm). Sides BC and DC must equal each other. The nipple is protracted with a traction suture. The surgeon makes the incisions based on the preoperative design and deepithelializes both rhombic incisions. The surgeon undermines the superior and inferior sides of the incision subcutaneously to create two rhombic

905

906

Part VIII 

A

Plastic Surgery of the Breast

B

Fig. 58-19  A, A grade III inverted nipple. B, Result 2 weeks after correction with the bilateral rhomboid flap technique.

areola-lateral-subcutaneous-pedicle flaps. Any retracting fibrous bands and tissues are dissected to fully release the nipple. The surgeon should avoid making horizontal dissections and damaging the lactiferous ducts. The surgeon then undermines beneath the nipple to create a tunnel. The two deepithelialized flaps are advanced through the tunnel, and they are sutured to the opposite incisions to increase protracting force, allowing constant protraction of the nipple. The wounds are closed in two layers. A representative case example is presented in Fig. 58-19. The postoperative photo was taken 2 weeks after the procedure.

Modified Two-Triangle Areolar Dermal Flap The two-triangle areolar dermal flap method was developed by Kim et al.12 The diameter of the nipple is measured before the procedure is performed. A circle is drawn around the nipple neck, and two triangular flaps are designed at the 3 o’clock and 9 o’clock positions. The base of the triangle (approximately 5 to 8 mm) and the length of each side of the triangle (approximately 9 to 12 mm) are designed according to the diameter of the nipple. The triangles are usually 1 mm shorter than the diameter of the nipple. The nipple is protracted with a traction suture. Incisions are made along the designs. The incisions on the sides of the triangles are deepened into the subcutaneous fatty tissue and are limited to the upper dermal layer on the bases of the triangles, allowing the areolar dermal flap to be medially based. The surgeon deepithelializes the triangles, raises the areolar dermal flaps, and finally preserves the subcutaneous fatty tissue to the flaps. The surgeon bluntly dissects the subcutaneous tissue beneath the nipple and avoids damaging the lactiferous ducts. The tethering fibrous bands are transected, and the nipple is released. If the nipple remains retracted after transiting the fibrous bands, the surgeon should transect most or all of the lactiferous ducts to free the nipple. A small longitudinal slit is made in the bundle of the preserved lactiferous ducts. A suture is placed on the tip of each areolar dermal flap, and the sutures are pulled through the slit under the opposite areolar dermal flap. By pulling the sutures, the areolar dermal flaps are turned down and pulled through the slit and cross each other within it. The flaps are located at the side of the remaining intact lactiferous ducts or beneath the nipple after some or all of the lactiferous ducts are transected. Sutures are placed in the lower dermis of the nipple base beside each of the opposite elevated triangular flaps. The incision is closed in two layers (Fig. 58-20). A representative case example is presented in Fig. 58-21. The patient wore a stent for 1 week for traction; to protect the wound site, it was then removed with the sutures. The patient was satisfi d with the outcome, and her corrected nipples maintained their shape without deterioration of sensation. Rebound events can occur in some patients. Secondary correction may be required in severely inverted nipples.

Chapter 58 

A

907

Correction of Common Nipple Deformities

B

C

E

D

F

G

Fig. 58-20  A modifi d two-triangle areolar dermal flap. A, An inverted nipple. B, A traction suture is placed on the nipple tip, and two triangular flaps are designed. C, Superfic al skin is removed, and the flaps are raised with subcutaneous tissue. D, Flap design shown from the side. E, The suture is placed on the tip of the flaps. F, The flap is pulled in the opposite direction and placed under the nipple. G, The sutured wound.

A

B

C

Fig. 58-21  Results of a modifi d two triangle areolar dermal flap technique. A, Preoperative inverted nipple. B, Postoperative stent in place. C, After surgery.

Management of Complications Both nipple hypertrophy and nipple inversion can cause functional and aesthetic problems that plastic surgeons must correct. Each correction technique mentioned has its advantages and disadvantages, and complications must be managed. Nipple hypertrophy is possibly caused by breast-feeding or hereditary reasons. It is less likely to recur after the excess tissues on the nipples are removed. However, an inaccurate estimate of the amount of tissue requiring removal can cause nipple size asymmetry, and a false design of incision lines can result in a nipple deformity caused by scar retraction. Nipple size asymmetry can be corrected by excision of excess tissues of the larger nipple, and scar retraction can be released with Z-plasty. Preservation of the central lactating duct is also an issue in nipple hypertrophy correction. In some patients, for example, the tip of the nipple is not hypertrophic; it can be spared from excision, thus preserving the central lactating duct. On the other hand, if the tip of the nipple is larger in diameter than that of its

K23345_Pu_c58 59_Crx Nip Deform_r4_cl_895-910.indd 907

4/3/2015 12:44:05 PM

908

Part VIII 

Plastic Surgery of the Breast

base, the tip must be removed to achieve an optimal aesthetic result. Therefore, as mentioned previously, patients must be well informed about the potential complications before surgery. Nipple retrusion is usually caused by a short lactating duct or short lactating duct ligament. To prevent a recurrence and ensure satisfactory results, short lactating ducts or ligaments must be cut or released, which can affect or completely negate the patient’s lactating ability. Unfortunately, no method can ensure that the patient will be able to breast-feed after surgery. Therefore patients must be well informed about the possible surgical complications. Other postoperative complications include recurrence, nipple asymmetry, and nipple deformity caused by scar contracture. Inversion recurrence can be corrected by rereleasing the short ducts or ligaments or by filling the foundation with soft tissue flaps 1 year after surgery. Postoperative nipple asymmetry or deformity can be the result of a single side retrusion recurrence or scar retraction. Secondary surgery can be performed to release the retracted ducts and ligaments and the retracted scar.

Discussion A successful procedure for an inverted nipple and nipple hypertrophy should be simple and reliable, with a low recurrence rate and no visible scars. Nipple hypertrophy often requires excising the excess tissue. To ensure optimal functional and aesthetic results, an accurate estimation of the amount of tissue that must be excised is important to avoid nipple asymmetry. While excising the excess tissues, the surgeon should avoid damaging the central lactating duct to preserve the patient’s lactating ability and to avoid linear incisions, which may result in scar retraction, causing nipple deformity. Grades II and III nipple inversion usually requires releasing the short lactating ducts and ligaments. Although ideally the surgeon should avoid damaging the central lactating duct and preserve the patient’s lactating ability, there is no guarantee. Often the key to success in nipple inversion correction is to fully release the retracted ducts and ligaments, and thus the patient’s lactating ability must be sacrific d to avoid a recurrence. To ensure protraction, the cavity under the released nipple must be filled.

Pearls for Success Nipple Hypertrophy • It is important to have an accurate estimate of the amount and position of the tissues that must be removed. • An accurately sized dome shape after tissue removal is estimated. • The most sensitive part of the dome should be preserved. • The surgeon should avoid damage to the central lactating duct. • Linear incisions should be avoided. Nipple Inversion • Normally only grades II or III require surgical correction. • The surgeon should fully release the short lactating ducts, ligaments, and fiber bands. • The cavity under the released nipple (for example, soft tissue flaps) is filled. • The surgeon must be aware of the nipples’ blood supply. • The surgeon should avoid linear incisions.

K23345_Pu_c58 59_Crx Nip Deform_r5_cl_895-910.indd 908

4/7/2015 11:52:56 AM

Chapter 58 

Correction of Common Nipple Deformities

909

Refer ences 1. Jin US, Lee HK. Nipple reduction using circumcision and wedge excision technique. Am Plast Surg 70:154-157, 2013. 2. Basile FV, Chang YC. The triple-flap nipple-reduction technique. Ann Plast Surg 59:260-262, 2007. 3. Wang W. Nipple inversion correction using lunar shaped skin flaps method. J Pract Aesthetic Plast Surg 3:189190, 1992. 4. Wang W. Plastic and Reconstructive Surgery. Hangzhou, China: Zhejiang Science and Technology Publications 1166-1169, 1922. 5. Park HS, Yoon CH, Kim HJ. The prevalence of congenital inverted nipple. Aesthetic Plast Surg 23:144-146, 1999. 6. Shafir R, Bonne-Tamir B, Ashbell S, et al. Genetic studies in a family with inverted nipple (mammillae invertita). Clin Genet 15:346-350, 1979. 7. Han S, Hong YG. The inverted nipple: its grading and surgical correction. Plast Reconstr Surg 104:389-395; discussion 396-397, 1999. 8. Chen SH, Gedebou T, Chen PH. The endoscope as an adjunct to correction of nipple inversion deformity. Plast Reconstr Surg 119:1178-1182, 2007. 9. Quan L, Ying C, Jingjing L. Correction of inverted nipples by double stitching of U-shape. Chinese J Reparative Reconstr Surg 22:593-596, 2008. 10. Broadbent TR, Woolf RM. Benign inverted nipple: trans-nipple-areolar correction. Plast Reconstr Surg 58:673677, 1976. 11. Zhang Q, Yang C. Correction of congenital nipple inversion with bilateral rhombus deepithelialized subcutaneous pedicle skin flaps and continuous traction. Chin J Plast Surg 20:21-23, 2004. 12. Kim DY, Jeong EC, Eo SR, et al. Correction of inverted nipple: an alternative method using two triangular areolar dermal flaps. Ann Plast Surg 51:636-640, 2003.

K23345_Pu_c58 59_Crx Nip Deform_r4_cl_895-910.indd 909

4/3/2015 12:44:05 PM

K23345_Pu_c58 59_Crx Nip Deform_r4_cl_895-910.indd 910

4/3/2015 12:44:05 PM

59 Breast Reconstruction With Pedicled TRAM Flap

I

Sin-Daw Lin, Lee L.Q. Pu

mportant factors that affect an Asian woman’s decision to have breast reconstruction are the availability and accuracy of information about the procedure. The patient and her family require adequate counseling regarding the procedure, including the expected outcomes and potential complications.1,2 Because cancer patients have very low tolerance for the failure of a major surgical procedure, they are unlikely to have breast reconstruction unless the procedure has a very high success rate and a very low complication rate. Hartrampf et al3 reported on a successful breast reconstruction with an autologous transverse abdominal island flap in 1982. Since then, the flap has undergone several modifi ations. Th s type of breast reconstruction has shown very high success rates, very low complication rates, and consistently high patient satisfaction.4-6 Th s chapter describes notable observations that we made during my extensive clinical experience performing autologous breast reconstruction with pedicled transverse rectus abdominis myocutaneous (TRAM) flaps in Asian women.

Anatomy The vascular supply to the rectus abdominis muscle is mainly from the superior and inferior epigastric arteries. The superior epigastric artery enters the posterior aspect of the muscle, and more than 90% of the artery is located in the middle third of the muscle.3,7 The superior artery and its branches are usually located intramuscularly. As these branches run downward within the rectus muscle, they anastomose with the intramuscular branches of the deep inferior epigastric artery. The deep inferior epigastric artery runs to the rectus muscle from the lateral aspect, 2 to 3 cm below the linea arcuata. As this vessel runs superiorly, it is usually located within the muscle. Moon and Taylor8 identifi d three patterns of blood supply to the rectus abdominis muscle through the superior epigastric artery and inferior epigastric artery (Fig. 59-1). The most common pattern (57%) was a division of the inferior epigastric artery into two major intramuscular branches at the linea arcuata level. Two other patterns were single inferior vessels (29%) and triple inferior vessels (14%). The deep inferior epigastric artery gives off

911

912

Part VIII 

Superior epigastric artery

Plastic Surgery of the Breast

Superior epigastric artery

Superior epigastric artery

Umbilicus

Umbilicus

Umbilicus

Inferior epigastric artery

Inferior epigastric artery Type I System (29%) Single inferior vessels

Type II System (57%) Double inferior vessels

Inferior epigastric artery Type III System (14%) Triple inferior vessels

Fig. 59-1  Th ee patterns of vascular supply of the rectus muscle. The connections between the deep superior and the

deep inferior epigastric arteries always occur above the umbilicus (U). The arcuate line is represented by the dashed line. (From Moon HK, Taylor GI. The vascular anatomy of rectus abdominis musculocutaneous flaps based on the deep superior epigastric system. Plast Reconstr Surg 82:815-832, 1988.)

K23345_Pu_c59_Br Recon Ped TRAM_r3_cl_911-930.indd 912

4/3/2015 12:46:45 PM

Chapter 59 

Breast Reconstruction With Pedicled TRAM Flap

small muscular and cutaneous perforators as it ascends superiorly. When the vessel penetrates the medial and lateral anterior rectus sheath, the branches can be differentiated as medial or lateral rows of cutaneous perforators of the inferior epigastric artery (Figs. 59-2 and 59-3). Perforators that extend to the dermal layer of the skin expand the size of the nourished area in the overlying skin by anastomosis, which occurs mainly in this layer. In 2007 Tregaskiss et al9 performed a detailed vascular study of the superior and inferior epigastric arteries. Their results confi med the intramuscular anastomotic processes involving these two systems. By opening the reduced-caliber choke vessels in these anastomotic arteries and arterioles, the superior epigastric artery can supply a TRAM flap by filling the vascular territory of the inferior epigastric system.8

1

1 w

w

w

Fig. 59-2  The lateral row of perforators (arrows) located medial to the lateral border of the rectus sheath (w) and the fascia of the external oblique abdominis muscle (1).

1 w

w

Fig. 59-3  The medial row of perforators (arrows) located lateral to the medial border of the rectus sheath and the linea alba (w). (1, Isolated umbilicus.)

913

914

Part VIII 

Plastic Surgery of the Breast

Fig. 59-4  Four zones of the TRAM flap. Zone I lies directly

over the ipsilateral pedicled rectus muscle. Zone II comprises the contralateral area immediately crossing the middle. Zone III is the ipsilateral area next to zone I. Zone IV is located lateral to zone II.

IV

II

I

III

Although Scheflan and Dinner10 were the fi st to divide the abdominal ellipse flap into four equal parts, the procedure was not widely known until Hartrampf et al3 reported on the pedicled TRAM flap for breast reconstruction. They divided the TRAM flap into the following four equal zones (Fig. 59-4): • Zone I: The area directly over the perforators of the ipsilateral pedicled muscle • Zone II: The contralateral area immediately crossing the midline • Zone III: The ipsilateral area next to zone I • Zone IV: The area lateral to zone II Zone I, which receives axial-pattern blood fl w directly from the underlying myocutaneous perforators, has the most reliable perfusion. Zone III, whose supply is similar to that of zone I, is well nourished. Zones II and IV are originally supplied by the contralateral vascular system but also by vessels crossing the midline and by random-pattern perfusion from the unilateral pedicle. Blondeel et al11 reported that 36% of patients who received the TRAM flap lacked suffici t venous connections across the midline. These data revealed the inconsistent circulation in zone IV. Because of its relatively poor perfusion, zone IV is rarely used in unilateral TRAM flaps.

Indications A successful TRAM flap reconstruction is possible in many patients who require breast reconstruction. A single-pedicled flap is performed more frequently than a double-pedicled flap, which is preferable when a reliable blood supply cannot be provided through a single pedicled flap. In a bilateral breast reconstruction, two single-pedicled flaps are performed (Box 59-1). An ideal candidate for a TRAM flap is a young or middle-aged and otherwise healthy breast cancer patient with sufficient subcutaneous fat and an adequate surface area of skin in the abdominal region. However, because of the complexity of this procedure, patients with risk factors that could jeopardize flap perfusion require careful management. Examples of factors associated with poor outcomes include obesity, poor

Chapter 59 

Breast Reconstruction With Pedicled TRAM Flap

Box 59-1  Indications and Contraindications for a Pedicled TRAM Flap Indications • Breast cancer patients who require breast reconstruction Contraindications • Uncontrolled diabetes mellitus • Poor cardiopulmonary function • Injury of the superior epigastric artery by a transverse operative scar • Extensive liposuction of the abdomen • A history of heavy smoking • Emotional instability

cardiopulmonary function, underlying diseases such as uncontrolled diabetes mellitus, and a history of heavy smoking. The procedure can be difficult or impossible in patients who have had a previous abdominal surgery that resulted in substantial scar tissue or division of the rectus abdominis muscle or superior epigastric artery. Other scars should not pose a signifi ant risk with an appropriately designed TRAM flap. Another unfavorable abdominal condition for flap harvest is a history of extensive abdominal liposuction, which can disrupt perforators. Emotionally unstable patients are poor candidates, because they are unlikely to be satisfi d with the results.

Preoperative Assessment Asian women are generally conservative when selecting management for breast-related problems such as breast cancer. However, most women with breast cancer understand that mastectomy is a lifesaving procedure, whereas the main purpose of breast reconstruction is to improve quality of life.12 Patients’ attitudes and expectations regarding reconstruction differ from those regarding treatment of the disease itself. Factors that signifi antly influence the decision to have breast reconstruction include the availability of information—or the prevalence of misinformation about the procedure. Therefore preoperative counseling with the patient and her family is essential: the surgeon needs to explain the course of reconstruction and its potential complications, results, and advantages. Such counseling is critical to encourage patients to undergo this procedure.1,13 A patient is admitted to the hospital 1 day before surgery. Gross anatomic markers are identifi d, including the suprasternal notch, midline from the suprasternal notch to the umbilicus, the inframammary folds, the umbilicus, and boundaries of the transverse ellipse TRAM flap and the pedicled rectus muscle (see Results). Other presurgical management includes the following: • The gross anatomic landmarks are identifi d and the TRAM flap shape and size are outlined with the patient standing and lying down (see Results). • The gastrointestinal system is prepared by administering a laxative the evening before surgery. • Fluids and electrolytes are given starting at midnight on the evening before surgery to maintain adequate total body volume, peripheral perfusion, and oxygenation. • Steroids, vasodilators, and prophylactic antibiotics are given early on the morning of the operation.

915

916

Part VIII 

Plastic Surgery of the Breast

Surgical Technique With the patient in a supine position, pillows are placed under the knees to maintain a flexion posture. The operating table is covered with an electric blanket to maintain a stable body temperature between 36° and 37° C (96.8° and 98.6° F).

Iso l ating the Umbilicus

Before the umbilicus is isolated from the TRAM flap, its orifice is closed by temporary suturing. In obese patients, the dissected base of the umbilicus must be suffici tly wide to prevent ischemic changes caused by tension produced when the umbilical stalk is tracked and sutured to the newly created position.

Des ign and Deep itheli aliz atio n of the Fl ap

The flap is based on the contralateral rectus abdominis muscle, and the main parts of the flap are designated as zone I and zone III. When a portion of skin is excised along with breast tissue in a mastectomy, a portion of similar shape and size is preserved on the corresponding flap during deepithelialization. After a skin-sparing mastectomy is performed and the nipple-areola complex is preserved, the total mass of the skin of the flap can be deepithelialized. Th s is easier and more effective when performed before the flap is dissected rather than after the flap is completely isolated. The vascular plexus that supplies the skin is located mainly in the dermal layer and crosses several zones. 9 Therefore deepithelialization should be limited to the plane between the epithelium and the upper dermal layer. Observation of diffuse pinpoint bleeding vessels confi ms that deepithelialization is being performed at the appropriate plane. In multiparous patients with redundant abdominal skin and marked striae, deepithelialization should be performed cautiously to prevent inadvertent removal of the entire dermal layer.

Ele vatio n of the Fl ap

Flap dissection begins from lateral to medial along the plane over the aponeurosis of the external oblique abdominal muscle. Dissection proceeds in the loose connective tissue space between the adipose tissue of the flap and underlying fascia. Delicate vessels are then visible under the surface of the elevated flap (see Fig. 59-2). The dissection continues medially until the lateral row of perforators emerges. Two to four perforators of various sizes and locations are visible. During dissection of the lower border, the superfic al inferior epigastric artery, the superfic al circumflex liac artery, and the external pudendal artery should be isolated and divided. The nonpedicled zones II and IV are dissected similarly, except that nourishing perforators are clipped and divided. The dissection continues across the midline to the medial row of perforators of the pedicle, which varies in number and location (see Fig. 59-3).

Ele vatio n of the Upper Abd ominal Skin

Elevation of the upper abdominal skin and subcutaneous fat from the abdominal muscular fascia reveals a series of perforators piercing the rectus sheath. These perforators are carefully dissected, clipped with clippers, and divided with scissors. Electrocautery is not recommended for division of these vessels. Electric coagulation can cause thermal damage, initially at the coagulated ends of these vessels and then throughout vascular networks of the superior and inferior epigastric arteries, which jeopardizes circulation in a TRAM flap.

Chapter 59 

Breast Reconstruction With Pedicled TRAM Flap

r 1

Fig. 59-5  Th subcutaneous tunnel (1) is formed mainly from normal breast tissue. (w, Design of the TRAM flap; r, mastectomy defect.)

w

Cr ea tio n of a Subcu t aneo us Tunnel

An intact inframammary fold is essential for achieving an aesthetically satisfactory reconstruction. Therefore disturbance of the inframammary fold should be minimized during mastectomy, particularly when the tunnel is formed for flap transplantation. Disruption of the fold needs to be corrected. Because the tunnel, which is about 10 cm wide, is formed mainly from normal breast tissue, most of the inframammary fold on the mastectomy side can remain in position (Fig. 59-5). The bulging deformity at the epigastric area caused by the transplanted, pedicled muscle is unnoticeable. When the fi h to seventh intercostal perforators of the internal mammary artery of the normal breast are encountered during dissection of this tunnel, they should be carefully dissected, clipped, and divided with scissors. The tunnel should be suffici tly large to allow flap transplantation without excessive tension.

Muscle-S par ing Diss ectio n of the Ped icled Rectus Abd ominis Muscle

After the xiphoid process and xiphoid costal angle are identifi d by palpation, the pedicle on the central part of the rectus abdominis muscle is marked. The pedicle includes the lateral and medial rows of perforators on both sides of the flap. The width of the rectus pedicle ranges from three fi hs to two thirds the width of the muscle, preserving one medial and one lateral strip of sheath and muscle. The incision of the anterior rectus sheath and the muscle begins medially above the umbilicus. The surgeon should not cut too deeply into the muscle to prevent injury to the vascular network immediately under the incision site (Fig. 59-6). When the muscle is split and divided, numerous small intramuscular vascular vessels are encountered. These should be carefully dissected, clipped, and divided (Fig. 59-7). Electrocautery should not be used. The transection in the distal muscle should be limited to 1 to 2 cm below the level of the linea arcuata.

917

918

Part VIII 

Plastic Surgery of the Breast

Fig. 59-6  A delicate vascular network (arrows) is located

immediately beneath the rectus sheath. Too deep an incision through the sheath can injure these vessels and jeopardize circulation of the flap. The umbilicus (r) is isolated.

r

A

1

1 w

w

1

1

1

w

r

Linea arcuata

Posterior rectus sheath

B

Intramuscular branches of inferior epigastric artery isolated, clipped, and transected

Anterior rectus sheath

Rectus abdominis muscle remnants

Distal

Proximal

Intramuscular branch of inferior epigastric artery

Retracted umbilical stump

Fig. 59-7  A and B, Intramuscular branches (small arrow) of the inferior epigastric artery are carefully isolated. Another one was clipped after isolation (large arrow). (1, Incised fascia; w, rectus muscle; r, umbilicus.)

K23345_Pu_c59_Br Recon Ped TRAM_r3_cl_911-930.indd 918

4/3/2015 12:46:50 PM

Chapter 59 

Breast Reconstruction With Pedicled TRAM Flap

A

w

w

1

B

Cut edges of left rectus abdominis muscle

Inferior epigastric artery and vein

Posterior rectus sheath

Fig. 59-8  A and B, The inferior epigastric vessels (small arrows) are clamped with a vascular clamp. The split rectus

muscle (w) is traced laterally. Before the lateral portion of the rectus muscle is split, the muscle is pierced with a hemostat (large arrow) to ensure that the inferior epigastric vessels are included within the pedicle. (1, Linea arcuata.)

At this point, laterally tracing the medial split rectus muscle exposes the deep inferior epigastric vessels. These should be isolated and clamped temporarily with a vascular clamp (Fig. 59-8). The ischemia resulting immediately after clamping stimulates early opening of choke vessels and enhances blood fl w from the superior epigastric artery to the inferior epigastric arterial region.14 To split the lateral portion of the rectus muscle from distal to proximal, the sheath is incised laterally to the lateral row of perforators. Before the muscle is split, its posterior aspect is gently pierced with a blunt-tip hemostat, and inclusion of suffici t inferior epigastric artery and veins within the pedicle is confi med. The split in the lateral muscle extends superiorly to the low costal cartilage ridge and can be extended over the costal arch to increase mobility of the transplanted pedicle. The rectus muscle has three to four tendinous intersections. Friable intramuscular vessels within this band require careful isolation and division but without electrocautery. Muscle splitting on the medial side continues superiorly toward the xiphoid process. The xiphoid-costal angle is avoided when this upper portion is split to prevent injury to the superior epigastric artery. Lidocaine is applied to the surgical fi ld during dissection.

919

920

Part VIII 

Plastic Surgery of the Breast

After dissection is completed, all blood vessels supplying the flap are blocked except that from the superior epigastric artery. Successful flap perfusion is confi med by active oozing of fresh blood when the most peripheral part of the flap is rubbed with gauze. The vascular clamp on the inferior epigastric vessels is released, and the distal end of the muscle pedicle is transected. The end of the pedicle that is cut is 2 to 3 cm distal to the linea arcuata and distal to the level where the inferior epigastric vessels approach or enter the rectus muscle. This distance ensures a tension-free suture between the transected, distal end of the anterior rectus sheath and the posterior rectus sheath (linea arcuata). The inferior epigastric vessels are isolated, clipped with clippers, and divided. The divided proximal end of the rectus muscle is sutured with two stitches in the anterior rectus sheath to prevent separation from the sheath during transplantation.

Pr epara tio n of the Trans pl anted TRAM Fl ap

After dissection, the TRAM flap is weighed with a spring scale (Fig. 59-9). The required shape and weight are individually designed according to the resected modifi d radical mastectomy tissue. A contralateral unipedicled TRAM flap is transplanted clockwise and counterclockwise to reconstruct the right and left sides, respectively. After the flap is transplanted through the tunnel to the mastectomy wound, it is positioned vertically or obliquely. The flap is inserted such that the repaired umbilical wound is located in the central portion of inframammary fold. Although the superior epigastric vessels are protected within the muscle, the pedicle should be carefully inspected for torsion or kinking after transplantation. Transplantation of the flap into the mastectomy defect exposes the posterior part of the proximal muscle pedicle. The surgeon can safely and easily detach the muscle from the costal ridge, divide the costoxiphoid ligament, and separate the pedicle from the posterior rectus fascia to achieve a tension-free transplantation. The eighth intercostal neurovascular bundle and the costomarginal artery are isolated and divided (Fig. 59-10). The superior epigastric artery is not dissected but should be well protected. The transplanted flap is further trimmed and contoured according to the weight and shape of the removed mammary tissue. The shape and position of the reconstructed breast can be fixed by internal or external suturing or dressed with an elastic bandage.

Fig. 59-9  Before transplantation, the dissected TRAM flap was weighed with a spring scale. (w, Muscle pedicle.)

w

Chapter 59 

Breast Reconstruction With Pedicled TRAM Flap

A

w

w 1

r

r

B

Rectus abdominis muscle Cut edge of left rectus abdominis muscle Linea alba Anterior rectus sheath

Neurovascular bundle Costoxiphoid ligament

Posterior rectus sheath

Fig. 59-10  A and B, After the flap had been transplanted to the mastectomy defect, tissues at the posterior aspect of the

proximal base of the pedicle are exposed. These include costal cartilage (1), the rectus muscle (w), the eighth intercostal neurovascular bundle (small arrow), the costoxiphoid ligament (large arrow), and preserved lateral and medial strips of the rectus muscle and sheath (r).

Cl os ur e of the Dono r Wound

The defect in the posterior rectus sheath below the linea arcuata is fi st closed by suturing the posterior rectus sheath to the remaining distal end of the anterior rectus sheath (Fig. 59-11). Th s suture enhances the weak area of the posterior rectus sheath and prevents postoperative abdominal hernia. Two-layer permanent interrupted sutures are placed between the preserved lateral and medial strips of the rectus sheath and muscle to restore the integrity of the donor rectus defect (Fig. 59-12). Reconstruction with a unilateral flap does not require a synthetic mesh to close the rectus sheath. However, in a bilateral pedicled flap performed in patients with low body fat or a history of an abdominal operation and tight fascia, incomplete closure of the bilateral anterior rectus sheath may require the use of surgical mesh (Fig. 59-13). A transverse full-layer incision (2.0 to 2.5 cm) is made in the abdominal midline 13 to 15 cm above the symphysis pubis so that the preserved umbilical stalk can be pulled through the open wound and sutured to create the new umbilicus.

921

922

Part VIII 

Plastic Surgery of the Breast

r 1

w

r

Fig. 59-11  The posterior rectus sheath is enhanced by suturing between the linea arcuata (1) and the distal end of the anterior rectus sheath (w). (r, Preserved lateral and medial strips of the rectus muscle.)

r

Fig. 59-12  The donor defect of the left ectus muscle is closed with two-layer suturing between the preserved lateral and medial strips of the rectus muscle and sheath. (r, Isolated umbilicus.)

w w w

r

1

w

Fig. 59-13  The donor defects of the bilateral unipedicled rectus flap are closed with two-layer suturing between the preserved lateral and medial strips of the rectus muscle and sheath on both sides (w). The remaining defect, which could not be closed completely, was repaired with mesh (1). (r, Umbilicus.)

K23345_Pu_c59_Br Recon Ped TRAM_r3_cl_911-930.indd 922

4/3/2015 12:46:53 PM

Chapter 59 

Breast Reconstruction With Pedicled TRAM Flap

Intraoperative Management During surgery, the following management protocol is carried out: • Stable blood pressure and core temperature are maintained throughout the operation. • Prednisolone, vasodilators, and prophylactic antibiotics are given. • Good peripheral perfusion is maintained by giving adequate fluids and electrolytes.

Postoperative Care After surgery, patients are managed as follows: • Stable blood pressure and body temperature are maintained. • Flap perfusion is monitored. • Antibiotics, steroids, and vasodilators are given continuously for 3 days. • A hot pad is applied to the surgical area to enhance local perfusion of the flap. • Forty-eight hours of bed rest are needed. • A corset is placed immediately after surgery to compensate for diminished muscular strength in the abdominal area and to prevent seroma formation. • The patient is discharged on day 7.

Results In my (S.L.) personal experience over the past 14 years, 945 patients underwent breast reconstruction with pedicled TRAM flaps. Of these, 921 cases (97.5%) were immediate reconstructions, and 24 cases (2.5%) were delayed reconstructions. The reconstruction was bilateral in 61 patients (6.5%). Most reconstruction patients (74.2%) were 31 to 50 years of age. Ninety-four (9.9%) were unmarried. Of the 481 procedures performed since 2004, the nipple-areola complex was preserved in 251 patients (52.2%). Complications after pedicled TRAM reconstruction are less common in my (S.L.) series15 and are summarized in Table 59-1.

Table 59-1  Complications After Immediate Pedicled TRAM Flap Reconstructions in 921 Patients Complications

Number

Percentage (%)

Total flap loss

0

0

Partial flap loss

8

0.8

Fat necrosis

36

3.9

Postoperative flap infection

10

1.0

Abdominal herniation

5

0.5

Abdominal wound necrosis

10

1.0

Umbilical wound necrosis

5

0.5

Mild to moderate ischemic changes of the native skin envelope

35

3.8

Hyperextension injury of the upper limb

2

0.2

From presentations at the Sixteenth International Confederation for Plastic, Reconstructive and Aesthetic Surgery (IPRAS) Convention, Vancouver, British Columbia, Canada, May 2011;and the Sixth Asian Symposium for Breast, Plastic and Reconstructive Surgery (ASBPRS) Convention, Bali, Indonesia, Oct 2014.

923

924

Part VIII 

Plastic Surgery of the Breast

Because a major goal of breast reconstruction is to improve quality of life, patient satisfaction with the results is a key outcome measure.12 In my (S.L.) series, the overall satisfaction rate was 89.4%, and 92.9% of the patients indicated that they would recommend this procedure to other patients having a mastectomy. The overall satisfaction rate with the abdominal donor wound was 87.5%. Complaints about the abdominal donor site included the appearance of the abdominal scar, a feeling of abdominal tightness, and other complaints in a small percentage of patients. The abdominal hernia or bulging rate was very low (0.5%).

A

C

B

D

Fig. 59-14 Th s 44-year-old woman had a biopsy-proven left reast carcinoma. She underwent a skin-sparing mastectomy with preservation of her nipple-areola complex and immediate breast reconstruction with a right pedicled TRAM flap. The resected left mammary tissue weighed 400 g. The dissected TRAM flap weighed 1000 g on a spring scale. We transplanted 430 g of the TRAM flap to the left reast. No fat necrosis occurred. The patient is satisfi d with her reconstruction. She is shown 2 years postoperatively.

Chapter 59 

Breast Reconstruction With Pedicled TRAM Flap

A

B

C

D

925

Fig. 59-15 Th s 48-year-old woman underwent a modifi d radical mastectomy for her right breast cancer 7 years ago. The breast was reconstructed with a left pedicled TRAM flap. The weight of the dissected TRAM flap was 650 g, and 560 g was used for reconstruction. Her postoperative course was uneventful. The reconstructed breast was nearly symmetrical with her normal left breast. No fat necrosis occurred. The patient is pleased with her results. She is shown 17 months postoperatively.

K23345_Pu_c59_Br Recon Ped TRAM_r3_cl_911-930.indd 925

4/3/2015 12:46:56 PM

926

Part VIII 

Plastic Surgery of the Breast

A

B

C

D

Fig. 59-16 Th s 43-year-old woman had had a mastectomy of her left reast cancer 5 years earlier. She requested reconstruction of this mastectomy deformity. On a preoperative evaluation, her right breast was small and ptotic and required augmentation. Bilateral unipedicled TRAM flaps were performed to reconstruct symmetrical breasts. The dissected TRAM flap (400 g) was divided into two parts that were based on individual rectus muscle pedicles. Her left breast was reconstructed with the larger part (250 g), and her right breast was augmented with the smaller part (150 g). The bilateral donor rectus muscle defects were sutured primarily. A defect (3 by 5 cm) remained in the lower abdomen. It could not be closed completely and was repaired with Marlex. Her postoperative course was uneventful. The reconstructed breasts are approximately symmetrical, and no fat necrosis has developed. The abdominal wall is stable. The patient is very satisfi d with the results. She is shown 21 months postoperatively.

K23345_Pu_c59_Br Recon Ped TRAM_r3_cl_911-930.indd 926

4/3/2015 12:46:58 PM

Chapter 59 

Breast Reconstruction With Pedicled TRAM Flap

A

B

C

D

927

Fig. 59-17 Th s 48-year-old woman had preoperative biopsy-proven left reast cancer. Her right breast was diagnosed with cancer intraoperatively. A skin-sparing mastectomy with nipple-areola complex preservation was performed for both breasts. Immediate breast reconstructions with bilateral unipedicled TRAM flaps were performed. The weight of the excised mammary tissue was 320 g bilaterally. The weight of the dissected TRAM flap was 610 g, which was divided into two parts for reconstruction. The right breast was reconstructed with 310 g and left breast with 300 g. Both rectus muscle donor defects were closed primarily without mesh. Her postoperative course was uneventful. The reconstructed breasts appear symmetrical. No fat necrosis has occurred. The abdomen is stable, without herniation or bulging. The patient is very satisfi d with her results. She is shown 40 months postoperatively.

K23345_Pu_c59_Br Recon Ped TRAM_r3_cl_911-930.indd 927

4/3/2015 12:47:00 PM

928

Part VIII 

Plastic Surgery of the Breast

Management of Complications In a pedicled TRAM flap procedure, the major concern is fat necrosis from insuffici t blood perfusion.4,16 However, this complication is rare in my (S.L.) series. Specific anagement is needed to achieve a high success rate and low complication rate. Th s includes ensuring good flap perfusion through maintenance of stable blood pressure and temperature, meticulous isolation and division of the intravascular branches, and giving vasodilators, steroids, and other medications as needed. In this series, zones I and III, in which circulation is relatively reliable, made up the largest portion of the transplanted flap and less than 60% of the TRAM flap. Therefore fat necrosis was rare. Steps were carried out to maintain flap perfusion before, during, and after surgery. The inferior epigastric artery was clamped with a vascular clamp early in the muscle pedicle dissection to enhance blood fl w from anastomotic vessels to the flap by inducing relative ischemic changes and the early opening of choke vessels. Blood flow in intravascular branches was not only maintained in this manner but actually enhanced by an intraoperative delay procedure. Therefore complications of fat necrosis and partial flap loss were minimized. Harvesting of the rectus sheath and muscle as the pedicle creates a weak area below the linea arcuata. Th s can result in postoperative abdominal hernia. The defect should be closed securely by suturing the linea arcuata to the transected distal end of the anterior rectus sheath and muscle. The donor defect in the rectus muscle is reconstructed by suturing two layers between the preserved lateral and medial strips of rectus sheath and muscle, and the fascial plication is extended downward to the insertion of the rectus muscle to the iliac bone. Th s procedure reestablishes abdominal muscle strength and prevents abdominal bulging and/or hernia. Abdominal weakness rarely occurs in patients who begin to wear an elastic abdominal corset immediately after the operation and for 4 months thereafter. The most common flap-related complication in my (S.L.) series was fat necrosis.17 Fortunately, the extent of fat necrosis was usually a limited part of the total transplanted flap. Generally, these cases can be managed with conservative measures, but sonography and/or biopsy is essential for confi ming that the problem is benign.18 In the rare cases involving large volumes of necrotic fat, the fat should be excised. Development of an abdominal hematoma or seroma is a potential early or delayed donor site morbidity. Th s can be minimized with the use of a closed-suction drain for at least 2 weeks postoperatively. An abdominal corset dressing may also be effective. After a pedicled flap procedure, the most common donor site morbidity is loss of abdominal muscle function. Comparative studies of deep inferior epigastric perforator flaps and pedicled TRAM flaps show a similar incidence of postoperative bulging in the abdominal wall, and the probability of such abnormalities is unrelated to the preservation of muscle or intercostal nerves.19-21 In all patients in this series, the integrity of the donor rectus defect was successfully reestablished. All patients recovered from the operation within 2 to 4 weeks postoperatively without signifi ant dysfunction of the abdominal wall. During reconstruction of symmetrical breasts, the weight of excised mammary tissue is used as reference data. In our series, 92% of the reconstructed breasts were approximately symmetrical when 50% to 60% of the dissected TRAM flap was transplanted. The inframammary folds are marked preoperatively with the patient standing. If the fold was disrupted during mastectomy or creation of the subcutaneous tunnel, it should be repaired by fixing the dermis down to the muscle fascia with nonabsorbable sutures of 2-0 PDS or Prolene.

Chapter 59 

Breast Reconstruction With Pedicled TRAM Flap

A pedicled TRAM flap is a relatively simple myocutaneous flap that can be performed with a short surgical time.4 When this relatively simple procedure is performed by a qualifi d plastic surgeon, consistently good long-term results are obtained, with minimal morbidities, if the principles, surgical techniques, and management described in this study are observed.

Pearls for Success • The patient and her family should be counseled preoperatively about the advantages of the procedure, expectations, potential results, and complications. • Peripheral perfusion of the flap is maintained with the following: ȤȤ Fluids and electrolytes are given to supply adequate total body volume. ȤȤ Steroids are given to inhibit tissue swelling after surgery. ȤȤ Vasodilators are given to promote circulation. ȤȤ A constant body temperature (36° to 37° C [96.8° to 98.6° F]) is maintained throughout the procedure. • Deepithelialization of the flap is quick and easy when it is performed before flap dissection. It should be limited to the appropriate superfic al layer. Excessive depth of deepithelialization can injure the vasculature in the dermal layer. • The lateral and medial rows of perforators are carefully dissected and preserved during flap elevation. All of these vessels are included in the pedicle. • To create and maintain the inframammary fold, which is essential for an aesthetically satisfactory reconstruction, the location of the subcutaneous tunnel is shifted to the side with the normal breast to prevent disruption of the fold of the mastectomy wound. • The central part (three fi hs to two thirds) of the rectus muscle is dissected as the pedicle, and the lateral and medial strips of the rectus sheath and muscle are preserved. • Injury to the small intramuscular branches is prevented when the muscle pedicle is prepared. These vessels should be carefully isolated, clipped, and divided with scissors. • Zones I and III are the main part of the transplanted flap. Vascularization is generally reliable when 50% to 60% of the TRAM flap is harvested. • Each transplanted flap is trimmed and tailored to match the contralateral breast. The flap is inset vertically, with the umbilical wound located at the central inframammary fold. • The integrity of the donor rectus sheath and muscle is established by suturing the linea arcuata to the transected distal end of the anterior rectus sheath and muscle and by suturing the preserved lateral and medial strips of the rectus sheath and muscle.

Refer ences 1. Reaby LL. Reasons why women who have mastectomy decide to have or not to have breast reconstruction. Plast Reconstr Surg 101:1810-1818, 1998. 2. Christian CK, Niland J, Edge SB, et al. A multi-institutional analysis of the socioeconomic determinants of breast reconstruction: a study of the National Comprehensive Cancer Network. Ann Surg 243:241-249, 2006. 3. Hartrampf CR, Scheflan M, Black PW. Breast reconstruction with a transverse abdominal island flap. Plast Reconstr Surg 69:216-225, 1982. 4. Buck DW Jr, Fine NA. The pedicled transverse rectus abdominis myocutaneous flap: indications, techniques, and outcomes. Plast Reconstr Surg 124:1047-1054, 2009. 5. Alderman AK, Wilkins EG, Lowery JC, et al. Determinants of patient satisfaction in postmastectomy breast reconstruction. Plast Reconstr Surg 106:769-776, 2000.

929

930

Part VIII 

Plastic Surgery of the Breast

6. Morrow M, Scott SK, Menck HR, et al. Factors influencing the use of breast reconstruction postmastectomy: a National Cancer Database study. J Am Coll Surg 192:1-8, 2001. 7. Milloy FJ, Anson BJ, McAfee DK. The rectus abdominis muscle and the epigastric arteries. Surg Gynecol Obstet 110:293-302, 1960. 8. Moon HK, Taylor GI. The vascular anatomy of rectus abdominis musculocutaneous flaps based on the deep superior epigastric system. Plast Reconstr Surg 82:815-832, 1988. 9. Tregaskiss AP, Goodwin AN, Acland RD. The cutaneous arteries of the anterior abdominal wall: a three-dimensional study. Plast Reconstr Surg 120:442-450, 2007. 10. Scheflan M, Dinner MI. The transverse abdominal island flap. I. Indications, contraindications, results, and complications. Ann Plast Surg 10:24-35, 1983. 11. Blondeel PN, Arnstein M, Verstraete K, et al. Venous congestion and blood fl w in free transverse rectus abdominis myocutaneous and deep inferior epigastric perforator flaps. Plast Reconstr Surg 106:1295-1299, 2000. 12. Edsander-Nord A, Brandberg Y, Wickman M. Quality of life, patients’ satisfaction, and aesthetic outcome after pedicled or free TRAM flap breast surgery. Plast Reconstr Surg 107:1142-1153; discussion 1154-1155, 2001. 13. Alderman AK, Hawley ST, Waljee J, et al. Correlates of referral practices of general surgeons to plastic surgeons for mastectomy reconstruction. Cancer 109:1715-1720, 2007. 14. Taylor GI, Corlett RJ, Caddy CM, et al. An anatomic review of the delay phenomenon. II. Clinical applications. Plast Reconstr Surg 89:408-416; discussion 417-418, 1992. 15. Kim EK, Eom JS, Ahn SH, et al. Evolution of the pedicled TRAM flap: a prospective study of 500 consecutive cases by a single surgeon in Asian patients. Ann Plast Surg 63:378-382, 2009. 16. Larson DL, Yousif NJ, Sinha RK, et al. A comparison of pedicled and free TRAM flaps for breast reconstruction in a single institution. Plast Reconstr Surg 104:674-680, 1999. 17. Ducic I, Spear SL, Cuoco F, et al. Safety and risk factors for breast reconstruction with pedicled transverse rectus abdominis musculocutaneous flaps: a 10-year analysis. Ann Plast Surg 55:559-564, 2005. 18. Serletti JM. Breast reconstruction with the TRAM flap: pedicled and free. J Surg Oncol 94:532-537, 2006. 19. Garvey PB, Buchel EW, Pockaj BA, et al. DIEP and pedicled TRAM flaps: a comparison of outcomes. Plast Reconstr Surg 117:1711-1719; discussion 1720-1721, 2006. 20. Nahabedian MY, Momen B, Galdino G, et al. Breast Reconstruction with the free TRAM or DIEP flap: patient selection, choice of flap, and outcome. Plast Reconstr Surg 110:466-475; discussion 476-477, 2002. 21. Petit JY, Rietjens M, Garusi C, et al. Abdominal complications and sequelae after breast reconstruction with pedicled TRAM flap: is there still an indication for pedicled TRAM in the year 2003? Plast Reconstr Surg 112:10631065, 2003.

K23345_Pu_c59_Br Recon Ped TRAM_r3_cl_911-930.indd 930

4/3/2015 12:47:01 PM

60 Breast Reconstruction With Microsurgical Flap

H

Jung-Ju Huang, Ming-Huei Cheng

artrampf 1 was fi st to describe breast reconstruction with autologous tissue in 1982, when he used a pedicled transverse rectus abdominis myocutaneous (TRAM) flap. The evolution from pedicled TRAM flap to free TRAM flap, free muscle-sparing TRAM flap, and free deep inferior epigastric perforator (DIEP) flap demonstrates the trend to decrease donor site morbidities. 2 In addition, the free superfic al inferior epigastric artery (SIEA) flap was developed to allow dissection of the vascular pedicle without dissection through the rectus abdominis muscle. The complete rectus abdominis muscle and sheath is preserved.3-4 Microsurgery not only makes it possible to transfer lower abdominal tissue without sacrifici g the rectus abdominis muscle, it also allows the transfer of flaps from different donor sites for breast reconstruction. The free gluteal artery perforator (GAP) flap, free transverse gracilis myocutaneous or perforator flap, Ruben’s flap, and profunda artery perforator (PAP) flap were introduced as alternatives for free autologous tissue breast reconstruction in patients in whom lower abdominal tissue was inadequate or used in a previous surgery. For some Asian women, free DIEP and free GAP flaps are preferred for microsurgical breast reconstruction. However, microsurgical breast reconstruction is less popular with most Asian women, because they tend to be thinner and their donor sites are limited. Autologous tissue breast reconstruction is even more difficult in small-breasted patients who request contralateral breast augmentation with unilateral breast reconstruction.

Anatomy of Common Microsurgical Flaps Suitable free flaps for breast reconstruction in most Asian women include abdominal-based flaps such as free DIEP, free muscle-sparing TRAM, free SIEA, and free GAP flaps. Free anterolateral thigh (ALT) flaps can be used in selected patients.

931

932

Part VIII 

Plastic Surgery of the Breast

Abd ominal-B a sed Fl aps

The deep inferior epigastric artery arises from the external iliac artery and runs deep to the inguinal ligament. It travels toward the umbilicus and traverses the deep fascia of the rectus abdominis muscle at either the lower (17%), middle (78%), or upper third (5%) of the muscle.5 Within the muscle, it divides into lateral and medial branches as it courses toward the umbilicus. Each branch gives off two to eight sizable perforators that penetrate the rectus abdominis muscle and nourish the lower abdominal fasciocutaneous flap. These sizable perforators are located in an area 1 to 6 cm lateral to the midline and 2 cm superior to and 6 cm inferior to the umbilicus. Elevation of a free muscle-sparing TRAM flap can include various amounts of the rectus abdominis muscle and one or more of the perforators. A free DIEP flap can be designed based on one or more of these perforators, without including the rectus muscle (Figs. 60-1 and 60-2). Two deep inferior epigastric veins (DIEVs) run with the deep inferior epigastric artery and are responsible for venous drainage. Superfic al inferior epigastric veins (SIEVs), which are sometimes the dominant system, can be selected preoperatively and included to provide additional drainage. The superfic al system supplying the lower abdominal wall comprises the SIEA and SIEV. The SIEA arises from the common iliac artery or the superficial circumflex iliac artery. However, it is absent in 35% of pa-

Fig. 60-1  Th s preoperative computed tomographic angiography of a 39-year-old woman with right breast cancer, stage T1N1M0,reveals sizable perforators for a DIEP flap from the left side.

Fig. 60-2  Preoperative appearance of the patient shown in Fig. 60-1. Immediate breast reconstruction was performed with a free DIEP flap.

Chapter 60 

Breast Reconstruction With Microsurgical Flap

tients6; therefore an SIEA flap is not an option in these patients. The vessel originates 1 to 3 cm below the inguinal ligament and travels superiorly and laterally in the femoral triangle. Before running superfic al to Scarpa’s fascia, the SIEA supplies the inguinal lymph nodes and can be used for vascularized lymph node transfer and simultaneous breast reconstruction. The vessel is located at the midpoint between the pubic symphysis and the anterior superior iliac spine at the level of the inguinal ligament. It then runs superiorly and medially, superfic al to Scarpa’s fascia. One concomitant vein runs with the SIEA. However, it is usually too small for adequate venous drainage. Another SIEV is located 1 to 2 cm lateral to the SIEA for additional venous drainage.

Gl uteal Ar ter y Per fo ra t or Fl ap

A GAP flap can be harvested with the superior gluteal artery (SGAP) or the inferior gluteal artery (IGAP). The superior and inferior gluteal arteries are the terminal branches of the internal iliac artery. The superior gluteal artery travels out of the pelvis above the piriformis muscle. After passing through the sciatic foramen, it divides into superior and deep branches. The deep branch then runs between the gluteus medius muscle and the iliac bone. The superfic al branch runs under the superior portion of the gluteus maximus muscle and supplies this muscle. It also gives off branches through the muscle to supply the overlying adipose tissue and skin of the buttock and is used as the pedicle artery for an SGAP flap. The inferior gluteal artery travels out of the pelvis below the piriformis muscle. It runs with the sciatic nerve, internal pudendal artery, and posterior femoral cutaneous nerve from the pelvis through the sciatic forearm. The vessel is surrounded by adipose tissue below the fascia. It penetrates the deep fascia caudal to the piriform muscle, courses under the inferior portion of the gluteus maximus muscle, and gives off branches that perforate the gluteus maximus muscle and subcutaneous tissue. These perforators can be used for a free IGAP flap. The perforators of an SGAP flap and an IGAP flap are usually very small in most Asians, and the dissection is typically extremely tedious. Both the superficial branch of the superior gluteal artery and the inferior gluteal artery supplying the buttock have relatively short pedicles, compared with that of a DIEP flap. The course of the perforator of an IGAP flap is relatively more oblique and tortuous than that of an SGAP flap; therefore the pedicle length of an SGAP flap can be slightly longer than that of an IGAP flap. About 2 cm or more in pedicle length can be gained with a more lateral perforator.

Indications and Flap Selection Candidates for free flap transfer have a good general health status, available recipient vessels, and adequate flap volume compared with the contralateral breast. Smokers need to cease smoking for at least 1 month before surgery. A preoperative computed tomographic angiography (CTA) is recommended to identify the internal mammary vessels and DIEPs in patients who will undergo delayed reconstruction, because recipient vessels may have been injured during the previous surgery and/or radiotherapy, prompting the need for bigger and more suitable perforators for easy flap dissection (see Fig. 60-1). In patients who have adequate lower abdominal tissue, an abdominal-based flap is the fi st choice for breast reconstruction with a free DIEP, free SIEA, or free muscle-sparing TRAM flap. All scar tissue or areas of previous abdominal surgery should be carefully evaluated. Blood supply can be compromised across scar tissue that is greater than 2 cm from the midline lower abdominal scar. Previous abdominoplasty is an absolute contraindication for performing abdominal-based flaps (Table 60-1). Perforators may have been damaged during previous abdominal liposuction; however, a free DIEP flap or a muscle-sparing TRAM flap may be available. Th s can be determined with preoperative CTA.

933

934

Part VIII 

Plastic Surgery of the Breast

Table 60-1  Indications and Contraindications for Microsurgical Breast Reconstruction Indications

Contraindications

Medical history

Generally healthy

Any medical history that precludes a long operation and anesthesia

Recipient vessel availability

IMA or TDA available

IMA and TDA were used/damaged

Adequate flap volume No previous abdominal surgery

Received previous abdominoplasty

Adequate flap volume No previous surgery on the flap

Previous buttock liposuction history

Flap availability   DIEP   GAP

DIEP, Deep inferior epigastric perforator; GAP, gluteal artery perforator; IMA, internal mammary artery; TDA, thoracodorsal artery.

In patients who have inadequate lower abdominal tissue for breast reconstruction and those in whom the lower abdominal tissue has been used previously, a GAP flap may be a second option for microsurgical breast reconstruction. The selection of an SGAP flap or an IGAP flap is based on the excess adipose tissue surrounding the buttock region. An SGAP flap uses the adipose tissue in the upper gluteal region and may cause an asymmetrical buttock deformity. An IGAP flap can be a better choice for patients who have a large excess of tissue in the saddlebag area, because the donor site scar is hidden. Previous liposuction is an absolute contraindication for SGAP and IGAP flaps. Preoperative CTA or magnetic resonance angiography (MRA) can confi m the presence of healthy perforators in patients who have had surgery in the area. For thin patients without suffici t tissue in the abdomen or gluteal area, flaps other than abdominalbased or gluteal flaps, such as the free ALT flap, free transverse gracilis myocutaneous flap, and PAP flap, can be alternatives.7

Preoperative Assessment In the past, a handheld Doppler device was used for perforator mapping. With more advanced imaging studies, more tools are available for preoperative perforator mapping, such as color duplex ultrasound, CTA, and MRA. Handheld Doppler ultrasonography is inexpensive and easy to perform for preoperative evaluation of the location of the perforators. However, its specific ty is low and it cannot provide a preoperative perforator map of the exact location and intramuscular course of all sizable perforators. Alternatively, color duplex ultrasound provides information regarding perforator size and fl w velocity and has increased specific ty. It is a recommended technique for preoperative perforator evaluation for free DIEP flaps. 8 Despite these advantages, it does not provide a three-dimensional preoperative perforator map, which is possible with CTA and MRA. Recently, CTA has become a routine procedure in many centers. We use it for preoperative perforator evaluation before breast reconstruction with perforator flaps (see Fig. 60-1). The multidetector CT introduced by Masia in 20069 demonstrates the advantages of CTA for breast reconstruction using abdominal flaps. Perforators larger than 3 mm can be identifi d accurately. CTA has become one of the standard preopera-

Chapter 60 

Breast Reconstruction With Microsurgical Flap

tive evaluations for breast reconstruction with free DIEP or SIEA flaps. It provides information about a perforator’s location and size, the three-dimensional course of the DIEA, and its path through the rectus abdominis muscle.10 CTA is a fast, yet costly examination. However, a preoperative perforator map facilitates preoperative planning and shortens overall operation time. Flap dissection can proceed to the major perforator detected by CTA, saving signifi ant surgical time otherwise spent on exploration. It provides information for the intraoperative selection of appropriate perforators, which is particularly important in patients who had previous surgery on the donor site. If no sizable perforators are available, a free DIEP flap can be converted to a free muscle-sparing TRAM flap intraoperatively. Th s is a straightforward procedure. The only disadvantages are the requirements of contrast agents and exposure to radiation. MRA is a more advanced tool for preoperative perforator evaluation. It is noninvasive and radiation free. With modifi ations to the contrast and technique, it is considered as effective as CTA in providing preoperative information. However, the cost of MRA is higher, and the examination takes longer. It is contraindicated in selected patients, such as those with a pacemaker or implanted metal device.

Surgical Technique Recip ient Vess el Pr epara tio n

In immediate breast reconstruction, usually the breast surgeons perform skin-sparing or nipple-sparing mastectomy; therefore a well-dissected subcutaneous pocket is already present for reconstruction. Meticulous hemostasis is needed before the recipient vessels are prepared. In delayed breast reconstruction, the scar is typically excised when the incision is made. Dissection is then carried out in the subcutaneous level, and all scar contracture is released. Dissection proceeds to the clavicle superiorly, the neoinframammary fold inferiorly, the anterior axillary line laterally, and close to the midline medially. The internal mammary artery and vein are our first choice as recipient vessels. The breast pocket is prepared for flap inset, and the third costal cartilage is identifi d by palpation. A segment of the costal cartilage is harvested and stored for later nipple reconstruction. The subperichondrial space is then prepared gently by dissection with a periosteal dissector. The costal cartilage is removed very carefully. After the costosternal junction is approached, the perichondrium is removed by careful dissection with bipolar electrocautery. The internal mammary vessels are exposed (Fig. 60-3). Because the internal mammary artery

Fig. 60-3  The right internal mammary artery and vein of the patient shown in Fig. 60-2 are dissected for use as recipient vessels.

935

936

Part VIII 

Plastic Surgery of the Breast

and vein can be very small in some Asian women, further dissection of these vessels is performed under a microscope with gentle dissection using microforceps. The vein is usually very thin-walled. The adventitia is gently removed, and all side branches of the artery and vein are clipped carefully with either bipolar cauterization or hemoclips. The vessels are then ready to be used as recipients.

Fl ap Har ves t

Abdominal-Based Flaps Allen and Treece11 introduced free DIEP flap dissection for breast reconstruction. The lower abdominal flap is marked as an ellipse. The upper margin of the flap can be designed 1 cm above the umbilicus; however, the lower margin is designed based on a patient’s flap requirements. In most Asians, flap width is 10 to 12 cm, and flap length is about 26 to 36 cm. The exact amount that can be harvested without complicating wound closure is different for each patient. Before a flap is harvested, with the patient’s thigh slightly fle ed, and a pinch test is performed to select a suitable flap width. Skin laxity and abdominal scars are assessed to determine how much to incorporate in the flap. A small segment of muscle containing several perforators is included in a muscle-sparing TRAM flap, and one or two of the largest perforators are usually chosen for a free DIEP flap. An incision is made along the inferior margin of the flap, and the superfic al inferior epigastric artery and vein are explored. The superfic al inferior epigastric veins should be carefully preserved and dissected for a length of about 5 to 7 cm for use as secondary venous drainage in case the flap develops congestion after completion of flap dissection or after flap revascularization. Th s is especially important in Asian patients, who usually require a larger percentage of the flap for reconstruction. In most Asians, if an SIEA flap is planned and the superfic al inferior epigastric artery is of adequate size for flap perfusion, vessel dissection is straightforward. The flap can be elevated in the suprafascial plane completely, without opening the anterior abdominal fascia. The subcutaneous incision is continued to the level just above the abdominal anterior fascia. After the SIEV is dissected and clipped, the upper margin of the flap is incised. The deep layer of subcutaneous tissue is beveled in the upper margin to include an additional 1 to 2 cm of soft tissue in the flap. Suprafascial dissection is then carried out from the flap edge toward the perforators. A fascial split usually is present around the perforator, allowing further dissection and opening of the fascia. A small piece of fascia attached to the perforator is preserved to prevent injury to the vessel when the fascia is opened. The main deep inferior epigastric vessels are traced from the perforator. The distal end of the pedicle is then clipped and divided. The muscle is split to expose the perforators. During flap dissection, if two or more sizable perforators are identifi d from the same split muscle, they can be included together (Figs. 60-4 and 60-5). Otherwise, the inclusion of more than one perforator will require some degree of damage to the rectus abdominis muscle. Motor nerves are preserved during flap dissection if only one perforator is included. During dissection, a small segment of the side branches of the main trunk is included in case a second venous anastomosis is indicated.12 If preoperative CTA does not show sizable perforators or if all perforators look small on exploration, a free DIEP flap can be converted to a free muscle-sparing TRAM flap with fewer flap-related complications. For a muscle-sparing TRAM flap, a small segment of the muscle and anterior fascia is included, usually 1 to 2 cm of muscle around the perforators. Perforators need not be dissected; instead, dissection proceeds directly to the main trunk under the muscle. Flap elevation is more straightforward.

Chapter 60 

Breast Reconstruction With Microsurgical Flap

Fig. 60-4  A free DIEP flap is harvested based on two perforators.

Fig. 60-5  A free DIEP flap measuring 11by 30 cm is

harvested.

Gl uteal Ar ter y Per fo ra t or Fl ap

A GAP flap can be elevated as an SGAP flap or an IGAP flap.13-15 During flap harvest, the patient is placed in a prone or lateral decubitus position. However, most Asian women are small in stature, and a two-team approach is difficult even with the patient in lateral decubitus position. We prefer to harvest the flap with the patient in the prone position. Preoperatively, a line is marked connecting the posterior superior iliac supine and the greater trochanter. Perforators are mapped with the use of a handheld Doppler device. Most of the sizable perforators for an SGAP flap are around the middle and medial third of the line. The flap margin is outlined obliquely from the medial inferior to the lateral superior area to include the perforators. In most Asian women, the flap width is about 6 to 8 cm, and the flap length is about 15 to 20 cm. Flap dissection starts with incisions in the upper and lower margin and proceeds directly down to the fascia of the gluteus maximus muscle. Two to three centimeters of width usually is beveled in the superior and inferior margin to allow wound closure. The perforators are dissected from the lateral to medial aspect of the flap to ensure that the biggest perforator in the subfascial plane is included. The muscle is opened along the muscle fiber directly and can be retracted with a retractor to expose the vessel well. The course of the perforator in a GAP flap is usually tortuous, and spasm is common. The vessel can be irrigated with lidocaine or papaverin. When dissection approaches the superior gluteal artery and vein, good exposure of the gluteus maximus muscle and piriformis muscle is extremely important to prevent injury to the vessels, which are very deep.

937

938

Part VIII 

Plastic Surgery of the Breast

The preoperative marking for an IGAP flap begins with the inferior gluteal line with the patient standing. A handheld Doppler unit is used to map the perforators along the line of the posterior iliac spine to the greater trochanter. The upper margin is marked, including all perforators. The flap is usually designed as a horizontal ellipse. The scar resulting from flap harvest is well hidden in the inferior gluteal line. An incision is made in the upper and lower margin of the flap directly down to the muscle layer. Beveling the superior and inferior deep layer of subcutaneous tissue up to 3 cm helps to include more tissue in the flap if necessary. The perforators are identifi d in the lateral aspect of the flap by subfascial dissection. Usually, medial perforators have a shorter pedicle length than lateral perforators. However, the most sizable perforator should be chosen to minimize postoperative complications such as partial flap loss. During perforator dissection, the light-colored adipose tissue in the medial aspect, which covers the ischium, should not be damaged or included to prevent postoperative discomfort when the patient is in a sitting position. After the biggest perforator is confi med, the gluteus maximus muscle is gently split or spread with retraction. All side branches are carefully cauterized with bipolar electrocautery or small hemoclips. When dissection approaches the inferior gluteal artery, the posterior femoral cutaneous nerve, which travels together with the pedicle, should not be injured. The pedicle is divided when sizable vessels are identifi d and pedicle length is 8 to 10 cm.

Micr ova scul ar Ana st omos is and Fl ap Inset

Before microvascular anastomosis is performed, the flap is securely sutured in the chest wall with the pedicle placed in a smooth route to reach the recipient vessels. Venous anastomosis is usually completed before arterial anastomosis, using 10-0 suture or a coupler. Arterial anastomosis is performed with 9-0 or 10-0 suture manually. After anastomosis, part of zone IV of the DIEP flap can be excised if congestion is observed for 30 minutes. If venous congestion occurs, one of the preserved SIEVs can be anastomosed to either the side branch of the DIEV or end-to-side to the DIEV to obtain a second means of venous drainage.16 Once good perfusion is confi med, the flap is inset with the patient in a sitting position. We prefer to use the ipsilateral pedicle and rotate the flap 180 degrees to obtain better medial fullness, with the bestperfused part of the flap in the medial pole. Zones I and II, or the ipsilateral medial and ipsilateral lateral zones, are better perfused and theoretically have the least possibility of developing fat necrosis. Th s ensures that the best-perfused part of the flap is superomedial. The appearance of this area is important to patients, because it contains cleavage and covers the pedicle. Zone III, or the contralateral medial zone, is an easier area for revision surgery if fat necrosis develops. Suture should be placed smoothly and loosely to prevent excessive tension on the flap. The flap usually swells on the second postoperative day. Th s can place tension on the pedicle, resulting in venous insuffici cy and flap congestion.

Postoperative Care Patients are admitted to the microsurgical ICU for 3 to 5 days. Nursing staff heck the turgor, color, and temperature of the flap every 2 hours and use a pencil Doppler device to assess the perforator artery and vein. In contrast to most white patients, Asians rarely develop deep venous thrombosis after a long surgery or bed rest; therefore prophylactic heparin is not required. In our 15-year experience, we have not given postoperative heparin and low-molecular-weight dextran routinely for flaps. Patients are allowed to ambulate on postoperative days 4 to 7. They are discharged 7 to 10 days postoperatively.

Results In general, the success rate of microsurgical breast reconstruction in most established microsurgical centers is more than 98%, and our success rate was 98.8%.16 Abdominal-based flaps are our fi st choice for microsurgical breast reconstruction and can be transferred successfully based either on the DIEA or SIEA.4 We

Chapter 60 

Breast Reconstruction With Microsurgical Flap

prefer to use a free DIEP flap, because it has a much lower complication rate (3.35% for DIEP flaps versus 25% for SIEA flaps) with similar cost effectiveness.17 Most Asian women are thinner with a smaller abdomen. In our experience, as much as 92% of an abdominal flap has to be used for unilateral breast reconstruction, and management of venous congestion is an important aspect of surgery. The incidence of venous insufficiency requiring secondary drainage with an SIEV was 13% in our series.16 For safe flap transfer, we recommend including the SIEV for additional drainage if a flap becomes congested postoperatively. Our salvage rate was as high as 95% by connecting the superfic al epigastric vein with the DIEV and draining both venous flows into the recipient vein. The overall long-term complication of fat necrosis was about 3.3% in free DIEP flaps.4 With careful perioperative planning, patients’ satisfaction with free flap breast reconstruction was high, even with contralateral breast symmetry procedures performed simultaneously.12

Immediate Deep Infer io r Epiga str ic Per fo ra t or Fl ap A

B

C

D

Fig. 60-6 Th s 39-year-old woman had right breast cancer, stage T1N1M0. She presented for immediate breast reconstruction. Preoperative CTA was performed to map the perforators before surgery. The breast surgeon performed a skin-sparing mastectomy, and immediate breast reconstruction was achieved with a free DIEP flap.

939

940

Part VIII 

Plastic Surgery of the Breast

Del ayed Deep Infer io r Epiga str ic Per fo ra t or Fl ap A

B

D

C

E

F

Fig. 60-7 Th s 43-year-old woman presented with a right breast defect after cancer treatment. A preoperative CTA study was carried out to map the donor flap perforators and to confi m that cancer had neither recurred nor metastasized. Delayed breast reconstruction was offered. A free DIEP flap measuring 11 by 30 cm was harvested (Fig. 60-7, B). The nipple and areola were reconstructed in a separate stage.

Chapter 60 

Breast Reconstruction With Microsurgical Flap

Gl uteal Ar ter y Per fo ra t or Fl ap A

B

C

E

D

F

G

Fig. 60-8 This 45-year-old woman presented after right breast cancer treatment with contralateral breast augmentation with implants. She requested right breast reconstruction with autologous tissue transfer because of cosmetic concerns. Her abdominal tissue was not adequate for reconstruction. A free IGAP flap (Fig. 608, C and D) was therefore used for delayed breast reconstruction.

941

942

Part VIII 

Plastic Surgery of the Breast

Table 60-2  Comparison of the Characteristics of Various Free Flaps for Breast Reconstruction TRAM

Pedicle length (cm)

DIEP

SGAP

IGAP

6-8

8-15

7-12

8-11

Pedicle diameter (mm)

2-3.6

2-3.6

1-3.5

2.5-3.5

Flap width (cm)

12-16

12-16

6-10

6-10

Flap length (cm)

30-40

30-40

20-26

18

1111

1111

11

11

11

11

1111

111

1111

1111

11

111

11

1111

111

111

1111

111

11

1

No

No

Yes

Yes

Flap softness Flap projection Flap volume Donor site morbidities Ease of dissection Change in position required

1111, Excellent; 111, good; 11, fair; 1, poor. DIEP, Deep inferior epigastric perforator; IGAP, inferior gluteal artery perforator; SGAP, superior gluteal artery perforator; TRAM, transverse rectus abdominis myocutaneous.

Table 60-2 summarizes characteristics of free TRAM, DIEP, IGAP, and SGAP flaps. DIEP and SIEA flaps have a larger area of skin. Therefore they are good donor sites for breast reconstruction even for large chest wall skin defects such as those induced by radiation that require a large amount of skin resection in a delayed reconstruction. On the other hand, the amount of skin included in an SGAP or IGAP flap tends to be much smaller and is sometimes difficult to inset in a tight breast pocket, which can result from radiation on the chest wall. Abdominal flaps are softer than SGAP or IGAP flaps. Subcutaneous fat tissue in a GAP flap is usually thicker and fi mer, and breasts reconstructed with free IGAP or SGAP flaps are more projected. The shape more closely resembles that of a young breast. Most of the free flap breast reconstructions that we perform are free DIEP flaps (see Fig. 60-6). Th s is the flap of choice in patients who have adequate abdominal soft tissue (see Fig. 60-7). Nevertheless, most autologous breast reconstructions with GAP and abdominal-based flaps are aesthetically pleasing, and the satisfaction rate is high (see Fig. 60-8). In general, free DIEP or muscle-sparing TRAM flaps provide the most symmetrical and natural result, matching the contralateral breast well.

Management of Complications One of the most common problems is venous congestion in free DIEP or muscle-sparing TRAM flaps. Although donor site morbidities are minimized with free DIEP flaps, venous drainage relies on only one or two perforators. In our previous publications, we reported that a relatively smaller flap was raised, but a larger proportion of the flap was used for flap inset, making venous congestion an even more frequent and important problem in most Asians.4,16 Venous insuffici cy resulted in the use of a limited percentage of the flap and compromised flap viability. The incidence of flap congestion after anastomosis of the DIEV was 20%, which was signifi antly higher than that reported in other publications (2% to 15%).16 Preservation of the SIEV during flap dissection was recommended.4,16 If congestion persists, one of the preserved SIEVs should be anastomosed to one of the side branches of the DIEV or directly to the DIEV in an endto-side manner or to another recipient vein. Intraoperative salvage procedures greatly reduce complications from venous insuffici cy and enhance the viability of the whole flap.

Chapter 60 

Breast Reconstruction With Microsurgical Flap

Midline abdominal scars can complicate breast reconstruction with free abdominal tissues, such as free DIEP, muscle-sparing TRAM, and SIEA flaps. Scarring is associated with higher complications, mainly from poor flap perfusion across the scar. Th s is more signifi ant in patients in whom a larger proportion of the flap has to be included. In our previous experience, the reliability of the flap across the scar was questionable beyond a distance of 2 cm from the scar. In these patients, several refi ement procedures can be performed. The easiest way is to use only a hemi-DIEP flap and excise all the tissues beyond the scar. Th s often results in inadequate flap volume, and patients require an additional implant or fat grafting for volume expansion. Another more difficult but effective option is to dissect bilateral pedicles and connect them to perfuse the entire flap (Fig. 60-9). Th s is more technically demanding, but the whole flap can be used for reconstruction without compromising flap perfusion.18

A

B

C

D

Fig. 60-9  A, Th s 60-year-old woman had a history of right breast cancer and requested breast reconstruction. She

presented with a right breast defect and a hypertrophic, ptotic left breast. She was thin, with a right lower paramedian scar; therefore the hemi-DIEP flap was not adequate for breast reconstruction. After a thorough discussion with the patient, we performed a contralateral breast reduction simultaneously. The entire abdominal flap was needed for reconstruction. B, Bilateral free DIEP flaps were harvested. C, After anastomosis of the right pedicle to the internal mammary artery and vein, bilateral pedicles were anastomosed together to ensure perfusion of the entire flap. D, She is shown 1 year postoperatively.

943

944

Part VIII 

Plastic Surgery of the Breast

The incidence of hernia was reported to be 0% to 4.1% with free DIEP flaps2,19,20 and 3% to 10% with free TRAM flaps.21,22 To reduce donor site morbidities, we suggest using free DIEP flaps if possible. Preoperative CTA is recommended and conversion of a free DIEP flap to a muscle-sparing TRAM flap is needed if no sizable perforators are available to transfer the flap safely. With muscle-sparing TRAM flaps, most of the abdominal fascia can be preserved, and the fascia can be closed primarily in two layers without mesh. However, if a complete free TRAM flap is elevated, use of the mesh is recommended to repair the fascial defect and prevent hernia. Free IGAP and SGAP flaps are considered more difficult to harvest, especially the perforator and pedicle dissection. In the postoperative period, a seroma often accumulates and usually requires maintaining a suction drain for about 2 weeks. In long-term follow-up, some patients notice a depression at the donor site, resulting in asymmetry of the buttocks. Few patients have discomfort when sitting. Fat grafting or scar release is sometimes required to correct the donor site deformity. Allen et al13 reported a donor site revision rate of about 4%. After modifi ation to place the donor site scar in the gluteal crease, fewer patients noted donor site deformity or discomfort during sitting after harvest of a free IGAP flap.

Discussion GAP flaps in most Asian women are usually small and provide inadequate flap volume for an aesthetic result. Some revision surgery will be required, especially to enhance upper medial pole fullness. Volume can be replaced with either an implant or fat graft de ending on the amount needed. With a thorough preoperative discussion with the patient, good preoperative planning, and appropriate flap selection, most free flap breast reconstructions have excellent aesthetic outcomes.

Pearls for Success • Preoperative evaluation of a patient’s general condition, contralateral breast, and available flaps is essential for a successful breast reconstruction. • A preoperative imaging study is highly recommended, particularly CTA or MRA, for perforator mapping that can decrease flap harvest time and total operation time. • The internal mammary vessels are usually the preferred recipient site. Vessel dissection under a microscope is recommended and mastery of microsurgical skills is essential. • A tension-free flap inset helps to prevent vascular compression postoperatively. • Proper management of intraoperative or postoperative complications is critical to ensure the overall success of microsurgical breast reconstruction.

Refer ences 1. Hartrampf CR, Scheflan M, Black PW. Breast reconstruction with a transverse abdominal island flap. Plast Reconstr Surg 69:216-225, 1982. 2. Nahabedian MY, Momen B, Galdino G, et al. Breast Reconstruction with the free TRAM or DIEP flap: patient selection, choice of flap, and outcome. Plast Reconstr Surg 110:466-475; discussion 476-477, 2002. 3. Arnez ZM, Khan U, Pogorelec D, et al. Breast reconstruction using the free superfic al inferior epigastric artery (SIEA) flap. Br J Plast Surg 52:276-279, 1999. 4. Ulusal BG, Cheng MH, Wei FC, et al. Breast reconstruction using the entire transverse abdominal adipocutaneous flap based on unilateral superfic al or deep inferior epigastric vessels. Plast Reconstr Surg 117:1395-1403; discussion 1404-1406, 2006.

Chapter 60 

Breast Reconstruction With Microsurgical Flap

945

5. Milloy FJ, Anson BJ, McAfee DK. The rectus abdominis muscle and the epigastric arteries. Surg Gynecol Obstet 110:293-302, 1960. 6. Ninkovic M. Superfic al inferior epigastric artery perforator flap. In Blondeel PN, Morris SF, Hallock GG, Neligan PC, eds. Perforator Flaps: Anatomy, Technique & Clinical Applications. St Louis: Quality Medical Publishing, 2006. 7. Bernier C, Ali R, Rebecca A, et al. Bilateral breast reconstruction using bilateral anterolateral thigh flaps: a case report. Ann Plast Surg 62:124-127, 2009. 8. Rand RP, Cramer MM, Strandness DE Jr. Color-fl w duplex scanning in the preoperative assessment of TRAM flap perforators: a report of 32 consecutive patients. Plast Reconstr Surg 93:453-459, 1994. 9. Masia J, Clavero JA, Larranaga JR, et al. Multidetector-row computed tomography in the planning of abdominal perforator flaps. J Plast Reconstr Aesthet Surg 59:594-599, 2006. 10. Rozen WM, Ashton MW, Stella DL, et al. The accuracy of computed tomographic angiography for mapping the perforators of the deep inferior epigastric artery: a blinded, prospective cohort study. Plast Reconstr Surg 122:1003-1009, 2008. 11. Allen RJ, Treece P. Deep inferior epigastric perforator flap for breast reconstruction. Ann Plast Surg 32:32-38, 1994. 12. Huang JJ, Chao LF, Wu CW, et al. Simultaneous scarless contralateral breast augmentation during unilateral breast reconstruction using bilateral differentially split DIEP flaps. Plast Reconstr Surg 128:593e-604e, 2011. 13. Allen RJ, Levine JL, Granzow JW. The in-the-crease inferior gluteal artery perforator flap for breast reconstruction. Plast Reconstr Surg 118:333-339, 2006. 14. Allen RJ, Tucker C Jr. Superior gluteal artery perforator free flap for breast reconstruction. Plast Reconstr Surg 95:1207-1212, 1995. 15. Guerra AB, Metzinger SE, Bidros RS, et al. Breast reconstruction with gluteal artery perforator (GAP) flaps: a critical analysis of 142 cases. Ann Plast Surg 52:118-125, 2004. 16. Ali R, Bernier C, Lin YT, et al. Surgical strategies to salvage the venous compromised deep inferior epigastric perforator flap. Ann Plast Surg 65:398-406, 2010. 17. Cheng MH, Lin JY, Ulusul BG, et al. Comparisons of resource costs and success rate between immediate and delayed breast reconstruction using DIEP and SIEA flaps under a well-controlled clinical trial. Plast Reconstr Surg 117:2139-2142, 2006. 18. Henry SL, Chang CC, Misra A, et al. Inclusion of tissue beyond a midline scar in the deep inferior epigastric perforator flap. Ann Plast Surg 67:251-254, 2011. 19. Hamdi M, Weiler-Mithoff EM, ebster MH. Deep inferior epigastric perforator flap in breast reconstruction: experience with the fi st 50 flaps. Plast Reconstr Surg 103:86-95, 1999. 20. Keller A. The deep inferior epigastric perforator free flap for breast reconstruction. Ann Plast Surg 46:474-479; discussion 479-480, 2001. 21. Moran SL, Serletti JM. Outcome comparison between free and pedicled TRAM flap breast reconstruction in the obese patient. Plast Reconstr Surg 108:1954-1960; discussion 1961-1962, 2001. 22. Kroll SS, Baldwin B. A comparison of outcomes using three different methods of breast reconstruction. Plast Reconstr Surg 90:455-462, 1992.

K23345_Pu_c60_Br Recon Microsurg_r3_cl_931-946.indd 945

4/3/2015 12:54:36 PM

K23345_Pu_c60_Br Recon Microsurg_r3_cl_931-946.indd 946

4/3/2015 12:54:36 PM

61 Breast Reconstruction With Implant

B

Chih-Wei Wu, Ming-Huei Cheng

reast reconstruction restores a woman’s body and femininity. Increasing incidences of breast cancer and skin-sparing mastectomies (SSMs) and nipple-sparing mastectomies (NSMs) have increased the need for breast reconstruction. Implants offer a simple approach to breast reconstruction and are the most frequent choice. In a 2012 statistical report by the American Society of Plastic Surgeons,1 80% of the breast reconstructions in the United States involved direct implants or tissue expanders with implants. In Asia, the overall breast reconstruction rate is far lower than in Western countries; however, the number has grown in recent years, especially for implant-based reconstruction.

General Considerations for Breast Implants in Asians Chara cter is tics of Asian Patient s fo r Impl ant Rec onstr uctio n

Compared with women in Western countries, Asian women are generally thinner, with small to moderatesized breasts that are typically round and nonptotic. The lack of suffici t donor fat tissue usually precludes autologous reconstructive options. Asian woman are typically younger, and fewer are smokers. Because of these characteristics, most Asian women are suitable candidates for reconstruction with implants.2,3 On the other hand, several factors can negatively affect the feasibility or aesthetic results of implant-based reconstruction in Asian women. In most Asian women with small breasts, a mastectomy can sacrifice considerable portion of the breast skin and result in a tight skin envelope that is unsuitable for immediate, one-stage, direct-to-implant reconstruction. Although genetic factors (the BRCA1 and BRCA2 gene mutations) play an important role in breast cancer in Western countries, this does not apply to Asians; therefore most mastectomies in Asian women are unilateral, and reconstructing a perfect match to the contralateral breast is more challenging. Furthermore, the dermis in Asians tends to be thicker, increasing the susceptibility to hypertrophic and unsightly scarring. Careful design of the mastectomy incision and tensionfree wound closure are critical not only to prevent mastectomy flap necrosis, but also to produce a more pleasing and better-hidden scar. Because of these factors, successful breast reconstruction with implants is very challenging in most Asians. Therefore strong collaboration and communication between the breast and reconstructive surgeons are important in the therapeutic approach to Asian breast cancer patients.

947

948

Part VIII 

Plastic Surgery of the Breast

Timing of Immediate Vers us Del ayed Rec onstr uctio n

Breast reconstruction with an implant can be performed either immediately or after a delay. The critical factors regarding the timing of reconstruction are the health of the mastectomy skin flap and the possibility that the procedure will adversely affect the treatment and progress of the breast cancer. If a defin tive implant is used in the fi st operation (an immediate, one-stage, direct-to-implant breast reconstruction), the patient requires only one surgical procedure. With maximal preservation of the native breast skin (an SSM) the aesthetic result and satisfaction rate can be maximized. Other advantages include a shortened time to recovery, a more rapid return to daily activities, and fewer operative procedures. If the viability of the mastectomy skin flap is in doubt or if radiation is to be delivered, either autologous reconstruction or a two-stage tissue expander–implant reconstruction should be considered.

Skin-S par ing Ma stect omy

Toth and Lappert4 fi st described an SSM procedure in 1991. The technique preserves maximal mastectomy skin and facilitates breast reconstruction. It preserves most of the breast skin envelope without violation of the inframammary fold (IMF); this allows the reconstructive surgeon to easily fill the empty breast pocket with a soft tissue flap or prosthesis. It also ensures a better skin color and texture match with the contralateral breast. Concerns with SSM include local recurrence and skin flap necrosis. Studies have shown that the local recurrence rate in patients with SSM is comparable to that in patients who have traditional mastectomy procedures.5 Mastectomy skin necrosis occurs easily in smokers and in patients with a higher BMI, previous radiotherapy, or overthinned mastectomy skin flaps. However, the low incidence of smoking and the low BMI in most Asian women serve as protective factors for mastectomy skin flap circulation. With proper selection of patients and meticulous surgical technique, the incidence of mastectomy skin flap necrosis in SSM can be as low as that of a traditional mastectomy. In our experience, an SSM with a transverse elliptical skin excision that includes the nipple-areola complex (NAC) typically results in the best aesthetic result.

Nipple-S par ing Ma stect omy

An NSM involves preserving the NAC to improve aesthetic outcomes after breast reconstruction. In the past, a signifi ant amount of glandular tissue was preserved within and under the nipple in subcutaneous mastectomy procedures. Th s technique was mainly adopted for prophylactic mastectomy. Because of oncologic concerns, the current approach involves removal of the glandular tissue beneath the nipple. Currently, an NSM is the primary option for patients with carcinoma in situ and those with early stage breast cancer with the primary tumor located at least 2 cm away from the nipple. The major concerns with NSMs are similar to those with SSMs, with the addition of necrosis of the NAC. Compared with traditional mastectomies, NSMs have a comparable oncologic risk; a recent meta-analysis reported a low local recurrence rate of 1.8% after NSM.6 Measures should be taken to prevent necrosis of mastectomy skin flaps and NACs. Studies have shown that smoking, higher BMI, preoperative irradiation, and incision type are predictors of complications in NSM patients.7 In our experience with patients whose breast skin can be fully spared in an NSM, making an incision at the lateral IMF provides the best aesthetic results and has the lowest complication rate. If a portion of breast skin is to be sacrific d, we prefer to incise the skin along the curvilinear line of the breast, where circulation of the NAC can be well preserved.

Selectio n of Impl ant s

Implants are available in different sizes, projections, and widths. Implant choice is largely based on the contralateral breast to achieve the best symmetry. Preoperatively, the contralateral breast base width is measured, and its projection is evaluated with the patient in the supine position. With these measure-

Chapter 61 

Breast Reconstruction With Implant

ments, a surgeon can roughly estimate the size of the implant. Intraoperatively, the implant selection is further aided by placement of a mammary sizer to simulate the implant. Another method for choosing an appropriate implant width is to measure the mastectomy specimen, which provides a quick reference. In two-stage tissue expander–implant reconstruction, the implant choice is largely based on the size of the contralateral breast, as determined with a breast sizer. Silicone implants are softer and have a more natural, tactile feel, compared with saline implants. Currently, silicone gel implants are the fi st choice for implant breast reconstruction in Taiwan; however, saline implants cause fewer problems if they leak, and they can be overfilled to overcome rippling. Postoperative rehabilitation varies, depending on the implant surface. A smooth surface implant needs to be mobile in its pocket; therefore patients with these devices are instructed to aggressively massage their breasts, typically beginning 1 week postoperatively. In contrast, a textured surface implant can be immobile yet soft; generally, massage is not needed. However, in our experience, the incidences of rippling and implant palpability are much higher with textured surface implants, which can be attributed to the tighter adhesion between textured surface implants and the thin subcutaneous fat in most Asian women. Therefore we generally prefer to place a smooth implant unless the patient has thick subcutaneous fat that can help to prevent rippling and implant palpability.

Impl ant-B a sed Rec onstr uctio n in a Pr evio us l y Ir rad iated Br ea st

Patients with a history of breast conserving surgery and those with locally advanced breast cancer often have their breasts irradiated before a mastectomy. In patients with a history of breast conservation treatment and radiotherapy, studies have shown that implant-based reconstruction can result in high failure rates even if a two-stage approach is performed.8 In patients with locally advanced breast cancer who receive neoadjuvant radiotherapy, the history of previous radiation negatively affects implant-based breast reconstruction. These patients have more complications and less pleasing aesthetic results compared with patients with nonirradiated breasts. However, this does not preclude the use of implants; it warrants a more individualized surgical approach instead. In some patients, a fibrotic skin change is not obvious after irradiation, and an implant is a good option for breast reconstruction. For patients with more obvious skin changes after radiotherapy, autologous reconstruction helps to replace the irradiated fibrotic skin and soft tissue and achieves signifi antly better aesthetic results.

Pos t mastect omy Rad iatio n

Patients considered to be at high risk for locoregional failure after a mastectomy traditionally have postoperative adjuvant radiotherapy; its increasing use has important implications for breast reconstruction. The possible use of postmastectomy radiation should be thoroughly evaluated before immediate breast reconstruction. Indications for adjuvant radiotherapy vary among institutions but generally include one to two positive axillary lymph nodes, tumors of 4 to 5 cm or more in diameter, and tumors near the resection margin. Despite the most recent prosthetic materials and modern radiation-delivery techniques, the rate of complications (or adverse events) from implant-based breast reconstruction with postmastectomy radiotherapy is high.9,10 Modifi d sequencing of two-stage implant reconstruction in which the expander is exchanged for the permanent implant before postmastectomy radiotherapy begins may result in better reconstructive outcomes,11 but results are contradictory.12 In our experience, in patients who are likely to undergo postmastectomy radiotherapy, the optimal approach is to place a tissue expander in the fi st stage. On the completion of radiotherapy, autologous

949

950

Part VIII 

Plastic Surgery of the Breast

reconstruction is the preferred method. Alternatively, when skin fibrosis is not obvious after radiotherapy, an implant exchange procedure can be performed.

Ind ica tio ns fo r Impl ant-B a sed Br ea st Rec onstr uctio n

Breast reconstruction with implants typically results in nonptotic breast mounds. It is generally indicated for young women with small, round breasts and slender bodies. It offers an effective solution for breast reconstruction in patients with inadequate autologous tissue for reconstruction, those who request shorter operation times or more rapid recovery, and those with medical diseases that preclude long operations.

Surgical Technique One-St a ge Immediate Br ea st Rec onstr uctio n With an Impl ant

One-stage immediate breast reconstruction plays an important role in the physical and mental rehabilitation of breast cancer patients; it has the advantages of (1) maximal preservation of native chest wall skin, (2) rapid recovery time, (3) acceptable cosmetic results, and (4) the need for only a one-stage procedure. One-stage reconstruction helps patients to regain breast shape immediately after one surgery and minimizes the psychological impact associated with the loss of a breast, while preserving the patient’s femininity and sexuality. Experience has shown that immediate reconstruction does not increase the risk of cancer recurrence or metastasis.13 No clinically apparent differences in healing have been observed when patients are treated with adjuvant chemotherapy, and the incidences of seroma, hematoma, wound disruption, and infection are not increased. Ideal candidates for one-stage immediate breast reconstruction with an implant include nonsmoking, lowBMI patients with small, round breasts and limited abdominal tissue. In addition, patients who request more rapid recovery are good candidates. The breast skin envelope should be maximally preserved and the defect accurately assessed to obtain an aesthetically pleasing result. Preoperatively, the midline, IMF, upper poles, and mastectomy incision are marked with the patient in a standing position. A separate incision is planned if axillary dissection is required for positive clinical or sentinel node cases. The procedure is conducted with the patient in a supine position with her arms adducted by her sides. During the mastectomy, a subcutaneous breast pocket is created medial to the sternal border, superior to the clavicle, lateral to the anterior or midaxillary line, and inferior to the IMF. After an SSM is completed, all instruments and drapes are changed, the mastectomy site is inspected, and hemostasis is ensured. Attention is then focused on elevating the pectoralis major muscle from the rib cage, with division of its origin from the 3 o’clock to the 9 o’clock position. After a subpectoral pocket is created superior to the clavicle, a 1 by 1 cm graft of costal cartilage with perichondrium is harvested from the fourth rib for future use in nipple reconstruction. Circulation of the mastectomy skin flaps is assessed, and compromised skin edges are trimmed. In patients at higher risk for mastectomy skin flap necrosis, intravenous injection of indocyanine green and visualization of fluorescence with an infrared detection device can be helpful for evaluation of the skin envelope viability. A breast sizer is then subcutaneously placed and the wound temporarily closed with staples. The patient is placed in a sitting position, and breast symmetry and the tension and circulation of the chest wall skin are assessed. Patients with pale skin may need to have the implant size reduced until the circulation returns to normal, or it may be necessary to convert the procedure to a two-stage reconstruction. The sizer is then replaced by an implant of the estimated size. A suction drain is placed laterally, and the cartilage is banked above the pectoralis major muscle at the medial side of the reconstructed breast. The subcutaneous tissue is approximated with 3-0 PDS, and the skin is closed with a subcuticular 4-0 Monocryl suture (Fig. 61-1).

Chapter 61 

Breast Reconstruction With Implant

951

A

B

C

E

D

F

G

Fig. 61-1  This 53-year-old woman had left breast ductal carcinoma in situ and was treated with one-stage immediate

breast reconstruction with a silicone implant. A, The patient is shown preoperatively (arrow indicates site of tumor). B, A skin-sparing mastectomy was completed. C, Careful hemostasis was necessary during dissection in the subpectoral plane because of the presence of numerous perforators. D, The completed subpectoral pocket. E, A breast sizer was placed and inflated to simulate the results. The patient was placed in a sitting position for a more accurate evaluation of volume and shape symmetry. F, A textured silicone implant was placed in the subpectoral plane, and the wound was closed. G, Th patient is shown immediately after the procedure.

K23345_Pu_c61_Br Recon Implants_r4_cl_947-960.indd 951

4/8/2015 8:00:16 AM

952

Part VIII 

Plastic Surgery of the Breast

Immediate Two-St a ge Tiss ue Expand er–I mpl ant Br ea st Rec onstr uctio n

Immediate two-stage tissue expander–implant breast reconstruction is currently the most common method used in prosthetic breast reconstruction in Western countries. It is a safe, reliable method of breast reconstruction, with minimal early complications. The incidence of early complications after this procedure is comparable to that after delayed reconstruction. Although the rate of perioperative complications is higher in previously irradiated patients, it is low in patients who do not have radiotherapy. In our experience, most Taiwanese women are better candidates for one-stage reconstruction with a defin tive implant. We generally consider two-stage reconstruction only when postoperative radiation is to be delivered or when compromised circulation of the mastectomy skin flap is confi med by indocyanine green fluorescence. The rate of early complications after an expander insertion is low, similar to the rate after an exchange procedure. Immediately after the mastectomy, the pectoralis major muscle is preserved. We prefer to place the tissue expander in a subcutaneous pocket; subsequently, we place a permanent implant in a subpectoral plane.3 With this method, the expansion process is less painful, and a rapid and more even expansion of the entire breast pocket is possible. Approximately 50 ml of normal saline solution is injected into the expander, a suction drain is placed, and the wound is closed in two layers with dermal 3-0 PDS and subcuticular 4-0 Monocryl sutures. Expansion generally begins 2 weeks after surgery, with the addition of 40 to 120 ml (typically 50 ml) of saline per week. Th s is adjusted based on the patient’s level of discomfort. It is generally safe to expand the expander during chemotherapy, but it is necessary to evaluate the local tissue condition carefully and to check complete blood cell counts regularly. Completion of expansion is determined using the contralateral breast as a guide, with 10% to 20% overexpansion. The implant exchange procedure (second stage) should take place at least 1 month after the last expansion, and a minimum period of 3 months separates the fi st and second stages. It is performed under general anesthesia, and the patient is not hospitalized. The footprint of the contralateral breast serves as a reference and is transposed to the reconstructive site. A 6 to 8 cm incision is made along the previous scar. The subcutaneous expander is explanted, and a capsulotomy is performed. The pectoralis muscle is elevated with preservation of its sternal origin at the level of the third or fourth rib, whereas its inferior border is divided completely. The serratus anterior muscle is preserved. With the patient sitting up, the optimal implant size is determined using a breast sizer. The implant is placed subpectorally, and the adequacy of the pocket dissection is reassessed to facilitate redraping of the breast envelope for the best symmetry. The wound is closed in two layers with no drains (Fig. 61-2).

Chapter 61 

A

Breast Reconstruction With Implant

953

B

C

D

E

F

G

H

Fig. 61-2  Th s 35-year-old woman had a history of a mastectomy for right breast cancer. She presented with a breast

defect and scar contracture. The quality of her right chest wall skin was good; thus a delayed, two-stage tissue expander– implant reconstruction was chosen. A, The patient is shown before the fi st stage. B, After full inflation of the tissue expander, the implant exchange procedure (the second stage) was performed. The patient was marked for transposition of the footprint of the contralateral, healthy breast to the diseased side. C and D, An incision was made along the previous scar, and the subcutaneous expander was removed, revealing a subcutaneous pocket. E, The pectoralis major muscle was elevated from the rib cage to allow implant placement in the subpectoral plane. F-H, Six months postoperatively, the patient was satisfi d with her cosmetic outcome. We generally encourage patients to also have NAC reconstruction, but this patient declined the procedure.

K23345_Pu_c61_Br Recon Implants_r4_cl_947-960.indd 953

4/8/2015 8:00:20 AM

954

Part VIII 

Plastic Surgery of the Breast

Del ayed Rec onstr uctio n

In most Asian women, the breast skin after a mastectomy is too tight for a one-stage implant reconstruction. If the patient was not given radiation previously, skin quality is generally acceptable, and a two-stage tissue expander–implant reconstruction can produce pleasing results. In patients with an irradiated breast, skin quality can help to determine whether implant-based reconstruction is appropriate. In patients whose chest walls display moderate skin changes without induration after irradiation, aesthetic outcomes after reconstruction can be comparable to those for nonirradiated breasts. In contrast, in patients who present with hyperpigmentation or severe radiation-induced skin fibrosis, the rates of poor aesthetic outcomes or capsular contracture are much higher than they are for patients without radiation.13

Postoperative Care Postoperatively, intravenous antibiotics are given for 3 days. Patients are discharged 3 to 5 days after surgery. The drainage tube is usually removed at the clinic 1 to 2 weeks after surgery. Patients are instructed to wear a soft, nonwired bra for 1 month, starting 2 to 3 days postoperatively. Massage typically begins 1 week postoperatively for smooth implants, but may be delayed or unnecessary for textured implants. Lateral or upward migration of the implant needs to be prevented and can be managed with bra adjustment or massage.

Results The success rate with implant reconstruction is generally high. Patient satisfaction is also high, with an average score of 3.2 (of 4) in our series. Though the success rate and patient satisfaction are promising, complications can adversely affect reconstruction outcomes. In our series, the overall complication rate is 21.2% in one-stage reconstruction; for two-stage reconstruction, the complication rate is 8.7% at the fi st stage and 13% at the second stage. Capsular contracture is the most common complication, followed by implant rupture, implant exposure, hematoma, and infection.

Chapter 61 

Breast Reconstruction With Implant

A

B

C

D

E

F

955

Fig. 61-3 Th s 52-year-old woman had ductal carcinoma in situ of her right breast. She had an NSM and one-stage immediate breast reconstruction with a smooth, round silicone implant. She is shown before and 6 months after surgery.

K23345_Pu_c61_Br Recon Implants_r4_cl_947-960.indd 955

4/8/2015 8:00:22 AM

956

Part VIII 

Plastic Surgery of the Breast

A

B

C

D

E

F

Fig. 61-4 Th s 58-year-old woman with right breast invasive ductal carcinoma underwent an SSM and one-stage immediate breast reconstruction with a textured, round silicone implant. She is shown before and 3 months after surgery.

K23345_Pu_c61_Br Recon Implants_r4_cl_947-960.indd 956

4/8/2015 8:00:24 AM

Chapter 61 

Breast Reconstruction With Implant

A

B

C

D

Fig. 61-5 Th s 35-year-old woman with left breast cancer had an NSM and immediate breast reconstruction with a smooth, round silicone implant. Contralateral augmentation was performed to achieve better symmetry; the contralateral implant was placed using a transmidline approach. She is shown before surgery (Fig. 615, A) and 6 months after surgery (Fig. 61-5, B through D).

Management of Complications Compared with autologous reconstruction, the major advantage of prosthetic breast reconstruction is a minimal rate of major complications. Nevertheless, the procedure has signifi ant complications, including chest wall skin necrosis, implant exposure, capsular contracture, infection, hematoma, implant rupture, rippling, and implant palpability. Postoperative bleeding or hematoma can occur if the perforators from either the internal mammary arteries or the intercostal arteries are not well ligated or coagulated during the operation; these complications also frequently occur in patients with coagulopathy. Careful selection of patients and meticulous hemostasis in the breast pocket are essential. Once one of these complications occurs, prompt evacuation is indicated; otherwise, the implant will deteriorate and easily become infected. In cases with severe coagulopathy, implant removal may be needed if bleeding persists after explorative surgery and aggressive correction of the coagulopathy.

957

958

Part VIII 

Plastic Surgery of the Breast

Infection can occur early in the postoperative period or at late stages. In our practice, the incidence is as low as 0% to 2.4% for one-stage and two-stage reconstruction.3 After mastectomy and expander or implant placement, the mastectomy skin flap typically appears reddish for a few days, which may be wrongly regarded as infection. Infection is indicated by progression of redness, painful breast skin, and purulent fluid drainage from the tube. Mild infection often resolves after intravenous antibiotics are given.2,3 If the infection progresses, implant or expander removal may be indicated. If the mastectomy skin flap is very thin, circulation of the chest wall flap can be compromised; thus caution is needed to prevent implant or expander exposure through the mastectomy skin flap or through a poorly healed mastectomy wound. Immediately after a mastectomy and before implant or expander placement, the devitalized edge of the mastectomy skin flap should be trimmed until healthy tissue with fresh bleeding is visible. Wounds should not be closed under excess tension. Th s most often occurs in reconstruction with an oversized implant. If poor skin circulation is observed after surgery, saline solution may need to be temporarily removed from the expander. Superfic al or partial-thickness skin necrosis can be successfully managed with local wound treatment, but care is taken to prevent secondary infection. Full-thickness skin flap loss of large areas may require debridement or removal of the prosthesis. Implant palpability is common in Asian patients. To resolve this problem, an acellular dermal matrix can be placed to cover the lower pole of the prosthesis. Rippling is more easily seen in textured surface implants, in underfilled saline implants, and in patients with thin skin at the upper pole. Efforts to correct this problem include replacement with a smooth implant, overfilling a saline implant, or grafting autologous fat to the upper pole. Autologous fat grafting is also effective in reducing implant palpability. Capsular contracture can occur within several months or after years of reconstruction. It is the most common local complication in prosthetic breast reconstruction, with an incidence rate of 8.3% to 15.9% at long-term follow-up.15,16 It is also the main cause of implant removal in implant breast reconstruction. Surgical intervention is indicated when the contracture has caused obvious deformity or discomfort and the patient chooses to revise or remove the implant. However, it is generally not evident under clothing. In our experience, patients with Baker grade II or III capsular contracture generally do not seek removal for cosmetic concerns, but those with severe discomfort or grade IV capsular contracture usually request treatment (see Chapter 53). A thorough capsulotomy plus a comprehensive rehabilitation program is effective to resolve grades III and IV capsular contracture. Autologous reconstruction with either fat grafting or abdominal flaps may be needed if repeated revisions fail to resolve the problem and the breast deformity becomes difficult to correct with an implant.

Contral ateral

Bal ancing Pr o ced ur es

After implant reconstruction, breasts generally look round and augmented, which may be signifi antly different from the contralateral, natural breast. Therefore contralateral balancing procedures are needed in some cases. In patients with round, projecting breasts, contralateral augmentation is indicated when the diseased breast is larger than the healthy breast. In these patients, an implant can be inserted into the healthy breast to match the size of the reconstructed breast. Patients with mild breast ptosis can have contralateral augmentation to correct the problem and achieve better symmetry. As breast size or the degree of ptosis increases, it becomes more difficult to match with an implant breast reconstruction. These patients may be candidates for a contralateral mastopexy or a reduction.17 Although exact symmetry is difficult to achieve, most patients are satisfi d with the balancing procedure and prosthetic breast reconstruction.

Chapter 61 

Breast Reconstruction With Implant

Nipple Rec onstr uctio n

Regardless of the type of mastectomy or method of reconstruction, we commonly harvest a cartilage graft from the third or fourth rib. In NSMs, nipple reconstruction is not needed. However, the central tissue of the nipple may be removed, resulting in loss of nipple height. A cartilage graft can restore the nipple projection. In patients who have the NAC resected, the cartilage graft is buried at the medial part of the subcutaneous pocket; nipple reconstruction is performed at least 3 months after implant placement or after completion of adjuvant radiotherapy. We previously proposed a modifi d top-hat flap technique for nipple reconstruction, in which the cartilage graft is carved into an inverted-T shape and wrapped around by the wing flaps to a create a neonipple.18

Discussion One-stage direct-to-implant and two-stage tissue expander–implant procedures are reliable approaches for prosthetic breast reconstruction. Compared with other reconstructive options, these procedures have the advantages of being relatively simple procedures with reduced operative time, rapid patient recovery, and no need for a donor site. One-stage immediate reconstruction can be considered when the circulation of the mastectomy skin flap is good and adjuvant radiotherapy is not indicated. Two-stage tissue expander–implant reconstruction can be a safer option with fewer potential complications; however, it requires more offic visits and an additional surgical procedure, causing more inconvenience to patients. Each method has advantages and disadvantages, and these should be comprehensively assessed for each patient. Careful patient selection and appropriate implant size selection are the key factors for successful breast reconstruction with an implant or a tissue expander and implant.

Pearls for Success • Careful patient selection is crucial. Patients who smoke and those with medical diseases, a higher BMI, and a history of irradiation require special precautions. • The native IMF needs to be preserved, or the contralateral IMF should be transposed to the reconstructed side. • Mastectomy skin flap circulation requires careful assessment. Fluorescent angiography can be performed for this purpose. • Mammary sizers are used to guide selection of appropriate implants. • Tagging sutures (either internal or external) are helpful to prevent lateral migration of a prosthesis. • Early bra support helps to prevent implant migration. • Early recognition of infection is critical for effective treatment. • Patients with smooth implants should massage their breasts beginning 1 week after surgery; those with textured surface implants should either delay or avoid massage.

959

960

Part VIII 

Plastic Surgery of the Breast

Refer ences 1. American Society of Plastic Surgeons. 2012 Plastic surgery statistics report. Available at http://www.plasticsurgery. org/news/plastic-surgery-statistics/2013.html. 2. Wang HY, Ali RS, Chen SC, Cheng MH, et al. One-stage immediate breast reconstruction with implant following skin-sparing mastectomy in Asian patients. Ann Plast Surg 60:362-366, 2008. 3. Engel H, Huang JJ, Lin CY, Cheng MH, et al. Subcutaneous tissue expansion and subsequent subpectoral implantation for breast reconstruction in Asian patients: safety and outcome. Ann Plast Surg 70:135-143, 2013. 4. Toth BA, Lappert P. Modifi d skin sparing incision for mastectomy: the need for plastic surgical input in preoperative planning. Plast Reconstr Surg 87:1048-1053, 1991. 5. Carlson GW, Bostwick J III, Styblo TM, et al. Skin-sparing mastectomy. Oncologic and reconstructive considerations. Ann Surg 225:570-575; discussion 575-578, 1997. 6. Endara M, Chen D, Verma K, et al. Breast reconstruction following nipple-sparing mastectomy: a systematic review of the literature with pooled analysis. Plast Reconstr Surg 132:1043-1054, 2013. 7. Colwell AS, Tessler O, Lin AM, et al. Breast reconstruction following nipple-sparing mastectomy: predictors of complications, reconstruction outcomes, and 5-year trends. Plast Reconstr Surg 133:496-506, 2014. 8. Hirsch EM, Seth AK, Dumanian GA, et al. Outcomes of tissue expander/implant breast reconstruction in the setting of prereconstruction radiation. Plast Reconstr Surg 129:354-361, 2012. 9. Cordeiro PG, McCarthy CM. A single surgeon’s 12-year experience with tissue expander/implant breast reconstruction. I. A prospective analysis of early complications. Plast Reconstr Surg 118:825-831, 2006. 10. Barry M, Kell MR. Radiotherapy and breast reconstruction: a meta-analysis. Breast Cancer Res Treat 127:15-22, 2011. 11. Nava MB, Pennati AE, Lozza L, et al. Outcome of different timings of radiotherapy in implant-based breast reconstructions. Plast Reconstr Surg 128:353-359, 2011. 12. Kronowitz SJ, Robb GL. Radiation therapy and breast reconstruction: a critical review of the literature. Plast Reconstr Surg 124:395-408, 2009. 13. Woerdeman LA, Hage JJ, Smeulders MJ, et al. Skin-sparing mastectomy and immediate breast reconstruction by use of implants: an assessment of risk factors for complications and cancer control in 120 patients. Plast Reconstr Surg 118:321-330; discussion 331-332, 2006. 14. Kronowitz SJ. Current status of implant-based breast reconstruction in patients receiving postmastectomy radiation therapy. Plast Reconstr Surg 130:513e-523e, 2012. 15. Cunningham B. The Mentor Core Study on Silicone MemoryGel Breast Implants. Plast Reconstr Surg 120(7 Suppl 1):19S-29S; discussion 30S-32S, 2007. 16. Spear SL, Murphy DK, Slicton A, et al; Inamed Silicone Breast Implant U.S. Study Group. Inamed silicone breast implant core study results at 6 years. Plast Reconstr Surg 120(7 Suppl 1):8S-16S; discussion 17S-18S, 2007. 17. Huang JJ, Wu CW, Leon Lam W, Cheng MH, et al. Simultaneous contralateral breast reduction/mastopexy with unilateral breast reconstruction using free abdominal flaps. Ann Plast Surg 67:336-342, 2011. 18. Cheng MH, Ho-Asjoe M, Wei FC, et al. Nipple reconstruction in Asian females using banked cartilage graft and modifi d top hat flap. Br J Plast Surg 56:692-694, 2003.

62 Nipple-Areola Complex Reconstruction

R

Lanhua Mu, Ru Chen, Xue Zhang, Wei Li, Lee L.Q. Pu

econstruction of the nipple-areola complex (NAC) can be achieved by composite grafting from the contralateral nipple, banking and replantation of the original nipple, and a skin graft from a distant site. In 1949 Adams1 reported the fi st NAC reconstruction with a labial skin graft. The development of the NAC reconstruction has paralleled the advancements in breast reconstruction. Continuous progress in the treatment of breast cancer, technical advances in reconstructive techniques, and increasing public awareness of the possibilities of breast reconstruction have stimulated the development of new techniques in NAC reconstruction. Over the years, numerous techniques of NAC reconstruction have been reported, but many surgeons may still choose their preferred technique for a NAC reconstruction.2-5 In addition, NAC reconstruction in Asian patients may present a unique challenge, because most Asian women have a relatively large nipple and much darker color of the nipple and areolar circle compared with white women. Asian women are also likely to develop a hypertrophic scar in the reconstruction site. In this chapter, we introduce several common techniques that are used for NAC reconstruction in Asian women after autologous or implant-based breast reconstruction with a satisfactory result.

Indications Reconstruction of the NAC is indicated after both autologous and implant-based breast reconstruction to restore the patient’s body image. After mastectomy for cancer, NAC reconstruction can be the final step of breast reconstruction, because prior creation of a symmetrical breast mound is essential. Other conditions requiring NAC reconstruction include congenital or developmental pathology (athelia or amastia), posttraumatic or burn deformities, and nipple loss from complications of breast surgery, such as reduction mammaplasty.

Preoperative Assessment The nipple-areola transforms the reconstructed mound into a breast. When breast reconstruction is done correctly and the nipple-areola reconstruction is attractive, the overall result is pleasing and natural. When the underlying breast reconstruction becomes deformed by capsular contracture or displaced as it settles, the position, size, and shape of the nipple-areola may change unpredictably and deteriorate until it becomes

961

962

Part VIII 

Plastic Surgery of the Breast

H

C

B

F D

G E

A

Fig. 62-1  The ideal position of the NAC. (A, Distance between the lateral and interior borders of the breast; B, dis-

tance between the nipple and the interior border; C, distance between the nipple and the lateral border; D, distance from the nipple to the lowest point of the breast; E, distance between the lowest point of the breast and the inframammary fold; F, semidiameter of the nipple-areola; G, nipple position relative to the inframammary fold; H, nipple position relative to the level of the chest.)

aesthetically unacceptable. To ensure a stable underlying breast mound, we ordinarily delay nipple-areola reconstruction for at least 2 months, or until the breast has assumed its fi al form and position so that the size and shape of the nipple-areola will not be altered. Specific identifiable landmarks help to determine the proper nipple-areola position visually and geometrically. These include the level of the nipple-areola, the triangles with the sternal notch and umbilicus, and the nipple-areola position relative to each breast and the inframammary fold. The nipple-areola position is determined visually with the patient in the standing position and the shoulders relaxed. The nipple-areola position must look right. The proper appearance takes precedence over the measurements, which only confi m the accuracy of the visual positioning. Ultimately, patient satisfaction and acceptance are directly related to the patient’s sense of involvement in the decisions regarding her surgery (Fig. 62-1).

Surgical Technique The most popular method of complete NAC reconstruction uses subdermal pedicle flaps, which are raised as full-thickness skin flaps that receive their blood supply from the subdermal plexus.

Skate Fl ap

The skate flap includes a vertical cutaneous skin flap with bilateral winglike split-thickness skin extensions (Fig. 62-2). Both split-thickness wings are then wrapped around the fat core to create a prominent nipple with approximately 50% overcorrection because of the expected loss of projection.6 Dissection of the vertical cutaneous fat flap leaves a deep V-shaped defect, which is difficult to close primarily without excessive tension and a loss of flap projection or scar dehiscence and hypertrophy. Therefore a small full-thickness skin graft s often needed to close larger defects. In addition, a well-healed skin graft

Chapter 62 

Nipple-Areola Complex Reconstruction

Fig. 62-2  The vertical cutaneous fat flap is elevated with a signifi ant 3.8-4.2 cm

1.5 cm

amount of fatty tissue to provide adequate volume to the nipple and to improve blood supply. The diameter of the NAC circle is usually 3.8 to 4.2 cm, depending on the size of the breast or the proposed size of the reconstructed nipple. The size of the flap should be designed between 1 and 1.5 cm with the same amount of projection.

Fig. 62-3  A 4 by 3 by 3 mm dermal fat graft, hich is harvested from the adjacent area of the full-thickness skin graft donor site, can be used to enhance and maintain the projection of a reconstructed nipple.

Fig. 62-4  An intraoperative view shows the completion of a skate flap for the nipple reconstruction in an Asian patient after an implant-based breast reconstruction.

can add better defin tion to the areolar circle even before tattooing so that the overall cosmetic result can be enhanced. In addition, a dermal fat graft can also be added to the reconstructed nipple before the fi al closure to enhance and possibly maintain the projection of the reconstructed nipple (Fig. 62-3). A dermal fat graft can be used to enhance and maintain the projection of a reconstructed nipple. Th s can be quite valuable for a nipple reconstruction in an implant-based breast reconstruction. Th s is suitable for most Asian women, because a larger nipple reconstruction with adequate projection is usually needed in these patients (Fig. 62-4). An adequate projection is created with the skate flap and a dermal fat graft. A ull-thickness skin graft s placed to cover the raw area after the skate flap reconstruction. Several weeks later, tattooing is done to create the areola. We recommend that the skate flap with a dermal fat graft hould be the fi st choice for the reconstruction of a large nipple, especially in Asian women. 

963

964

Part VIII 

Plastic Surgery of the Breast

St ar Fl ap

The star flap is a modification of the skate flap. It includes a vertical cutaneous fat flap and bilateral fullthickness skin arms oriented at 90-degree angles, which are wrapped around the central flap to cover its subcutaneous surface. Th s design allows direct closure of the donor defect without skin grafting but limited flap dimension. Although the size of the flap was pushed to its limits for primary closure, inadequate projection frequently resulted in patients with large nipples. However, the star flap has become a popular alternative to the skate flap in women with small-size and moderate-size nipples (Fig. 62-5). 

C-V Fl ap

The basic concept of nipple reconstruction with the C-V flap is straightforward. The nipple design is composed of two V flaps and a C flap.7-10 The width of the two V flaps determines the projection of the nipple, whereas the diameter of the C flap determines the diameter and top of the new nipple reconstruction. The flaps are designed as a V to permit primary closure, and the C flap is incised to cap the nipple reconstruction. Harvesting of the C portion of the flap permits a circular site for insetting the V flaps. The flap is planned to the proper diameter; however, an additional 50% projection is planned to provide the best long-term result and to allow shrinkage of the tissues after flap reconstruction. Composite nipple graft do not shrink as much (Fig. 62-6). A

B

C

Fig. 62-5  Star flap. A, A vertical cutaneous fat flap and bilateral full-thickness skin arms oriented at 90-degree angles. B, The two skin arms are sutured to reconstruct the nipple. C, The donor defect should be closed directly.

A

B

C

D

Fig. 62-6  C-V flap. A, The diameter of the C flap will be similar to that of the fi al nipple diameter, and the overall circumference of the two V flaps will approximate the circumference of the new nipple. B, Incisions are made to define the two V flaps and the C flap, and the two V flaps are then elevated from the underlying subcutaneous tissue. C, The fi st suture secures the lowest points of the two V flaps to the center portion of the original site of the C flap. D, The donor site skin is closed.

Chapter 62 

Nipple-Areola Complex Reconstruction

A

B

C

D

Fig. 62-7  Double opposing tab flap. A, The double opposing tab flap is designed. B, The incisions are made. C, The two

flaps are elevated from the underlying subcutaneous tissue and sutured against each other. D, The donor site skin is closed.

Double Oppos ing Tab Fl ap

The double opposing tab flap,11which was based on the concepts of the dermal flap of Hartrampf 5 and the skate flap of Little,6 has avoided some of the problems of those methods and has successfully achieved good nipple shape and projection. Each of the two flaps is similar to the flap used by Hartrampf, but with the tab added to the flap’s lateral aspect. The donor sites of the two flaps are closed similar to Burow’s triangles, which bring the flaps into opposition so that they support each other’s projection. The flap has proved to be a good all-purpose method for nipple reconstruction that is easy to do and easily taught. Projection has remained satisfactory in most patients and has averaged 3.8 mm at 10 months. Ultimately, it will be similar to that of the skate flap to which the double opposing tab flap is conceptually related (Fig. 62-7).

Ar r ow Fl ap

Nipple reconstruction with the arrow flap combines a local skin fat flap shaped as an arrow with a rib cartilage graft. The closure of the vertical limb of the arrow flap occurs at a 45-degree angle and redistributes the wound contracture and centrifugal forces, to which the forces on the surface skin envelope contribute. The new scar develops at the interface of the flap edges at 45-degree angles. After closure of the breast flap, the cartilage is placed between the deepithelialized breast flap and the chest wall skin, where it remains until the second stage of nipple reconstruction. It is routinely placed at the six o’clock position on the new breast. It is easily palpated under the skin and subsequently localized at the time of nipple reconstruction. Nipple reconstruction with the arrow flap breaks up the straight vertical scar that is placed on the nipple. The forces of wound contracture are redistributed to maintain nipple projection. The rib cartilage graft provides additional support and projection for the skin–soft tissue envelope. The blood supply to the arrow flap is random and is derived from vessels in the dermal plexus of the newly reconstructed breast. The arrow flap and rib cartilage graft combination results in an aesthetically pleasing nipple reconstruction that maintains projection over time12,13 (Fig. 62-8).

965

966

Part VIII 

A

Plastic Surgery of the Breast

B

D

C

E

Fig. 62-8  Arrow flap. A, The design of a flap shaped as an arrow. B, The flap is elevated from the underlying subcutane-

ous tissue. C, The nipple is reconstructed and the skin closed. D, Six months after the reconstruction of the nipple. E, Final result after reconstruction of the nipple-areola with a tattoo.

Nipple-Ar eo l a Complex Tat t o oing

Tattooing is used to complete the NAC after primary reconstruction with any technique. Tattooing is simple and effective and can be performed in the outpatient setting. The depth of pigment introduced into the skin is of paramount importance. If pigments are placed superfic ally, they will be lost with desquamation, and those introduced too deeply will be taken up by the lymphatics. Both scenarios result in fading of the tattoo. After several months, pigment particles eventually reside in the upper dermis and only within the cell membranes of the fibroblasts. Bhatty and Berry14 reported that they have had to retattoo 10% of their patients, and Hugo et al15 stated that 40% of their patients required retattooing. The frequency of retattooing will decrease with improved pigments and the use of Munsell color charts. In Asian patients, the NAC is usually large, with a dark areola. The goal is to match the coloring of the NAC of the opposite breast. Sometimes, to achieve symmetry, it is necessary to tattoo the NACs of both breasts. Nearly every Asian patient needs tattooing after NAC reconstruction because of the obvious scar and dark color of the contralateral NAC (Fig. 62-9). In general, Asian patients need darker pigment and more frequent tattooing.

Chapter 62 

A

Nipple-Areola Complex Reconstruction

B

D

967

C

E

Fig. 62-9  Tattooing. A, Before mastectomy. B, Reconstruction of the nipple. C, Reconstruction of the nipple-areola with a tattoo. D, The tattoo machine and dye. E, The fi al appearance of the nipple-areola.

Postoperative Care Postoperative care focuses on maintaining areola graft stability and nipple projection. The skin graft areola reconstruction must remain fi ed to the recipient bed; motion could disrupt the fi e capillaries. Hematoma also prevents a take of the areola graft. Bacterial enzymes could cause skin loss of the reconstructed areola. To protect the graft, the areola is stabilized with tape and a silicone disk that conforms to the graft and resists motion. If the skate flap is compacted and compressed in the postoperative period, it may heal without suffici t projection. To protect the nipple against disruption, a plastic protector is used for the fi st 7 to 10 days. After the initial dressing is removed, the nipple-areola reconstruction is protected with Steri-Strips for another 1 to 2 weeks until there is complete healing and no further drainage. Postoperatively the nipple-areola reconstruction is typically dry, because the normal apocrine and exocrine glands are not functioning. We recommend the use of a moisturizer. Because of erythema during the early postoperative period, the patient usually mistakenly believes that the color match is good and dismisses the need for tattooing. Nonetheless, the redness and excess coloration will subside, and the need for tattooing will soon become apparent.

K23345_Pu_c62_Nip Areola Recon_r2_cl_0961-0972.indd 967

4/3/2015 1:36:28 PM

968

Part VIII 

Plastic Surgery of the Breast

Results In our series the mean projection of the reconstructed nipple at 6 months was 10 mm, which was usually 50% of the primary projection. About 90% of patients were satisfi d with the results of their newly reconstructed NAC. Five percent of women had concerns about the gradual loss of nipple projection and an inadequate return of sensation. Five percent of patients developed some minor complications, such as scarring or loss of color.

Fig. 62-10 Th s 45-year-old woman had NAC reconstruction with a delayed arrow flap after breast reconstruction with a DIEP flap. She had NAC reconstruction with a double opposing tab flap 3 years ago but was not satisfi d with the results. Th s time, the arrow flap was used fi st. Nipple reconstruction was done 2 weeks later. Tattooing of the areola will be performed next.

K23345_Pu_c62_Nip Areola Recon_r2_cl_0961-0972.indd 968

4/3/2015 1:36:29 PM

Chapter 62 

Nipple-Areola Complex Reconstruction

969

Fig. 62-11 Th s 51-year-old woman had NAC reconstruction with an arrow flap and rib cartilage graft after breast reconstruction with a deep inferior epigastric perforator (DIEP) flap. The base of the flap usually measured between 15 and 20 mm, depending on the desired size of the nipple. The two lateral skin flaps were designed to be 20 mm in length. Th s allowed the surgeon to create a skin fat flap that measured up to 60 mm in length. The ultimate height selected was usually based on the opposite nipple but should be designed 25% to 50% longer than desired to account for wound contracture. The cartilage was carved with an arm that extended to provide projection. Since 2005, we have used this technique to reconstruct the NAC in 34 patients. The patients were very pleased with the results.

Fig. 62-12 Th s 48-year-old woman had NAC reconstruction with a double opposing tab flap after breast reconstruction with a DIEP flap. The patient had tattooing of the areola. The results at 24 months after surgery are shown. The patient was very pleased with the results.

K23345_Pu_c62_Nip Areola Recon_r2_cl_0961-0972.indd 969

4/3/2015 1:36:30 PM

970

Part VIII 

Plastic Surgery of the Breast

A

B

C

D

Fig. 62-13 Th s 45-year-old Chinese-American woman initially had bilateral breast reconstructions with a tissue expander and cellular dermal matrix after bilateral mastectomies for stage I breast cancer of the right side and contralateral risk reduction. She had an uneventful course after initial breast reconstruction and underwent tissue expander/silicone implant exchange 3 months later (Fig. 62-13, A). She then underwent bilateral NAC reconstructions with the skate flap, dermal fat graft, and full-thickness skin graft. Both the dermal fat graft and full-thickness skin graft were from each groin for each side of the reconstruction (Fig. 62-13, B). She did well after surgery, and her NAC reconstruction sites healed. Early postoperative followup at 2 months showed that the reconstructed nipple was of adequate size with good projection (Fig. 62-13, C). Late postoperative follow-up at 8 months showed that the projection of both reconstructed nipples was well maintained. Also, this patient had well-defi ed areolar circles without tattooing (Fig. 62-13, D).

Management of Complications NAC reconstruction in Asian women is challenging because they usually have a large nipple and dark areola. In Asian patients we need more available tissue and more effective ways to maintain the projection of the reconstructed nipple. In addition to the classic techniques of NAC reconstruction, a rib cartilage graft r dermal fat graft an frequently be added to achieve long-term projection. The average height of the reconstructed nipple shrinks about 50% within 1 year after surgery. Th s is especially problematic after implant-based breast reconstruction because of the lack of available soft tissue for nipple reconstruction.

Chapter 62 

Nipple-Areola Complex Reconstruction

971

Several methods are used to maintain the projection, such as the use of a rib cartilage graft and dermal fat graft, but the fi al outcome remains less satisfactory for many patients. The limitations associated with NAC reconstruction should be discussed carefully with the patient during the preoperative consultation. Complications of NAC include poor color match, malposition, incorrect size, and necrosis. Intradermal tattooing is the best method for improving poor color match. Complete healing of the NAC is necessary before tattooing. NAC malposition usually occurs when the nipple-areola is reconstructed on an unstable or incomplete breast mound. Therefore it is better to wait until the breast mound becomes stable. Tattooing can alter the size and shape of the areola without surgical intervention. To prevent tissue necrosis, the surgeon must ensure that suffici t tissue is available for nipple reconstruction and that the tension on the closure is not too tight. For implant-based reconstructions in Asian women, the surgeon should use a different technique, such as the double opposing tab flap, to redo nipple reconstruction. Occasionally the local skin flap is delayed to ensure the viability of more tissue that can be used for future large nipple reconstruction.

Pearls for Success • The nipple-areola reconstruction should be placed on a stable breast mound with adequate soft tissue. • A skin graft can be added to close the skin flap donor site to minimize the distortion and enhance the cosmetic appearance of the areolar circle. • The surgeon should add a rib graft r dermal fat graft o maintain long-term projection of the reconstructed nipple. • Proper protection of a reconstructed nipple and immobilization of a placed skin graft an be critical during the postoperative period. • Skin tattooing is a frequent procedure for completion of the NAC reconstruction in Asian women. • Further revision surgery may be needed to improve the reconstructive outcome.

Refer ences 1. Adams WM. Labial transplant for correction of loss of the nipple. Plast Reconstr Surg (1946) 4:295-298, 1949. 2. Farhadi J, Maksvytyte GK, Schaefer DJ, et al. Reconstruction of the nipple-areola complex: an update. J Plast Reconstr Aesthet Surg 59:40-53, 2006. 3. Boccola MA, Savage J, RozenWM. Surgical correction and reconstruction of the nipple-areola complex: current review of techniques. J Reconstr Microsurg 26:589-600, 2010. 4. Shestak KC, Gabriel A, Landecker A, et al. Assessment of long-term nipple projection: a comparison of three techniques. Plast Reconstr Surg 110:780-786, 2002. 5. Anton M, Eskenazi LB, Hartrampf CR. Nipple reconstruction with local flaps: star and wrap flaps. Perspect Plast Surg 5:67-78, 1991. 6. Little JW. Nipple-areolar reconstruction. In Habal MB, et al, eds. Advances in Plastic and Reconstructive Surgery, vol 3. Chicago: Year Book Medical Publishers, 1987. 7. Valdatta L, Montemurro P, Tamborini F, et al. Our experience of nipple reconstruction using the C-V flap technique: 1 year evaluation. J Plast Reconstr Aesthet Surg 62:1293-1298, 2009. 8. Losken A, Mackay GJ, Bostwick J III. Nipple reconstruction using the C-V flap technique: a long-term evaluation. Plast Reconstr Surg 108:361-369, 2001.

K23345_Pu_c62_Nip Areola Recon_r2_cl_0961-0972.indd 971

4/3/2015 1:36:32 PM

972

Part VIII 

Plastic Surgery of the Breast

9. El-Ali K, Dalal M, Kat CC. Modifi d C-V flap for nipple reconstruction: our results in 50 patients. J Plast Reconstr Aesthet Surg 62:991-996, 2009. 10. Eo S, Kim SS, Da Lio AL. Nipple reconstruction with C-V flap using dermofat graft. Ann Plast Surg 58:137-140, 2007. 11. Shestak KC, Nguyen TD. The double opposing periareola flap: a novel concept for nipple-areola reconstruction. Plast Reconstr Surg 119:473-480, 2007. 12. Li W, Mu LH, Luan J, et al. [Nipple-areolar reconstruction with the modifi d arrow flap] Zhonghua Zheng Xing Wai Ke Za Zhi 24:23-25, 2008. 13. Li W, Mu LH, Luan J, et al. Current study of nipple areola reconstruction. Chin J Aesthet Med 14:66-68, 2008. 14. Bhatty MA, Berry RB. Nipple-areola reconstruction by tattooing and nipple sharing. Br J Plast Surg 50:331-334, 1997. 15. Hugo NE, Sultran MR, Hardy SP. Nipple-areola reconstruction with intradermal tattoo and double-opposing pennant flaps. Ann Plast Surg 30:510-513, 1993.

K23345_Pu_c62_Nip Areola Recon_r2_cl_0961-0972.indd 972

4/3/2015 1:36:32 PM

Part IX

Cosmetic Surgery of the Body and Extremities

K23345_Pu_c63 64_Spec Consid Asian_r4_dc_973-982.indd 973

4/3/2015 12:59:31 PM

K23345_Pu_c63 64_Spec Consid Asian_r4_dc_973-982.indd 974

4/3/2015 12:59:32 PM

63 Special Considerations in Asian Cosmetic Body Contour Surgery

B

K. Alex Kim

ody contouring surgery has become the most commonly performed cosmetic surgical procedure in the United States.1 Patient awareness of these procedures is increasing, along with the prevalence of obesity and weight loss trends; therefore body contouring will continue to be one of the most commonly requested procedures. On the other hand, the number of Asian American patients in the United States has been steadily increasing; in 2013, Asian Americans comprised approximately 6% of all patients who underwent cosmetic procedures in the United States. Among cosmetic surgical procedures, the most commonly performed procedures for Asian American patients are augmentation mammaplasty, blepharoplasty, and rhinoplasty, but not body contouring procedures, because obesity is still not prevalent in this population. Currently, the most commonly performed cosmetic surgical procedures among Asians are still blepharoplasty and rhinoplasty; however, the number of Asian patients seeking body contouring procedures is increasing. These procedures include liposuction and abdominoplasty as well as thigh lift and calf reduction. Asian patients are motivated to undergo these procedures by the desire to have an “ideal” body contour. In this chapter, I summarize unique considerations for body contouring surgery among Asians and introduce a guideline to help determine whether an Asian patient is a candidate for body contouring surgery.

Body Mass Index and Body Image To analyze body contouring procedures in Asian patients, surgeons need to understand the cultural bias and body image perception among Asians or Asian Americans. BMI distribution in Asian countries is strikingly different from that in the United States 2,3 (Table 63-1).

975

976

Part IX 

Cosmetic Surgery of the Body and Extremities

Table 63-1  Distribution of Body Mass Index in Asian Countries and the United States* Country

Normal (18.5-24.9) (%)

Overweight (.25) (%)

Obese (.30) (%)

Japan

68.9

23.2

3.1

China

58.9

18.9

2.9

South Korea

63.2

32.1

3.2

Singapore

58.5

32.5

6.9

Vietnam

68.5

5.2

0.5

United States

35.7

66.9

33.9

From WHO Expert Consultation. Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. Lancet 363:157-163, 2004. *Indicated as percentage of population.

Although Asians, and Asian Americans in general, are more slim than non-Asian Americans, there is a strong cultural bias among the Asian population to be “thin” or “thinner” to the point of being signifi antly underweight. Particularly in their teens and twenties, Asian and Asian American women are almost considered “fat” if they weigh more than 100 pounds. In Asian countries, this trend is further reinforced by the increasing obsession with pop culture and Asian celebrities as well as fashion trends. In contrast, the influence of Western pop culture is minimal to Asian people. Patients who have an obsession with being thin routinely use diet pills, count calories, and exercise to be “fit.” Western pop culture does put an emphasis on being thin, but in general, the degree of the “thinness” that these Asian women are seeking goes so far beyond the average “thin” Westerners. The desired facial appearances favored by Asian patients may be influenced by Western culture, but as far as the body contouring procedures are concerned, Asian patients are far more picky and obsessed with being extremely thin. Because average BMI is already low, the desired BMI of Asians is extremely low for the Western standards. Asians are obsessed with having a small amount of excess fat in their abdomen, thighs, back, and upper arms. They want their thighs to be as small as possible. One of my patients said, “I want no fat.” Th s desire to have an extremely thin body is the driving force for their seeking body contouring surgery. Many Asian patients follow various diets and exercise regimens, with limited success, and often become frustrated by not being able to achieve their goals. These patients are not interested in bariatric procedures and are not good candidates for such procedures. Because most Asians are shorter in stature than average whites, many Asian patients want to be seen as taller by being thinner. A thin frame makes a person look taller; therefore some Asians seek calf reduction to make their legs look longer by reducing their width. This far-reaching shift in aesthetic goals prompts surgeons to adjust their perceptional norm of the ideal body shape. Typically among whites, having a subcutaneous tissue of 2 cm by the pinch test is a satisfactory goal after liposuction. Many Asian patients already have less than 2 cm subcutaneous fat in the abdomen, yet they request that the area be liposuctioned further, because they think there is still too much fat (see Fig. 63-1). I do not think it is wise to dismiss these patients as unrealistic, because society admires the thin body image, and everyone strives to be thin.4

Chapter 63 

Special Considerations in Asian Cosmetic Body Contour Surgery

Results

A

B

D

C

G

E

F

I

H

Fig. 63-1 Th s 27-year-old Asian woman requested liposuction of the unwanted fat in her lower abdomen, flanks, upper arms, and medial and posterior thighs (Fig. 63-1, A through F). Six months after surgery, the changes are subtle, but the patient is quite satisfi d with the results (Fig. 63-1, G through I).

977

978

Part IX 

Cosmetic Surgery of the Body and Extremities

Patient Selection Plastic surgeons for this type of patient have a primary objective to assess the nature of the patient’s complaints and attempt to accurately estimate the amount of improvement that the patient is expecting. There may be a signifi ant gap between the patient’s expectation and what can be realistically achieved through surgery. For example, a patient may request liposuction of her thighs to look very thin, but she may have substantial muscle mass and very little subcutaneous fat, making liposuction or any other approach unsuitable to achieve her goal. It is important for the surgeon to validate the patient’s complaints and requests; however, the surgeon must inform the patient about what can and cannot be achieved through surgery. When presented with an Asian patient who wishes to have a body contouring procedure, the surgeon needs to evaluate the patient’s medical history in detail and understand the patient’s aesthetic goals. Often the patient brings photographs of Asian models who she considers to be ideal. During the physical examination, it is important for the surgeon to determine the distribution of subcutaneous fat; the locations of the excess fat or lack thereof, the quality of skin, including the extent of striae; skin thickness; any previous surgical scars and their quality; laxity of the abdominal muscles; the amount of abdominal protrusion; the presence or absence of hernias; and the overall tone and bulk of muscles. In the lower extremities, the surgeon should examine the amount of subcutaneous fat in the inner thigh extending to the knees, overall leg shape, surface irregularities, the level of infragluteal crease and visibility, subcutaneous fat in the calf area, and the contour of the outer thigh and the silhouette down to the ankles. Often the patient points out her “trouble spots” where excess fat is located. Some patients may request removal of subcutaneous fat throughout the abdomen, flanks, and back to lessen the subcutaneous tissue by distributing it evenly, which is possible, because the overall amount of subcutaneous fat is quite small. Commonly cited trouble spots are the lower abdomen, flank area, upper back below the scapula, inner thighs, knees, and calves. The patient’s past medical history should be reviewed carefully. The presence of a serious medical condition, such as hypertension or diabetes, may be a significant risk factor, and medical clearance should be obtained if necessary. Many Asian patients neglect or are reluctant to disclose prior cosmetic procedures, particularly procedures performed in a surgeon’s office, including blepharoplasty, rhinoplasty, and liposuction; therefore the surgeon should inquire about whether the patient has had such procedures. The surgeon needs to be aware that patients also often neglect to inform the surgeon about previous liposuction in the desired area, which may complicate the nature of the procedure and possibly its outcome.

Treatment Options After identifying the patient’s fat distribution and objectives, the surgeon should formulate the treatment options and present them to the patient. Patients who have loose excess skin and multiple striae of the abdomen after multiple pregnancies, for example, may not have many options. These patients are best served with abdominoplasty or mini-abdominoplasty, depending on the degree of excess skin or subcutaneous fat (see Chapter 64). On the other hand, a patient with good skin thickness with moderate subcutaneous fat may be better served with liposuction, with its minimal scarring. To augment some portion of the body, such as the buttocks, the surgeon may consider autologous fat transfer, although many Asian patients may not have a substantial amount of subcutaneous fat as donor material. For liposuction, there are a number of treatment modalities: • Traditional suction-assisted lipectomy • Power-assisted lipectomy

Chapter 63 

Special Considerations in Asian Cosmetic Body Contour Surgery

• Ultrasonic-assisted lipectomy • VASER Lipo System • Laser lipoplasty Surgeons should employ the technology with which they are most familiar, because these technologies are just tools that provide comparable results to those achieved by experienced surgeons. Many Asian patients consider the scar from an abdominoplasty to be very visible and unsightly. The patient does not want a “big ugly scar,” but rather a flat abdomen without any scarring; however, it is often difficult to avoid scarring with abdominoplasty. To obtain informed consent from patients undergoing abdominoplasty or excisional brachioplasty, the surgeon should review the nature of scarring with the patient. Particularly in Asian patients, the scar from brachioplasty tends to be very conspicuous and often hypertrophic and hyperpigmented. Fortunately, very few Asian patients benefit from brachioplasty, and if any patient requests brachioplasty, I would consider performing the procedure with a limited incision within the axilla. A linear scar along the ulnar border of the upper arms should be avoided. Other procedures commonly employed for body contouring include thigh lift with liposuction of the thighs and knees, as well as calf reduction. Liposuction of the calf is a useful adjunct for thigh and knee liposuction; however, the patient needs to be warned about the prolonged swelling and relatively modest improvement this will achieve.5 For cosmetic calf reduction, a new technique to remove a portion of the gastrocnemius muscle through the endoscopic approach or selective neurectomy of the medial gastrocnemius and soleus muscles has been described.6,7

Important Considerations When discussing the treatment options, the surgeon should consider three important factors for Asian patients who are potential candidates for surgery: (1) treatment frequency, (2) invasiveness of the treatment, and (3) the resulting scar (Box 63-1).

Box 63-1  Factors to Consider When Discussing Treatment Options With Asian Patients 1.  Treatment frequency • Number of visits required • Interval of each treatment • Any external signs of the procedure 2.  Invasiveness of the treatment • Type of anesthetic required or requested (patient safety should be the fi st priority) • Duration of the surgery • Amount of pain and discomfort after the procedure • Duration of the recovery (and amount of time off work) 3.  The resulting scar • Scar tends to be more hyperpigmented • Scar maturation tends to take longer for Asians than it does for whites • Location of scar (abdominoplasty and liposuction) • Postoperative scar management plan • Treatment option if a hypertrophic scar develops (steroid injection)

979

980

Part IX 

Cosmetic Surgery of the Body and Extremities

Tr ea t ment Fr eq uency

It is very common for Asian patients to accept making frequent office isits for minor procedures rather than a single visit for a major procedure. As much as possible, it is important for them to be able to continue their daily routines even in the midst of a course of treatment. Asian patients are particularly embarrassed if they have signs of surgery, such as ecchymosis or swelling, that are visible to their family and friends, and even strangers. Furthermore, patients often may not be able to get enough vacation days from their employers to undergo surgery. When liposoluble injections were introduced, many Asian patients were happy to undergo multiple injections over as many as 20 sessions to achieve the desired result, largely because the procedure imposed minimal modifi ations on their daily routines. Asians tend to be patient, so they are more likely to accept multiple minor treatments.

Inva siveness of the Tr ea t ment

The invasiveness of the treatment relates to the stressfulness of the procedure. Asian patients are more likely to avoid having a procedure with a general anesthetic, preferring a procedure performed with a local anesthetic, despite the pain of injections of local anesthetic agents or occasional pain during the procedures. When discussing a liposuction procedure with a surgeon, patients often inquire whether the procedure can be performed with a local anesthetic. As advocated by the proponents of tumescent liposuction, and more recently laser lipoplasty, using a local anesthetic allows a fairly large amount of liposuction to be performed, although such procedures tend to take a lot longer and can be very uncomfortable for the patient. When discussing abdominoplasty with potential patients, the surgeon needs to be straightforward about what is involved during postoperative recovery. Postoperative pain is quite signifi ant for approximately 48 hours after abdominoplasty, and this discomfort may last 3 to 4 weeks or longer, which may not be acceptable for some patients, particularly working professionals.

The Res ul ting Scar

The third factor is the quality of the resulting scar. It is well recognized that the scar quality of Asian patients is not as good as that of white patients. Asian patients tend to develop thicker, more palpable scars with more brownish pigmentation; thus they have a higher risk of having a conspicuous surgical scar. In particular, the abdominoplasty scar in the lower abdomen tends to be more visible and palpable for quite some time after surgery, even up to 1 year postoperatively. I have found that the maturation of the scar seems to take longer in Asian patients; therefore, before surgery, it is imperative to thoroughly discuss with the patient the nature of the resulting scar and the options for minimizing it, including topical therapy and steroid injection. Asian patients are particularly concerned with the appearance of the scar and often refuse to have abdominoplasty because of the resulting scarring. However, they tend to follow instructions quite well for postoperative care, and their level of compliance is very high. In general, compared with white patients, Asians do not expect a dramatic miracle from the operation, tend to be more respectful of the surgeon’s opinions, and do their best to follow instructions. Once the surgeon establishes a good rapport with an Asian patient, the patient can be loyal and may even be a patient for life.

K23345_Pu_c63 64_Spec Consid Asian_r4_dc_973-982.indd 980

4/3/2015 12:59:36 PM

Chapter 63 

Special Considerations in Asian Cosmetic Body Contour Surgery

981

Discussion When determining the best option, as agreed on by both the surgeon and the patient (which may not be the best option according to the surgeon only), the surgeon and the patient must discuss each factor described previously. Th s process is very helpful in establishing rapport with the patient, improving communication, and building trust. If the patient chooses to have a less dramatic procedure that is less invasive and stressful, the surgeon needs to make certain that the patient understands that such a procedure may require multiple treatments. Once the patient agrees to continue with the treatment plan, the surgeon must be aware of the patient’s progress, monitor him or her closely, and make further recommendations when any issues arise.

Pearls for Success • The surgeon needs to understand the psychology of Asian patients seeking body contouring, particularly the Asian perception of body shape and beauty. • The surgeon must have a thorough discussion with the patient before undertaking any procedure. Asian patients tend to ask few questions regarding the procedures, and some patients do not want to know about the potential risks and complications. • A treatment plan must be established that is agreed on by both the surgeon and the patient, with consideration of the treatment frequency, invasiveness of the treatment, and resulting scar. • Th ough the informed consent process and skilled execution of the procedures, the surgeon can establish lifelong loyalty with the Asian patient.

Refer ences 1. American Society of Plastic Surgeons. Report of the 2010 Plastic Surgery Statistics. Arlington Heights, IL: The Society, 2011. 2. World Health Organization. Global Database on Body Mass Index. Geneva, Switzerland: WHO, 2006. 3. WHO Expert Consultation. Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. Lancet 363(9403):157-163, 2004. 4. Chen HC, Karri V, Yu RL, et al. Psychological profile of Taiwanese female cosmetic surgery candidates: understanding their motivation for cosmetic surgery. Aesthetic Plast Surg 34:340-349, 2010. 5. Tsai FC, Chen CH, Lin CY, et al. Analysis of the body mass index and leg profiles of Asian women after total leg sculpture. Plast Reconstr Surg 124:643-650, 2009. 6. Kim IG, Hwang SH, Lew JM, et al. Endoscope-assisted calf reduction in Orientals. Plast Reconstr Surg 106:713718; discussion 719-720, 2000. 7. Tsai FC, Mardini S, Fong TH, et al. Selective neurectomy of the gastrocnemius and soleus muscles for calf hypertrophy: an anatomical study and 700 clinical cases. Plast Reconstr Surg 122:178-187, 2008.

K23345_Pu_c63 64_Spec Consid Asian_r4_dc_973-982.indd 981

4/3/2015 12:59:36 PM

K23345_Pu_c63 64_Spec Consid Asian_r4_dc_973-982.indd 982

4/3/2015 12:59:36 PM

64 Abdominoplasty

A

K. Alex Kim

bdominoplasty was fi st popularized in the 1960s as a means to remove the pannus and tighten the abdominal fascia through a lower abdominal incision, to achieve a narrow waistline and scaphoid-shaped anterior abdomen. There were many technical variations, including various designs of the incision.1 In the 1980s, liposuction technology was introduced, and this procedure quickly became the mainstay of bodycontouring procedures. However, patients with signifi ant excess skin of the abdomen were still candidates for abdominoplasty, and liposuction became an adjunct procedure to augment the effects of the abdominoplasty. Since the 1990s, further refi ements of the surgical technique have been proposed, including the lateral tension abdominoplasty pioneered by Lockwood.2,3 Abdominoplasty in Asian patients can be a very challenging procedure for many surgeons, largely because Asians typically have signifi antly less excess subcutaneous fat and skin (pannus) than Western patients. Thus removal of abdominal tissue may result in a higher location of the scar, or hypertrophic scarring, since some Asians are more prone to such scarring. However, with a thorough preoperative evaluation, careful patient selection, and meticulous execution of the procedure, surgeons can still achieve a highly satisfactory result in these patients. Th s chapter will feature a technique for Asian abdominoplasty with an emphasis on preoperative evaluation, patient selection, indications, surgical techniques, and postoperative care.

Anatomy The key landmarks on the abdomen are the xiphoid process, costal margin, umbilicus, iliac crest, and pubic symphysis. The umbilicus is located on the midline at the level of the superior border of the iliac crest. The abdominal fascial system consists of three fascial layers (the external oblique, internal oblique, and transversalis) that extend laterally to medially, merging to the anterior and posterior rectus sheaths. In the lower abdomen below the arcuate line, all three fascial layers merge to form the anterior rectus sheath. The anterior abdominal skin is innervated by multiple branches of the intercostal nerves (T7 through T12), which penetrate the muscle at the midaxillary line. Some of the lower cutaneous nerves are divided during an abdominoplasty, but most patients experience complete recovery of sensation, with the exception of a small area of skin in the suprapubic area. Of particular note is the lateral femoral cutaneous nerve, which is at risk when the incision is designed low near the anterior superior iliac spine. The injury to this nerve will result in numbness in the anterior superior thigh.

983

984

Part IX 

Cosmetic Surgery of the Body and Extremities

Superior epigastric artery and vein Branches of intercostal artery Branches of lumbar artery

Inferior epigastric artery and vein

Area undermined Line of plication

Area of excision

Fig. 64-1  The key landmarks of an abdominoplasty. The abdominal skin flap is perfused by the branches and perfora-

tors from the musculophrenic, intercostal, and lumbar arteries. The area of undermining shows the extent of the dissection; as a result of this dissection, the direct perforators from the superior and inferior epigastric arteries are divided. Typically, the elliptical area from the mons pubis to the umbilicus is removed.

The anterior abdomen has a rich network of blood supplies. There are perforators from the superior and inferior epigastric arteries that provide perfusion to the central abdomen. The superior lateral skin is supplied by the musculophrenic arteries, which are branches of the intercostal, subcostal, and lumbar arteries. Inferiorly, there is the superfic al epigastric artery and branches of the deep circumflex iliac artery. These arteries create a network of anastomosis and interconnection, making abdominoplasty a safe procedure4 (Fig. 64-1).

Indications Asian patients tend to be thin and have a small frame. The amount of excess skin and fat is relatively minimal, but often patients present with loose skin, extensive striae, protrusion of the abdomen, and rectus diastasis. When treating Asian patients seeking abdominoplasty, the surgeon should consider the nature, location, and extent of the resulting scar; the need for plication of the anterior abdominal fascia; and handling of the subcutaneous fat deposit in the anterior upper abdomen and flank areas. The surgeon must recommend the best option for the patient: abdominoplasty or limited (mini-) abdominoplasty, with or without liposuction. Abdominoplasty is indicated for a patient who has excess skin of the anterior abdomen, and/or protrusion of the anterior abdominal wall from pregnancies or weight loss, and for whom liposuction is not a suffici t procedure to achieve the desired effects. The patient’s body weight should be stable without significant fluctuations. If the patient is actively losing weight successfully, the procedure should be postponed until the weight loss is complete or stationary for at least 6 months. The selection of the procedure, such as full abdominoplasty versus limited (mini-) abdominoplasty, is based on the amount of skin excess and distribution. When there is little skin excess in the lower abdomen, a mini-abdominoplasty is recommended, unless the patient accepts a little higher position of the resulting scar from an abdominoplasty.

Chapter 64 

Abdominoplasty

Table 64-1  Factors Affecting the Feasibility of Abdominoplasty and Appropriate Procedure Modifi ations Condition

Modification

Previous abdominal scar in the upper abdomen (subcostal)

Avoid procedure if the scar is relatively new (less than 5-10 yr); consider reverse abdominoplasty if the scar is bilateral

Smoking

Instruct patient that cessation of smoking is essential; consider miniabdominoplasty or liposuction, or delay the procedure

Comorbidities (diabetes, hypertension, coronary artery disease)

Optimize the condition and consider mini-abdominoplasty if feasible

Previous liposuction

Perform conservative skin excision

Box 64-1  Important Findings on Physical Examination • General shape of the abdomen; excess fat in upper abdomen, flank, and back • Presence of an abdominal scar; particularly a supraumbilical scar • Presence of a hernia, particularly an umbilical hernia • Rectus diastasis • Presence and extent of stretch marks; particularly extension above the umbilicus

Certain patient histories or preexisting conditions constitute relative contraindications to abdominoplasty; modifi ation of the procedure will be required to minimize the risks involved with the procedure (Table 64-1).

Preoperative Assessment A comprehensive physical examination is very important for a successful abdominoplasty (Box 64-1). Any comorbidities should be identifi d, such as a history of hypertension, diabetes, atherosclerosis, previous abdominal surgery, and smoking. The abdominal skin should be thoroughly assessed. In particular, the nature of the skin, such as thickness, elasticity, and pigmentation, should be documented. The extent of skin excess (pannus) needs to be accurately evaluated by palpating the lower abdominal skin with the patient standing, sitting, and bending over (the diver’s test). The amount of excess subcutaneous fat as well as the striae of the abdomen and their distribution need to be assessed and documented (Fig. 64-2). Previous scars of the abdomen also need to be documented accurately. In principle, lower abdominal scars do not interfere with an abdominoplasty, but the presence of a subcostal scar may signifi antly impair the perfusion of the anterior abdominal skin below the scar, resulting in scarring or even skin necrosis. It is best to limit the dissection in this area, or reduce the area of skin at risk by designing the scar slightly higher. A midline scar that extends to the epigastric area requires careful assessment as well. The umbilicus is at risk for necrosis, and the scar will limit the elasticity of the abdominal flap, restricting the extent of the flap to be excised. In this situation, the other option would be a fleu -de-lis type of incision for abdominoplasty, although the patient is unlikely to accept such an extensive scar.

985

986

Part IX 

Cosmetic Surgery of the Body and Extremities

A

B

Fig. 64-2  A indicates the distance from the xiphoid process to the umbilicus; B is the distance from umbilicus to the symphysis pubis. The surgeon should be cautious when A is substantially greater than B; this often suggests the presence of substantial intraabdominal fat, and an abdominoplasty may not result in signifi ant flattening of the abdomen.

Zones of adherence are not a signifi ant factor in most Asian abdominoplasties, because the amount of excess fat is not signifi ant enough to create a second roll in the upper abdomen.

Patient Selectio n

Patients who present with excess skin and subcutaneous tissue of the abdomen after pregnancy or largevolume weight loss are well served with an abdominoplasty, with or without liposuction of the flank or hip areas. The criteria for an ideal candidate for a full abdominoplasty are described below and illustrated in the patient in Fig. 64-3, A: • Stable body weight. In white patients, the BMI should be less than 30; however, in Asian patients, the BMI should be less than 25. If the patient is actively losing weight, abdominoplasty should be postponed until the body weight is reasonably stable (at least 6 months). • No future pregnancies expected. Although there is no medical contraindication to future pregnancies, it is certainly possible that a pregnancy will cause a recurrence of protrusion of a pannus. • Comorbidities. The ideal candidate should have minimal medical problems, or any existing condition should be under adequate control. • Psychological stability. The patient is willing to accept a lower abdominal scar that may take a long time to mature. The procedure also requires 2 to 4 weeks of recovery time. Before surgery, the surgeon should discuss the impact on daily life with the patient and family members. The patient has to be motivated to have the procedure and have a good comprehension of the nature of the procedure and realistic expectations of the outcome (Box 64-2). The criteria for an ideal candidate for a limited (mini-) abdominoplasty are illustrated in the patient in Fig. 64-3, B: • Minimal or moderate amount of excess skin, mostly confi ed to the area below the umbilicus • Minimal or moderate subcutaneous fat of the abdomen • Protrusion of the abdomen from the rectus diastasis, particularly in the lower abdomen • Relatively high level of the umbilicus • Patient request for a short scar; tendency to hypertrophic scarring

Chapter 64 

A

Abdominoplasty

B

Fig. 64-3  A, Typical candidate for abdominoplasty. Th s patient has diffuse but moderate fat deposits over her abdo-

men, and rectus diastasis of the abdomen. There is substantially extended lower abdominal skin and soft tissue. These fi dings make this patient an excellent candidate for a full abdominoplasty. B, Typical candidate for a mini-abdominoplasty. Th s patient has minimal subcutaneous fat deposits over the abdomen and a minimal amount of excess skin; however, she has substantial central and lower rectus diastasis of the abdomen. These fi dings make this patient a good candidate for a mini-abdominoplasty.

Box 64-2  Additional Points to Discuss With Patients Besides the general issues of the procedure and anesthesia, the surgeon should discuss the following with the patient: • The possibility that not all skin and subcutaneous tissue between the suprapubic incision and umbilicus may be removed. In Asians this is certainly a possibility, and the surgeon needs to discuss the potential that there will be a short vertical scar from the closure of the original umbilicus site. • The possibility of skin necrosis of the abdominal flap and umbilicus. If the closure is tight, there is also the potential for dehiscence and delayed healing. • The possibility that revisional procedures, such as correction of dog-ears and scar revision, may be necessary.

Surgical Technique Full Abd ominopl a st y

Preoperative photo documentation is essential. Anterior, lateral, oblique, and posterior views with adequate lighting should be taken with the patient standing. Preoperative markings should be done in the preoperative holding area, also with the patient standing (Fig. 64-4). First, the midline, bilateral costal margin, xiphoid process, anterior superior iliac spine, and the superior border of the iliac crest are marked. Then the incision line in the suprapubic area extending to the inguinal area is marked. The level of the suprapubic incision is generally at the superior border of the pubic hair, or approximately 6 cm from the vulvar commissure. Laterally, the incision should be approximately 3 cm below the anterior superior iliac spine. Many advocate that the lateral line be as high as the anterior superior iliac spine, but most patients prefer that the incision be placed lower.5 The location of the incision and resulting scar—stressing that the resulting scar may be slightly higher—should be discussed with the patient before the procedure to accommodate the

987

988

Part IX 

Cosmetic Surgery of the Body and Extremities

Fig. 64-4  Preoperative markings. The costal margin, the planned incision, and the amount of skin to be removed are marked with the patient in a standing position. A lateral incision is marked about 4 cm below the anterior superior iliac spine.

A

B

Fig. 64-5  A, Intraoperative view after dissection. The blue line shows the costal margin. The black line is the planned plication line. The width of plication at the level of umbilicus is approximately 12 to 15 cm. B, After plication. The umbilicus was brought out between two sutures. No sutures were placed between the base of the umbilicus and the fascia.

patient’s preferences. The surgeon should have the patient adopt a bending-over position to confirm that the planned excision is feasible. An attempt should be made to make the incision as symmetrical as possible.6 The patient is placed in the supine position on the operating table and antiembolic sequential compression devices are applied to the legs. General endotracheal anesthesia is administered. When liposuction of the flanks is planned, the area is infiltrated with a tumescent solution, and after it takes effect, liposuction is completed fi st. The abdominal incision is made deep to the level of fascia and the flap is elevated toward the umbilicus. On reaching the umbilicus, an oval incision is made around the umbilicus to keep it attached to the abdominal fascia. Further elevation of the flap is carried out all the way near the costal margins and over the xiphoid process at the midline (see Fig. 64-1). After the dissection, the anesthesiologist is asked to provide maximum relaxation of the musculature. Then the abdominal fascia is pinched with gauze, which will estimate the maximum amount of plication possible, and a vertical elliptical line of plication is drawn (Fig.

Chapter 64 

Abdominoplasty

64-5, A). Usually the width of the plication at the umbilical level is approximately 12 to 13 cm, and even up to 15 cm. It should be noted that the area between the lowest point of the ribs and iliac crest has no lateral attachment to the bone; thus this area is amenable to more aggressive plication of the fascia. The upper and lower portions are more difficult to aggressively plicate because of the attachment to the ribs and iliac bone, respectively. I use 0 or 1 braided nonabsorbable Ethibond polyester sutures in a buried interrupted fashion, starting from below the xiphoid process down to the pubic symphysis (Fig. 64-5, B). I think that aggressive plication, particularly in the midportion, is essential to achieve a narrow waistline. If the patient has a pad of excess fat over the pubis, the deep portion of the fat (deep to Scarpa’s fascia) can be excised directly to avoid prominence of the mons pubis after abdominoplasty. After the plication, the operating table is fle ed to relieve the tension over the closure. The excess skin is marked as the flap is pulled down and removed. Two 15 Fr round drains are placed through the pubic area under the abdominal skin flap. The location of the neoumbilicus is marked. The incision is closed in layers. The deep layer (Scarpa’s fascia) is closed with interrupted 2-0 PDS sutures and the skin with interrupted 3-0 PDS dermal sutures (Fig. 64-6, A). It is essential to start closing the incision laterally to medially toward the midline to avoid dog-ears (Fig. 64-6, B). A

B

Fig. 64-6  A, Closure of the abdominal incision. Note the vector of skin closure (arrows). The operating table is fle ed to allow a no-tension closure. B, Closure completed.

989

990

Part IX 

Cosmetic Surgery of the Body and Extremities

Muscle plication Area undermined

Skin flap

Fig. 64-7  Full abdominoplasty.

Finally, an oval incision is made over the new umbilical location, and the umbilicus is brought out and sutured with 3-0 PDS dermal sutures. On completion of the procedure, a dry sterile dressing is applied and a compression garment is applied while the patient is on the operating table. The full abdominoplasty is outlined in Fig. 64-7.

Modifica tio ns fo r Mini-Abd ominopl a st y

The markings for a limited abdominoplasty—known as a mini-abdominoplasty or a modifi d abdominoplasty—are also done with the patient standing. The midline is drawn, and the costal margins and xiphoid process are marked. The incision is set relatively low, approximately 6 cm from the vulvar commissure. The incision extends laterally approximately 10 to 15 cm, at the midpoint over the inguinal ligament. Iliac crest and anterior superior iliac spines are marked and horizontal lines drawn to the contralateral side to provide a reference to the location of the umbilicus. An incision is made down to the anterior surface of the abdominal fascia. The anterior abdominal flap is elevated toward the xiphoid process. Laterally, the dissection extends near the anterior axillary line. As the dissection of the flap reaches the umbilicus, the umbilicus is divided at the base, and the location of the umbilicus is marked on the abdominal fascia. Th s will provide a reference when the flap is closed. The superior extent of the dissection is the same as abdominoplasty. It should reach to the costal margin and xiphoid process. The dissection cephalad to umbilicus could be quite difficult without proper instrumentation. A wide (2 inch) lighted retractor with a long, straight blade (20 cm or more) is a useful tool to obtain adequate exposure. The use of a headlight combined with a wide retractor is also a good option. The electrocautery and other instruments need to be long to perform adequately. The plication of the ab-

Chapter 64 

991

Abdominoplasty

Area undermined Muscle plication Skin flap

Fig. 64-8  Mini-abdominoplasty.

dominal fascia should be done in the same way as in an abdominoplasty. Even if the patient has protrusion only in the lower abdomen, the plication should be done from the xiphoid process to the pubic symphysis. If plication is done only below the umbilicus, the upper abdomen may protrude signifi antly more after surgery. Placing sutures in a buried fashion with a long instrument can be difficult, but the surgeon should start from near the xiphoid process and proceed down toward the pubis. After completion of plication, the amount of skin to be excised is determined and the new position of the umbilicus is marked. One should be careful not to aggressively pull the skin downward, because placing the umbilicus too low would be unaesthetic. Typically, the umbilicus is lowered up to 5 cm, depending on its original position. The normal position is at the level of the iliac crest, but I think that within 5 cm of this line is well within the normal range. I use 3-0 PDS sutures to reattach the base of the umbilicus to the corresponding abdominal fascia after plication. The excess skin is removed, drains are placed, and the incision is closed. The abdominal incision is closed in the same way. The deep layer is closed with 2-0 PDS sutures and the skin incision is closed with buried 3-0 PDS dermal sutures. The incision is then dressed with dry sterile gauze, and a compression garment is applied. The mini-abdominoplasty is outlined in Fig. 64-8.

Postoperative Care The patient is instructed to maintain flexi n of the hips while in bed to avoid any excessive tension on the incision and to wear the compression garment all the time for 3 to 6 weeks. The drains are usually removed in 1 to 2 weeks. The patient may resume normal daily activities about 2 to 3 weeks postoperatively, with exercise gradually beginning at about 6 weeks, and full activities at 3 months.

992

Part IX 

Cosmetic Surgery of the Body and Extremities

Results With meticulous attention to details, I think the abdominoplasty in Asian patients provides an excellent improvement in body contour. The following cases demonstrate the signifi ant improvement of the anterior abdominal contour and resulting scar. As seen in Fig. 64-10, the scar from the abdominoplasty shows signifi ant improvement after several years.

Fig. 64-9 Th s 40-year-old Asian patient had rectus diastasis and moderate excess skin and subcutaneous tissue in the abdomen. She requested a full abdominoplasty to achieve a flat, smooth contour. A full abdominoplasty was performed, with plication of the rectus fascia and excision of the skin up to the umbilicus. Although the resulting scar may be slightly asymmetrical, it is satisfactory. She is shown 3 months postoperatively.

Chapter 64 

Abdominoplasty

993

Fig. 64-10 Th s 29-year-old Asian woman with two children presented with extensive striae of the abdomen and rectus diastasis. She had no plans for future pregnancies and requested an abdominoplasty. Four years after the procedure, she continues to maintain her body weight and healthy lifestyle. The scar matured very well after several years, with only a slight discoloration.

K23345_Pu_c64_Abdominoplasty_r5_cl_983-998.indd 993

4/3/2015 1:48:35 PM

994

Part IX 

Cosmetic Surgery of the Body and Extremities

Fig. 64-11 Th s 38-year-old Asian patient had a protruding lower abdomen after having triplets. She was very thin and had a minimal amount of excess skin. She declined a full abdominoplasty because she did not want a long scar, so a mini-abdominoplasty with plication of the fascia from the xiphoid process to the pubis was performed. The umbilicus was floated and reattached to the abdominal fascia. She is shown 1 year postoperatively.

K23345_Pu_c64_Abdominoplasty_r5_cl_983-998.indd 994

4/3/2015 1:48:36 PM

Chapter 64 

Abdominoplasty

995

Fig. 64-12 Th s 44-year-old Asian patient who had had two children requested an abdominoplasty. She had thick skin with minimal striae. A moderate amount of excess subcutaneous fat was diffusely distributed in the anterior abdomen. A full abdominoplasty was recommended, but she declined this because of the long scar, so a mini-abdominoplasty was performed. Th ough the short incision, the plication of the abdominal fascia was performed from the xiphoid process to the symphysis pubis. The procedure left her anterior abdomen flat and accentuated her waistline. She is shown 1 year postoperatively.

K23345_Pu_c64_Abdominoplasty_r5_cl_983-998.indd 995

4/3/2015 1:48:37 PM

996

Part IX 

Cosmetic Surgery of the Body and Extremities

Management of Complications When the procedure is performed systematically, complications are rare. Early complications include infection, bleeding, wound dehiscence, skin flap necrosis, and umbilical necrosis. There is no large study examining the risks of complications in abdominoplasty in Asian populations; however, I think the risks are comparable to the published data.7,8 In my experience, the incidence of seroma seems to be lower in Asian patients, probably because of the smaller areas of dissection. If a seroma develops, needle aspiration is suffici t, although usually multiple aspirations are needed. The most serious complication is skin necrosis in the central lower abdomen. When this occurs, the surgeon needs to decide when to perform debridement. If the area of necrosis is small, such as 1 cm from the incision, it is best to wait until there is a clear demarcation and then proceed with debridement. However, if the area of necrosis is large, the surgeon should promptly perform debridement and attempt to close the wound with vacuum-assisted dressing changes (VAC). Umbilical necrosis is seen more often; however, the wound can be treated conservatively with minimal consequences.

Sur gical Revis io ns fo r Late Aes the tic Pr oblems

There are several issues that need to be considered regarding late aesthetic deformities. In general, the wound closure is relatively tight in Asian patients; thus it is likely that some patients will develop hypertrophy of the resulting scar. Asian patients tend to have a longer period of erythema and induration of the scar after abdominoplasty and therefore require closer monitoring. After initial wound closure, I recommend that patients use a topical scar preparation such as a silicone-based gel for up to 6 months postoperatively. If there are any signifi ant signs of prolonged induration of the scar, a triamcinolone (Kenalog) injection may be administered. Aggressive scar management is warranted. Many patients may lose weight after abdominoplasty, but a recurrence of excess skin and soft tissue in the abdomen is uncommon in Asian patients. More often, patients may return with a more prominent mons pubis after the procedure. Th s can be treated by direct fat excision over the mons pubis at a later date, or liposuction can be performed, which may not be as effective as surgical excision. Th s can be prevented by recognizing the prominence before the abdominoplasty and removing the excess fat during the procedure. Some patients with diffuse fat deposits throughout the anterior abdomen, which diminishes the effect of the abdominoplasty, may require liposuction of the anterior abdomen at a later date. Dog-ears are easy to correct, but this should be postponed until 3 to 6 months postoperatively. The current fashion trend of low-rise pants may create a problem of the scar being “too high,” but this issue can be avoided by thoroughly discussing the location of the scar with the patient preoperatively.

Specific Iss ues With Asian Patient s Und er go ing Abd ominopl a st y

First, the surgeon must make every effort to ensure that patients understand the location and extent of the resulting scar. In Asian patients, the scar tends to take a lot longer to mature and often leaves hyperpigmentation or hypertrophy. The surgeon should develop a standard protocol for wound care and scar management for Asians, discuss the importance of the regimen, and implement the plan throughout the postoperative period.

Chapter 64 

997

Abdominoplasty

Some patients present with more protrusion on the upper portion of the abdomen and with a slightly lower level of the umbilicus. These patients are often difficult to manage, because they have characteristics of central obesity, often found in those with metabolic syndrome.9 These patients tend to have substantial “intestinal fat” and more protrusion in the upper abdomen. Performing the plication of the abdominal fascia could be quite difficult, since the fascia in the upper abdomen is tightly attached to the costal margin, and the plication in the midportion of the abdomen is also very tight despite the muscle relaxation. Th s often results in an improvement in abdominal contour, but residual round protrusion, particularly in the central upper abdomen. Th s type of patient should be treated medically under the care of an internist and an attempt made to lose weight before any surgical procedure is performed. However, when there is a substantial fat deposit in the anterior abdomen in the presence of rectus diastasis, I perform an abdominoplasty, and at least 6 months later, perform liposuction if the patient fails to lose further weight or requests an additional procedure. Concomitant liposuction of the anterior abdomen with abdominoplasty has been advocated by some authors,10,11 but I think this carries a high risk of skin necrosis, particularly in Asian patients with thin subcutaneous tissues, and this combination approach should be avoided (Fig. 64-13).

A

B

C

D

E

F

Fig. 64-13  Th s 49-year-old Asian woman underwent abdominoplasty and liposuction of the flanks. She presented with

rectus diastasis and a moderate amount of excess skin and subcutaneous fat in her abdomen and flanks. A and D, Preoperative views. Seven months later, she returned with persistent subcutaneous fat in the anterior abdomen and underwent liposuction of the abdomen, correction of dog-ears, and scar revision. B and E, Markings for the second procedure are shown, including the areas for liposuction and the widened scar are marked. C and F, The patient is shown 6 months after the second procedure.

998

Part IX 

Cosmetic Surgery of the Body and Extremities

Pearls for Success • It is essential to understand what the patient desires; it is often helpful to be inquisitive. • The abdominal anatomy must be thoroughly understood. • Careful examination of the abdomen and trunk is essential. • Any existing comorbidities that may increase the surgical risk must be identifi d. • Skin resection should be conservative, and plication of the abdominal fascia should be aggressive. • A scar management regimen should be developed that patients can easily follow for a considerable period. • Maturation of the scar will take a long time, so patients need to be aware that patience is important. • Patient selection must be done carefully and the procedure executed meticulously to ensure good outcomes.

Refer ences 1. Matarasso A. Traditional abdominoplasty. Clin Plast Surg 37:415-437, 2010. 2. Lockwood T. High-lateral-tension abdominoplasty with superfic al fascial system suspension. Plast Reconstr Surg 96:603-615, 1995. 3. Lockwood T. Maximizing aesthetics in lateral-tension abdominoplasty and body lifts. Clin Plast Surg 31:523-537, 2004. 4. Nahai FR. Anatomic considerations in abdominoplasty. Clin Plast Surg 37:407-414, 2010. 5. Ramirez OM. Abdominoplasty and abdominal wall rehabilitation: a comprehensive approach. Plast Reconstr Surg 105:425-435, 2000. 6. Thi umalai A, Varma SK. Geometric incision designing for abdominoplasty. Plast Reconstr Surg 109:2534-2536, 2002. 7. Matarasso A, Swift RW, Rankin M. Abdominoplasty and abdominal contour surgery: a national plastic surgery survey. Plast Reconstr Surg 117:1797-1808, 2006. 8. Momeni A, Heier M, Bannasch H, Stark GB. Complications in abdominoplasty: a risk factor analysis. Br J Plastic Surg 62:1250-1254, 2009. 9. Hamdy O, Porramatikul S, Al-Ozairi E. Metabolic obesity: the paradox between visceral and subcutaneous fat. Curr Diabetes Rev 2:367-373, 2006. 10. Saldanha OR, Federico R, Daher PF, et al. Lipoabdominoplasty. Plast Reconstr Surg 124:934-942, 2009. 11. Samra S, Sawh-Martinez R, Barry O, et al. Complication rates of lipoabdominoplasty versus traditional abdominoplasty in high-risk patients. Plast Reconstr Surg 125:683-690, 2010.

K23345_Pu_c64_Abdominoplasty_r5_cl_983-998.indd 998

4/3/2015 1:48:39 PM

65 Liposuction of Trunk, Hips, and Extremities

T

Weigang Cao

he   most frequently performed aesthetic procedure in the world in recent years, traditional liposuction is still one of the most effective modalities for body contouring. With the advent of new techniques such as ultrasonic liposuction, laser-assisted liposuction, and water-jet–assisted liposuction, subcutaneous fatty tissue can be removed with minimal invasive trauma. In this chapter I will describe the anatomy of the trunk and hip regions and the extremities and my preferred technique for performing liposuction in these areas. Several cases are included to demonstrate what can be achieved with this technique and how to avoid complications.

Fat Distribution Tendencies Tr unk

Men and women differ in their fat distribution in the trunk, especially in the abdomen and hips. The superficial fascial system zone of adherence is at the iliac crest in men and several centimeters inferior to the iliac crest in women, and excess extraabdominal fat tends to accumulate above this in the “spare-tire” distribution in men1 (Fig. 65-1).

Fig. 65-1  Characteristic patterns of abdominal and hip fat distribution in men and women.

999

1000

Part IX 

Cosmetic Surgery of the Body and Extremities

During preoperative evaluation the surgeon must distinguish subcutaneous fat from intraabdominal and visceral fat, which is usually seen as a “beer belly,” most often in men. A pinch test or pull-in test will determine the cause of a protuberant abdomen: when the patient is asked to tighten the abdominal muscles, the protuberance lessens and the pinch thickness is minimal, in which case the patient’s protuberance is the result of intraabdominal fat accumulation, often from muscle laxity and poor posture.2 Th s type of intraabdominal fat cannot be removed by any liposuction techniques. If the nature of intraabdominal fat is not properly recognized and is mistakenly thought to be subcutaneous fat, visceral perforation may occur during a liposuction procedure, especially when the procedure is performed by an enthusiastic but inexperienced physician. In general, men tend to accumulate fat intraabdominally, which appears as a convexity in the midline. They accumulate fat extraabdominally in the waistline (the “love handle” deformity) and take on an apple shape. In contrast, women tend to accumulate fat in the lower abdomen, hips, and thighs, giving them more of a pear shape. Women have a lower superfic al fascial system zone of adherence, which is situated laterally approximately 5 cm below the iliac crest near the greater trochanter of the femur, separating the hip from the lateral thigh. Women generally tend to accumulate fat more extraabdominally than men do, because most women habitually pull in the abdominal muscles, which makes intraabdominal fat accumulation less likely. In addition, the presence of numerous striae in the abdominal skin resulting from pregnancy or rapid weight fluctuations contributes to a tendency toward subcutaneous fat accumulation in women. The trunk can be subdivided into smaller subunits, including breasts, the anterior thoracic and lateral thoracic (flanks), the upper abdomen, lower abdomen, lateral lumbar region, back (including upper, middle and lower parts), hips, and so on. Liposuction can be performed on these subunits alone, but more often several of these are combined as an aesthetic unit and are suctioned together in one session to obtain the optimal outcome. In my experience, the abdominal aesthetic unit usually contains not only the upper and lower abdomen itself, but also both the lateral lumbar and midback region and even the lateral hips. There are the other aesthetic units, such as the thoracic unit (the breasts and anterior and lateral thoracic area or flanks, sometimes including the subaxillary regions) and the back unit (the upper, middle, and lower areas of the back). These truncal units can also be combined with the arms, thighs, and buttocks to form new combinations. For instance, the upper and middle areas of the back are frequently suctioned with the arms, and the lower back is usually combined with the hips, buttocks, and thighs.

Extr emities

Fat in the arms tends to accumulate in the lateral and posterior compartments, the deltoid region, and the paraaxillary regions, but it is rarely seen in the medial and anterior aspects of the superfic al brachial compartments. As in the truncal region, there are variations between men and women in fat distribution in the arms: upper arm fat deposits and skin laxity are more often seen in women than in men. Bothered by both fullness and skin laxity of the upper arms, patients are usually reluctant to wear any garments that will reveal the deformity. Male and female fat distribution in the thighs also differs signifi antly. Men rarely have focal fat accumulation in the thighs, whereas women commonly present with saddlebag deformity, a trochanteric bulge lateral to the gluteal crease, and violin deformity,3 a particularly female contour that includes a narrow waist, full hips, and full lateral thighs, with a depression in the zone of adherence to the superfic al fascial system1 between the hips and thighs (Fig. 65-2). Fat often accumulates in the inner aspects of the thighs and knees, and even a circumferential pattern of diffuse fat accumulation is not uncommon in women.

Chapter 65 

Liposuction of Trunk, Hips, and Extremities

1001

Fig. 65-2  Th s healthy young woman is shown before and after correction of a saddlebag deformity as well as a typical violin deformity: a narrow waist, full hips, and full lateral thighs, with a depression in the zone of adherence between the hips and thighs.

Fat accumulation in the calves and ankles is distributed unevenly and is much thinner than in the thighs; it is most likely to be seen in women. The fat is usually accumulated in the posterior, medial, and lateral aspects of the calves and the posterolateral supramalleolar region, whereas fat accumulation in the pretibial area is rare. Interestingly, fat accumulates more in the lateral half of the calf than in the medial half.

Indications With proper patient selection, liposuction of the torso can dramatically improve body contour. Patients with overall obesity are poor candidates for liposuction, whereas individuals with focal, well-demarcated adipose depositions that have proved resistant to a diet and exercise regimen are good candidates. Many patients who seek truncal and hip liposuction are usually overweight or obese. These patients should be encouraged to lose weight fi st before diet-resistant areas are addressed with liposuction. Liposuction should not be offered as a treatment for obesity but rather as a body-contouring technique. However, in practical terms, liposuction is not contraindicated in moderately obese individuals. The patient must commit to undergoing strict lifestyle changes by following a realistic diet program and a goaloriented exercise regimen that he or she will be able to maintain postoperatively. Without this commitment, liposuction should not be the fi st step to enhancing the body’s contour, because this is likely to lead to failure or to only temporary improvement. Patients with fullness of the arms and good skin tone are good candidates for arm liposuction. If the pinch thickness is 2 cm or more on the posterior aspect of the arm and the skin is not extremely lax, liposuction will produce a satisfactory outcome with predictable contour improvement and skin retraction. If the skin is excessively loose, a brachioplasty may be indicated with or without liposuction, but the resultant upper arm scar after brachioplasty is still considered less acceptable by both the patient and surgeon, especially among Asian patients.

K23345_Pu_c65_Lipo Trunk_r4_cl_0999-1022.indd 1001

4/3/2015 1:07:23 PM

1002

Part IX 

Cosmetic Surgery of the Body and Extremities

Every aspect of the thigh may be effectively suctioned with no obvious contraindications as soon as the patient is confi med to be in good general health if local or full thigh lipodystrophy exist. In general, the lateral thigh is the most frequently treated site. The medial thigh is also often suctioned in women who desire a straighter line along the inner aspects of the thigh and medial knee. Enlargement of the calves and ankles resulting from excessive fat accumulation is an indication for liposuction, whereas enlargement from muscular fullness is a contraindication for liposuction of the calves and ankles. Although liposuction may be performed on the calves and ankles alone, it is more often combined with liposuction procedures on other body areas such as the thighs, buttocks, and hips.

Preoperative Assessment The surgeon must carefully evaluate the patient’s medical history, laboratory test results, and observations on physical examination before a liposuction procedure is considered. Perhaps the most important consideration is determining whether the patient’s expectations for the procedure are realistic. The medical history is reviewed to rule out conditions that may exacerbate the risk of bleeding. A history of infection, emboli, thrombophlebitis, edema, and previous surgery in the area of interest, particularly abdominal surgeries, may increase the risks associated with liposuction. During the physical examination the patient is asked to stand and sit so the surgeon can assess the patient’s general habitus and suitability for liposuction and consider the effects of gravity on the overlying skin. The major considerations are the amount of fat and its distribution as well as the characteristics of the overlying skin. Adipose tissue is not evenly distributed in the subcutaneous space because of the intermittent existence of fibrotic connections between the derma and deep fascia, which results in formation of specifi fat compartments in different body areas (Fig. 65-3). Excess accumulation and hypertrophy of adipose tissue in these compartments usually leads to a distorted body configur tion, such as love handles or sparetire deformity, bra bulges, and so on.

Fig. 65-3  The existence of adhesion zones from fibrotic connections between the derma and deep fascia brings about

uneven distribution of fatty tissue in the abdomen and waist, resulting in such deformities as the spare-tire, saddlebags, and bra bulges. (A, Lower abdomen; B, upper abdomen; C, flanks and bra bulges; D, waist; E, hips.)

Chapter 65 

Liposuction of Trunk, Hips, and Extremities

An abdominal bulge results not only from subcutaneous adipose tissue accumulation but also from the visceral intraabdominal fat that cannot be reduced by liposuction; the latter is believed to be the major cause of abdominal bulges in men. It is very important to lower these patients’ expectations and to make it clear to them that a liposuction procedure is not a weight-loss surgery but a body-contouring procedure. and a diet and exercise regimen is essential for a better correction. Other important factors affecting the potential results of liposuction are the patient’s skin tone and dermal thickness. Good skin elasticity ensures its contraction after the operation. A thicker dermis is more likely to retract after liposuction; excessively loose skin or poor skin elasticity will not contract smoothly and evenly, and excess hanging skin may remain after surgery. Skin resection procedures such as abdominoplasty or mini-abdominoplasty in combination with liposuction in such patients may be the best plan, and further postoperative skin-tightening treatments such as radiofrequency therapy are suggested to improve the fi al aesthetic result. Liposuction is appropriate for healthy people with no major systemic disorders. Patients with localized fat deposits who have elastic, thicker, and well-retracted overlying skin will be more likely to have an optimal outcome. Liposuction is not suitable for obese patients who are reluctant to change their lifestyle and to begin and sustain an exercise and diet regimen. Patients should also understand that a postoperative weight gain will negatively affect the improved body contour after liposuction, and fat will accumulate elsewhere on the body. Awareness is increasing in public and medical societies about recent developments in assisted liposuction technologies, such as focused ultrasound, the use of lasers, and radiofrequency. These new devices deliver energy to adipose and connective tissues, fi ally resulting in fat reduction and skin tightening; this helps practitioners to obtain optimal outcomes and avoid complications during liposuction procedures. When a large volume of fi e microfat grafts is needed, such as in combination with a breast or buttock augmentation as well as the other procedures, water-jet–assisted liposuction is preferred.

Surgical Technique I prefer to perform circumferential thigh liposuction in two stages, with the patient in the supine position or prone position, respectively. In the fi st stage, the patient is usually positioned prone for liposuction of the thighs—posterior, posteromedial, and posterolateral—as well as the medial knees. The hips, buttocks, calves, and ankles are usually suctioned together when the patient is in the prone position. The second stage may be performed 3 months later, the remaining areas of the thighs—anterior, anteromedial, and anterolateral—are suctioned with the patient in the supine position. A combination of abdominal liposuction may be planned if the patient so desires. The patient may decide which part of the thigh is fi st suctioned, depending on individual characteristics of lipodystrophy. Circumferential liposuction can also be considered if the patient has a diffuse pattern of fat accumulation in the thighs.

Mar king and Pho t o grap hing

After consultation and completion of the pretreatment assessment, when the patient confi ms the decision to undergo the procedure, informed consent is obtained. Preoperative markings are drawn in a topographic manner. Concentric circles are drawn around the protuberant areas, and the parallel or radial lines indicate feathering areas (Fig. 65-4). The patient stands in a well-lighted room and is photographed. Eight views are usually obtained, including frontal, posterior, and oblique and lateral views from the left and right sides.

1003

1004

Part IX 

Cosmetic Surgery of the Body and Extremities

Fig. 65-4  Preoperative markings outline this patient’s topographic fat distribution characteristics and adhesion zones as she is prepared for a circumferential abdominal and back liposuction procedure, combined with liposuction of the anterior aspects of the thighs.

Tumescent Sol utio n and Selectio n of Anes thes ia

There are several slightly different formulas for tumescent solution, but the main ingredients of the tumescent fluid are similar, including saline solution, lidocaine, epinephrine, and sodium bicarbonate. The recommended maximum dose of lidocaine is 55 mg/kg of body weight according to the American Society for Dermatologic Surgery (ASDS) guidelines4 of care for tumescent liposuction, and some authors adhere to a maximum dosage of 35 mg/kg of body weight, although total doses of 90 mg/kg have been used without inducing symptoms or signs of lidocaine toxicity.5,6 Over the past decade, repeated efforts have been made to lower the total dose of lidocaine in large-volume liposuction by lowering the lidocaine concentration to enable treatment of greater body areas. The lidocaine concentration in our protocol is now reduced to as low as 0.0252%,7 which has been shown to have enough anesthetic effect in combination with a higher concentration of epinephrine without any supplementation with oral or venous sedation. Our standard of tumescent anesthesia is composed of 40 ml 2% lidocaine, 5 ml 1:1000 epinephrine and 125 ml 5% sodium bicarbonate in every 3 L of saline solution (Box 65-1). Injection of tumescent solution warmed to normal body temperature will help to reduce patient discomfort and prevent hypothermia. A large dose of lidocaine can be safely administered during the operation, because resorption is controlled by the dilution of the tumescent solution, and infiltration into a poorly vascularized adipose tissue space is slow; more importantly, epinephrine provides a vasoconstrictive effect. Peak plasma lidocaine levels remain below the threshold of lidocaine toxicity, although a large dose of lidocaine is infused in one session.8 Epinephrine toxicity is rarely seen during a liposuction procedure; 10 mg of epinephrine in one operation is routinely used in our practice if needed, and total epinephrine doses as high as 15 mg have been used without complications. The tumescent technique involves infiltration of 1 to 3 ml for every 1 ml of fat plus infiltrate removed, so it is of paramount importance to remain aware of the risk of pulmonary edema and difficulties with fluid management when large-volume liposuction is performed. The volume of infiltration varies with the size

Chapter 65 

Liposuction of Trunk, Hips, and Extremities

Box 65-1  Formula for Standard Tumescent Solution • 3 L 0.9% saline solution • 40 ml 2% lidocaine • 5 ml ampule of epinephrine (1:1000) • 125 ml 5% sodium bicarbonate Total volume: 3170 ml Lidocaine concentration 0.0252%

A

B

C

Fig. 65-5  Patient preparation and draping. A, Half of the trunk and

buttocks are sterilized and draped, then the patient is asked to turn to the other side. B, The other half of the trunk and buttocks are sterilized and draped. C, The area to be suctioned is circumferentially prepared and draped.

of the fat deposit and other local factors; of utmost importance is the character of the overlying skin. In my experience, the total volume up to 6 L can be infused at a time; otherwise, infusion can be done by stages if a larger volume of tumescent fluids is needed in one session.8 Because most patients undergo treatment of multiple areas now, and some patients may worry about the upcoming procedure and request that discomfort be alleviated during infusion of the tumescent solution, a combined intravenous conscious sedation is administered by an anesthesiologist. Standard sterile preparation and draping are performed, and the patient is placed in the supine or prone position on the operating table, as noted earlier (Fig. 65-5). Some surgeons prefer the lateral decubitus position for body-contouring surgery, but the supine and prone positions provide the most versatile access for treatment and allow bilateral comparison without changing the patient’s position during the operation. The prone position allows contouring of the arms, back, hips and flanks, and lateral, posterior, and medial thighs, whereas the supine position is usually best for contouring the breasts or gynecomastia, the abdomen in truncal regions, and the anterior aspect of the thighs.

1005

1006

Part IX 

Cosmetic Surgery of the Body and Extremities

Infus io n of Tumescent Sol utio ns

Entry incisions for infusion of tumescent solution are selected in the natural skin creases or other inconspicuous sites. The tumescent fluid is infiltrated into the subcutaneous space with a peristaltic pump at 100 to 180 ml per minute. Infiltration is sequenced from one entry site to the next and from one side of the body to the other. The cannula is bent to fit the various shapes in different body areas. The path of the cannula should lie in the plane of the superfic al subdermal fat layer, and “peau d’orange” skin is usually observed during infiltration (Fig. 65-6). Skin gradually becomes fi m and blanches in 15 to 30 minutes as the tumescent solution diffuses evenly into the whole layers of the subcutaneous space. It usually takes 30 to 60 minutes to complete the instillation, depending on the areas instilled and the patient’s sensitivity to pain. It is more appropriate to reduce the infusion speed when only tumescent anesthesia is applied if the patient does not tolerate pain well. When the skin of the area to be treated is fi m, cold, and blanching from the vasoconstrictive effects of epinephrine, this indicates that adequate anesthesia has been achieved (Fig. 65-7). Suction is usually initiated from the area in which the tumescent solution was fi st infused, then advances to other areas in the same sequence as infusion. The interval between infusion and suction in each anatomic site is usually 30 to 60 minutes.

Cho ice of Cannul a

The most commonly used cannulas for liposuction are 3, 4, and 5 mm in diameter. To avoid causing contour irregularities and to ensure a smooth contour, an experienced surgeon may select larger diameter cannulas for effici t fat removal; otherwise, smaller cannulas are preferred. In practice, relative large fat particles in the deep plane are suctioned fi st with a larger cannula, and the suction process gradually moves into the superfic al fat layer with a smaller cannula. Very small fat deposits may be treated with a fi e 2.4 mm cannula.

Fig. 65-6  Infusion of tumescent solution. With infusion in the superfic al subcutaneous plane, the “peau d’orange” phenomenon is often observed.

Fig. 65-7  Signs that infusion of tumescent solution

is complete: the infiltrated skin blanches and feels fi m and cold as a result of the vasoconstrictive effects of epinephrine.

Chapter 65 

Liposuction of Trunk, Hips, and Extremities

Techniq ue

The operative technique in liposuction is frequently anatomic site–specific and slightly different from one individual to another, but the fundamental principles are universal. The surgeon’s nondominant hand helps to secure the suctioned area for easy and precise removal of the deep fat layer (Fig. 65-8, A) while the dominant hand moves the cannula back and forth with reciprocating motions on the superfic al fat (Fig. 65-8, B). Changing the roles the two hands play is convenient for accessing specific anatomic regions and will reduce the surgeon’s fatigue. Crisscrossing, crosshatching, and triangulation describe similar techniques that ensure even, smooth reduction of the fatty layer (Fig. 65-8, C) through suctioning from several entry sites in a series of overlapping fanning motions (Fig. 65-8, D). For most patients both the superfic al and deep layers of fat tissues are suctioned for an optimal cosmetic outcome. The cannula is usually bent to fit the body contour in the waist, back, and hip regions. During the circumferential abdomen liposuction procedure (Fig. 65-8, E), the flanks and lateral midback (bra bulges) are also accessed from the hip incision using a bent cannula (Fig. 65-8, F); thus the patient remains in the supine position and does not change position during the operation. The deep fat layer between the superfic al fascia and deep fascia is usually debulked fi st with a relatively larger cannula, suctioning with a smaller cannula then gradually goes into the superfic al compartment between the subdermal vascular plexus and the superfic al fascia. Great care should be taken to preserve a thin layer of subdermal fat at any anatomic sites treated during liposuction or liposculpture procedure. It is imperative to use a fi e cannula for sculpting in the subdermal fat plane; otherwise, contour irregularities will inevitably occur. The surgeon should evaluate the contour and skin thickness periodically when liposuction proceeds. Determining the endpoint of the procedure is a matter of judgment gained only through experience, but the following criteria are very important. The most important criterion is visual assessment of the contour: A

B

C

D

E

F

Fig. 65-8  A, Debulking of the deep fat layer is begun by pressing the skin surface with the nondominant hand. B, Pinch-

ing the upper fat and moving the cannula in the center of the fat mass facilitates superfi ial fat removal. C, A crisscrossing, crosshatching, or triangulating technique from different entry sites ensures smooth, even contouring and an optimal outcome. D, The surgeon turns to the waist and back after the upper and lower abdomen areas are properly suctioned. E, A second patient is shown. The cannula should be bent properly to fit the body contour in specific anatomic sites. F, Th flank and lateral midback is accessed from the hip incision using a bent cannula.

1007

1008

A

Part IX 

B

Cosmetic Surgery of the Body and Extremities

C

Fig. 65-9  A, Visual assessment of contour will confi m a smooth, symmetrical, proportionate body shape, indicating the

endpoint of the procedure. B, A pinch thickness of less than 2 cm is another important determinant of the endpoint. C, The thickness and flatness of suctioned areas may also be judged by elevating the cannula under the skin through the entry site.

an area is “done” when an optimal contour has been achieved. A smooth transition of the concavities and convexities of the patient’s body frame and underlying structures should be taken into account throughout the process. In the “feathering” technique, fat tissues are gradually removed less and less in the transforming zone from the treated sites to the nearby nontreated sites. Feathering helps to prevent contour irregularities from occurring. Bilateral symmetry is another fundamental assessment for ideal contouring (Fig. 65-9, A). It is easier to perform a secondary liposuction procedure for removing residual fat deposits caused by undercorrection than it is to graft a depressed area resulting from overcorrection. The surgeon should never overcorrect intentionally; if in doubt, removing less fat is a better choice. Pinch thickness is another important criterion for determining the endpoint of the procedure (Fig. 65-9, B). Although the exact pinch thickness varies from site to site and is mainly dependent on the thickness of the dermis, an even thickness at the same anatomic site is the primary request. Palpation is as important as the pinch test: small fat masses or subtle areas of depression may be more easily felt than seen and can be immediately corrected by fi e aspiration or fat equalization, in which a small fat mass is separated into smaller particles using a fi e cannula without negative pressure, and the minute fat particles will graft automatically into subtle depression areas by gently rubbing the skin surface with the hand. Small fat pockets and subtle unevenness can also be observed by elevating the cannula under the skin through the entry site (Fig. 65-9, C). During the liposuction process, the surgeon should be aware of the evolving character of the liposuction aspirate. Suctioning at a specific area should be discontinued when the aspirate turns to bloody red, with little fat aspirated. Once fi al contouring is performed, the sanguinous fluid is evacuated thoroughly before the entry incisions are approximated with 5-0 absorbable sutures in the dermis and then 6-0 nylon sutures for a tight closure. The patient is placed in a fitted compression garment immediately after the incisions are sutured. The patient is usually discharged without discomfort after 30 minutes of observation if only local anesthesia was used. If the patient feels dizziness, nausea, or any discomfort as a result of intravenous sedation or when large-volume liposuction has been performed, it is better to keep the patient under observation for a longer period until all abnormal signs disappear, but overnight hospitalization is usually unnecessary. Some surgeons recommend leaving small incisions open to allow the wetting solution to drain, but continuous exudation will cause inconvenience and discomfort and may make the patient nervous after he or she returns home. A drain is rarely needed after liposuction in my experience; the tumescent solution remaining in the tissue space will soon be absorbed and the leakage of tissue fluid in the suctioned areas will stop after compression garment application.

Chapter 65 

Liposuction of Trunk, Hips, and Extremities

Liposuction of Special Areas Arms

Most commonly, the arms are treated in conjunction with other body-contouring procedures. It is preferable to perform arm liposuction in combination with the back regions of the trunk from the upper back down to the hips and sometimes including the nape of the neck, because all these areas can be treated in one session without changing the patient’s position (Fig. 65-10). If only the arms are to be suctioned, tumescent anesthesia alone is usually enough; otherwise tumescent anesthesia combined with intravenous conscious sedation is appropriate. I usually insert the cannula within the posterior axillary line during liposuction of the arms. The postoperative hypertrophic scar formation is usually not obvious and is often concealed in the line when the arm is at the side. The major fat deposit sites of the arms are easily accessible with this incision. Moreover, liposuction of the subaxillary, lateral thoracic, and lateral region of the midback and upper back can be accomplished through this incision. The patient is placed in the prone position. The arms then can be abducted, adducted, rotated, and extended without limitations at the sides, and the elbows are extended or slightly bent. The operated regions are prepared and draped, with the hands covered with sterile dressings, so the entire upper limb can be freely rotated 0 to 180 degrees from cephalic to caudal along the side of the body, facilitating adequate and smooth fat removal. A smaller caliber cannula is preferable for arm liposuction, usually starting with 2.4 to 3 mm cannulas for deep fat layer and 1.8 to 2 mm cannulas for fi al contouring. The cannula is frequently bent to facilitate access to the lateral compartment and the deltoid regions in the lateral aspect of the arm. The surgeon frequently changes his or her standing position to access the different sites.

A

C

B

Fig. 65-10  Positioning and liposuction of the arms, posterior

axillary region, and upper midback. A, After the patient is placed in the prone position with the forearms and hands covered to facilitate position changes without contamination, the arm is placed in the cephalic direction to suction the fat distributed in the lateral compartment of the arm and the deltoid region. B, Liposuction of the posterior axillary region, back, and shoulder can easily be performed if the hand is dropped down naturally beside the table. C, With the upper limb turned caudally, the posterior and anterior aspects of the arm and subaxillary region can be accessed.

1009

1010

Part IX 

Cosmetic Surgery of the Body and Extremities

Thighs

For liposuction of the thighs, the patient is usually placed in the prone or supine position. The whole thigh as well as the buttocks and legs are sterilized circumferentially and properly draped. If liposuction of the thighs is to be combined with other regions of the body, such as hips, calves, or abdomen, both lower extremities and related parts of the body should be prepared and draped. For liposuction of the anterior half of the thigh, incisions are made at the anterior groin crease and the suprapatellar crease. For the posterior half of the thigh, only one incision is placed in the gluteal crease. Cannulas 3 or 4 mm in diameter with different lengths are used through each entry incision for debulking the most protuberant areas fi st, such as upper posterolateral thighs and upper medial thighs. When suctioning of the deep fat layer is accomplished, I prefer to suction superfic al fat using a 2.4 or 3.0 mm cannula, and fi al contouring is done using a smaller cannula.

Cal ves and Ankles

The calves and ankles can be suctioned with the patient in the prone position. The entry incisions are usually placed in the popliteal fossa crease and in the fossa between the lateral malleolus and the Achilles tendon, and any other places, if necessary. Multiple incisions are not recommended, despite the fact that the manipulations required to remove fat evenly will be more difficult with fewer incisions. Th s is because scars in the calves and ankles are more obvious, as a result of higher skin tension and being hard to conceal, especially in Asians who have a greater tendency to develop scar hypertrophy. It is helpful to bend the liposuction cannulas to maneuver around the calves. It is of paramount importance to use only small, fi e cannulas, usually less than 3 mm (such as 2.4 to 2 mm in diameter), for precise sculpting in the calf and ankle regions because of the relative thinness of fat deposits in these areas. The surgeon should know the targeted fat to be removed and retain a thin layer of subdermal fat to ensure a smooth contour without contour irregularities from liposuction. Performing a frequent pinch test will help the surgeon to fi d any missed small fat masses and subtle irregularities in the suctioned areas. Final contouring is routinely done at the end of each liposuction procedure; this is extremely important in the calves and ankles. Fat equalization, as described previously, is routinely performed to correct any small irregularities, and feathering will create a smooth transition between the suctioned and nonsuctioned areas.

K23345_Pu_c65_Lipo Trunk_r4_cl_0999-1022.indd 1010

4/3/2015 1:07:28 PM

Chapter 65 

Liposuction of Trunk, Hips, and Extremities

Postoperative Care Oral antibiotics are prescribed for 3 to 5 days; intravenous injection of antibiotics is unnecessary unless the liposuction procedure is combined with large-volume fat grafting or other procedures. After fi al contouring has been completed, infiltrated liquids and exudation are evacuated as described previously, and incisions are approximated with 5-0 absorbable sutures in the dermis and 6-0 nylon sutures for skin closure. A drain is unnecessary, and a special compression garment should be applied immediately (Fig. 65-11). The sutures are removed 7 to 10 days after the operation, and the patient is allowed to take a shower and again don the compression garment if necessary until the edema gradually subsides. Patients should begin ambulating on the day of surgery and be encouraged to increase their activity gradually for 3 to 5 days when edema begins to subside. Early postoperative activity will help to reduce complications such as deep venous thrombosis. About 4 weeks after the procedure, edema and bruising resolve and the patient can return to full activity.

Fig. 65-11  Postsurgical compression garments help postoperative edema to subside and aid in prevention of hematoma

and seroma formation. The patient is instructed to wear it day and night until the fi st dressing change approximately 3 to 5 days postoperatively.

1011

1012

Part IX 

Cosmetic Surgery of the Body and Extremities

Results

First procedure

Second procedure

Fig. 65-12 Th s 29-year-old obese woman (BMI of 32) presented requesting total body liposuction. Staged procedures were planned; three operations were carried out over a period of 8 months. In the first procedure, circumferential liposuction of the abdomen, flanks, midback, and hips was performed. In a second procedure 4 weeks later, the posterior, posteromedial, and lateral thighs, as well as the lateral-lower quarter of the buttocks and medial knees were treated.

K23345_Pu_c65_Lipo Trunk_r4_cl_0999-1022.indd 1012

4/3/2015 1:07:30 PM

Chapter 65 

Liposuction of Trunk, Hips, and Extremities

1013

Third procedure

Postoperative results

Fig. 65-12, cont’d Eight months later, she underwent suctioning of the arms and the upper and middle parts of the back. Over three procedures, the total aspirate volume was 15,700 cc and the volume of supernatant fat tissue was 9200 cc. Her weight loss has been continuous through these procedures, from 87 kg (192 pounds) before the fi st treatment to 82 kg (181 pounds) before the second operation and 71 kg (157 pounds) before the third operation, resulting in a BMI of 26.

K23345_Pu_c65_Lipo Trunk_r4_cl_0999-1022.indd 1013

4/3/2015 1:07:31 PM

1014

Part IX 

Cosmetic Surgery of the Body and Extremities

Fig. 65-13 Th s 27-year-old woman presented for liposuction of her arms and back. The fat distribution was marked topographically, and incisions were placed in the posterior axillary line and midline of the back, which can be concealed under a bra strap. Signifi ant reduction of fatty tissue in the lateral compartments of the arms and parascapular region are obvious 5 months after the procedure.

K23345_Pu_c65_Lipo Trunk_r4_cl_0999-1022.indd 1014

4/3/2015 1:07:32 PM

Chapter 65 

Liposuction of Trunk, Hips, and Extremities

1015

Fig. 65-14 Th s 25-year-old woman, who weighed 70 kg (154 pounds), presented for liposuction of the abdomen. Her abdominal protuberance was partly the result of intraabdominal fat accumulation. A circumferential truncal liposuction procedure was designed, including the upper and lower abdomen, love handles, hips, and bra bulges. She was satisfied with the outcome and returned 31 months later for liposuction of her arms and thighs.

K23345_Pu_c65_Lipo Trunk_r4_cl_0999-1022.indd 1015

4/3/2015 1:07:34 PM

1016

Part IX 

Cosmetic Surgery of the Body and Extremities

Fig. 65-15 Th s 26-year-old woman requested improvement of her saddlebag deformity. I performed liposuction of the trochanteric-buttock areas, outer and inner thighs, and medial knees. Improvement is evident postoperatively in the proportions between the upper and lower areas of the thighs.

K23345_Pu_c65_Lipo Trunk_r4_cl_0999-1022.indd 1016

4/3/2015 1:07:35 PM

Chapter 65 

First procedure

Liposuction of Trunk, Hips, and Extremities

Second procedure

1017

Postoperative result

Fig. 65-16 Th s 21-year-old patient complained of diffuse fullness in her thighs; after consultation, a two-stage operation was devised for her. The anterior, anteromedial, and anterolateral thighs were treated fi st. Th ee months later, she returned for the second procedure, in which the posterior thighs, the calves and ankles, and the lower-lateral quarter of the buttocks were treated. Care should be taken to enclose both the medial and lateral aspects of the thighs as well as the medial knees during two-stage operations to ensure circumferential sculpturing of both thighs. Fat accumulates primarily on the lateral aspect of the calves and ankles, but little fat was seen on the medial calves and ankles in this young woman, so the medial halves of her legs were not treated.

K23345_Pu_c65_Lipo Trunk_r4_cl_0999-1022.indd 1017

4/3/2015 1:07:36 PM

1018

Part IX 

Cosmetic Surgery of the Body and Extremities

Discussion A thorough preoperative discussion with the patient is essential regarding the liposuction procedure, including the associated risks, operative details, expected recovery time, and fi ancial costs for possible revision surgeries. It is wise to rule out poor candidates who have unrealistic expectations of the procedure. It is imperative to distinguish intraabdominal fat from extraabdominal fat accumulation in the abdomen, especially in men. The surgeon should be aware of the physiologic limitations of the surgery. Tumescent liposuction is a highly effective, extremely safe, well-tolerated means for permanent body-contour improvement without signifi ant downtime. Usually tumescent liposuction with or without intravenous sedation can be performed on an outpatient basis without major complications. A 30- to 60-minute interval between infusion of warmed tumescent fluid and initiation of the liposuction procedure is recommended to minimize intraoperative bleeding and patient discomfort. Caution should be exercised in large-volume liposuction procedures and liposuction with extensive areas treated because of the greater risk of fluid overload, lidocaine toxicity, longer duration of operative time, deep venous thrombosis and pulmonary embolism, and signifi ant blood loss. A simple strategy of staged procedures can minimize these risks. Because Asians are prone to hypertrophic scarring at an entry incision, these incisions should be placed in skin folds or other inconspicuous anatomic areas, and the number of incisions should be minimized if possible. Asians are also more likely to develop hyperpigmentation, which may be caused by aggressive superfic al suctioning. Fortunately, most hyperpigmentation will resolve over time. Hematoma and seroma may also be caused by excessive intraoperative trauma. Skin necrosis has been reported rarely and may be associated with damage of the subdermal vascular plexus as a result of very vigorous superfic al fat removal. Infections and necrotizing fasciitis are extremely rare; inadequate sterility and cleaning of surgical instruments may be a causative factor.9 Contour irregularities are the most common permanent undesired sequelae of liposuction. Chang10 classifi d contour irregularities into major and minor, according to the size of the area, difficulty of correction, the severity and visual impact of the contour irregularities, and the need for dermolipectomy. Gingrass and Hensel11categorized contour irregularities into four types: undercorrection, overcorrection, failure of skin retraction or abnormal skin retraction, and complex deformities consisting of combinations of undercorrection, overcorrection, and abnormal skin retraction. Undercorrected areas are simply treated with further liposuction and usually have the most promise for a good result, whereas overcorrection is relatively more difficult to correct; autologous fat grafting is almost the only feasible treatment. Abnormal skin retraction usually results from aggressive superfic al liposuction with large cannulas and damage of the subdermal vascular plexus, subsequent scar adhesion between the dermis and deep structures is formed. The scar adhesion should be released and interrupted, followed by fat grafting if necessary. Complex deformities usually demand combined revision liposuction, fat grafting, releasing of abnormal scar adhesions,12 and skin excision for correction.

Chapter 65 

Liposuction of Trunk, Hips, and Extremities

The upper arm is one of the most concerning areas of the body for many patients, especially women. Enlarged or pendulous arms often embarrass women, leading them to change their clothing style and even preventing them from participating in special social activities. Common complications after arm liposuction are usually aesthetic ones: a hypertrophic scar at entry sites may develop in the early postoperative period, which is why I put the incision into the concealing posterior axillary line. Sometimes minor contour irregularities such as depression caused by overcorrection may occur, and fat grafting will improve surface smoothness.13,14 Fat accumulation in the thighs, either focally along the lateral and medial thighs or in a more diffuse circumferential pattern, is quite common in women. Women often complain that they cannot wear skirts during summer, or their jeans wear through in the inner thigh area, because their “legs rub together” when they walk. Others may complain of disproportion of the thighs and buttocks to the trunk and arms. Fortunately, body-contouring liposuction, if correctly employed in the hands of an experienced surgeon with good technique, can successfully correct all these deformities or an unsightly body contour. Some surgeons prefer to place the patient in the lateral decubitus position to facilitate suctioning of the lateral thigh; however, I prefer the prone or supine positions, because this allows intraoperative assessment of bilateral symmetry between the two sides while I work, and a position change during the operation is usually not needed. For most patients whose fat accumulation in the anterior, posterior, lateral, or medial thigh, the medial knee and lower lateral buttock is not immediately obvious, these areas may only be accessible through one incision, placed in the middle of the gluteal crease. Th s is especially important in Asians, because the only scar will be minimal and is concealed in the gluteal fold. Th s gluteal crease access may make correcting ptosis of the buttocks unnecessary because overcorrection in the banana roll area is more difficult than undercorrection. In practice, it is wiser to remove fat conservatively and superfic ally in this area and to preserve the deep fat for its supporting role to the buttocks.15 For patients with circumferential lipodystrophy of the thighs, an additional anterior thigh liposuction procedure is performed alone or more often is combined with an abdominal liposuction procedure, with the patient placed in the supine position. The incisions are placed in the anterior groin crease and suprapatellar crease. Suctioning in the anterior thigh should be performed carefully and conservatively because less fat is typically accumulated in this area, and too superficial suctioning usually leads to contour irregularities. The full length of the thighs and the lower buttocks and knees should be suctioned and feathered properly, either in the prone or supine position. For a smooth transition between different anatomic sites, it is of paramount importance that “cross-suctioning” be done. Th s means that for optimal aesthetic outcome, both the medial and lateral thigh areas should be accessed twice from different incisions, during staged procedures of the thigh. Contour or surface irregularities may be the most common aesthetic side effects after thigh liposuction. The best way to prevent irregularities is to avoid them. If irregularities are noted during the procedure, it is best to correct them at once, because secondary repair is more difficult after a scar has formed. The best strategy for correction of surface irregularities that are noted in the postoperative months is to perform repeat liposuction of an undercorrected area and to graft fat into an overcorrected area if necessary.10,11,13,15,16 It may take two or three fat grafting sessions for fi al successful correction of severe surface irregularities.16

1019

1020

Part IX 

Cosmetic Surgery of the Body and Extremities

A

B

C

D

E

F

G

H

Fig. 65-17  A-D, Markings for fi st corrective procedure. E, Markings for fat grafting of calves in a second procedure. F, Improved thigh and calf contours. G and H, Final results 17 months later.

The woman shown in Fig. 65-17 presented 2 years after liposuction of the medial and lateral thighs and calves that left her with obvious irregularities of her lateral thighs and calves and a deficit of fatty tissue, especially in the inner thighs. Because of the severity and complexity of the situation, staged procedures were planned for her. Fortunately, the contour of the posterior thighs had been left intact, so fat was harvested from her posterior thighs, and 400 cc of refi ed fat was placed into the depressed areas of her lateral and inner thighs (Fig. 65-17, A through D). The patient returned 11 months after the first operation with great improvement in thigh contour and wanting fat grafting of her calves (Fig. 65-17, E). Fatty tissue was harvested from her hips and lower back, and transferred to the lateral thighs and calves regions (Fig. 65-17, F). After two operations, the irregularities of her thighs are almost fully corrected, with a pleasing contour of the thighs restored. The patient is seen 17 months after two sessions of fat grafting on the thighs and 6 months after one session of fat grafting on calves and ankles (Fig. 65-17, G and H). Further fat grafting is needed for her calves and ankles.

Chapter 65 

Liposuction of Trunk, Hips, and Extremities

Calves and ankles may be among the most difficult sites for successful liposuction because of the relatively thin fat layer in this area, in contrast to the underlying bulging musculature. Patient selection is important: liposuction is contraindicated for those whose calves are large as a result of strong musculature. Surface irregularities can easily occur in this area, even with a brief moment of carelessness. Hypertrophic scarring is more easily formed and is difficult to conceal in the calves and ankles, so the fewer incisions the better. Fat grafting is almost the only feasible treatment for correction of irregularities on the calves and ankles13,14 (see Fig. 65-17, E and F). There has been a considerable increase of interest in the prevention of venous thromboembolism (VTE) in recent years. VTE refers to a continuum of disease that begins with deep venous thrombosis (DVT) and can progress to fatal pulmonary embolism (PE). Early ambulation and proper positioning on the operating table are logical measures that should be applied to all patients undergoing liposuction procedures. Ambulation should be encouraged as soon as the patient is able, with assistance when necessary. These measures are recommended for all patients and are suffici t alone in most cases, because almost all liposuction procedures are completed within 2 hours with the use of a local anesthetic. If the procedure lasts for more than 1 hour under general or regional anesthesia or 2 hours under sedation, mechanical prophylaxis is recommended in the form of either intermittent pneumatic compression devices (ICP) or venous foot pumps (VFP). The main benefit of these devices is to reduce the risk of DVT. Additional chemoprophylaxis is recommended to reduce risks associated with body-contouring procedures such as abdominoplasty in combination with liposuction or other procedures performed with the patient under general anesthesia. Low-molecular-weight heparin, low-dose unfractionated heparin, or fondaparinux is usually recommended for chemoprophylaxis.17

Pearls for Success • Traditional liposuction remains the benchmark procedure for removal of large quantities of subcutaneous fat, although many advances have been introduced in the evolution of body sculpting technology. • Adhering to the generally accepted rules, liposuction is a highly effective, extremely safe bodycontouring procedure that can achieve very satisfactory results. • Staged procedures are preferable when overweight patients request treatment of major body areas. • Meticulous preoperative evaluation and assessment of the patient, skillful manipulations for contouring during the procedure, and proper postoperative care will help to ensure an optimal outcome and maximize patient satisfaction. • Liposuction of enlarged arms usually provides satisfactory contours with few complications. Brachioplasty is generally not considered in Asian patients, who typically are concerned about long scars. Moreover, good skin retraction is usually achieved in Asians after a single liposuction procedure in the arms. • Lipodystrophy and excessive fat accumulation in thighs can be successfully treated with staged or circumferential liposuction procedures. • Signifi ant caution should be exercised to preserve the integrity of a thin layer of subdermal fat during liposuction of the calves and ankles. Meticulous and patient manipulation using fine cannulas will ensure a smooth contour of calves and an optimal result.

1021

1022

Part IX 

Cosmetic Surgery of the Body and Extremities

Refer ences 1. Lockwood T. Superficial fascial system (SFS) of the trunk and extremities: a new concept. Plast Reconstr Surg 87:1009-1018, 1991. 2. Pitman GH, Giese SY. Body contouring: comprehensive liposuction. In Mathes SJ, ed. Plastic Surgery, ed 2. Philadelphia: Elsevier, 2005. 3. Gingrass MK, Greenberg L. Liposuction of the trunk and lower extremities. In Mathes SJ, ed. Plastic Surgery, ed 2. Philadelphia: Elsevier, 2005. 4. Svedman KJ, Coldiron B, Coleman WP III, et al. ASDS guidelines of care for tumescent liposuction. Dermatol Surg 32:709-716, 2006. 5. Klein JA. Tumescent technique for regional anesthesia permits lidocaine doses of 35 mg/kg for liposuction. J Dermatol Surg Oncol 16:248-263, 1990. 6. Lillis PJ. Liposuction surgery under local anesthesia: limited blood loss and minimal lidocaine absorption. J Dermatol Surg Oncol 14:1145-1148, 1988. 7. Wang G, Cao W. Tumescent liposuction: partitioning of lidocaine at a lower dose (252 mg/l). Dermatol 222:274277, 2011. 8. Wang G, Cao WG, Li SL, et al. Safe extensive tumescent liposuction with segmental infiltration of lower concentration lidocaine under monitored anesthesia care. Ann Plast Surg. 2013 Sep 18. [Epub ahead of print] 9. Cao W. Necrotizing fasciitis complicated with abdominal liposuction. J Tissue Eng Reconstr Surg 3:241-243, 2007. 10. Chang KN. Surgical correction of postliposuction contour irregularities. Plast Reconstr Surg 94:126-136, 1994. 11. Gingrass MK, Hensel JM. Secondary liposuction. In Mathes SJ, ed. Plastic Surgery, ed 2. Philadelphia: Elsevier, 2005. 12. Wang G, Ren Y, Cao W, et al. Liposculpture and fat grafting for aesthetic correction of the gluteal concave deformity associated with multiple intragluteal injection of penicillin in childhood. Aesthetic Plast Surg 37:39-45, 2013. 13. Coleman SR. Structural fat grafts: the ideal filler? Clin Plast Surg 28:111-11 9, 2001. 14. Coleman SR. Long-term survival of fat transplants: controlled demonstrations. Aesthetic Plast Surg 19:421-425, 1995. 15. Alam M, Kaminer MS. Liposuction. In Katz BE, Sadick NS, eds. Body Contouring. Philadelphia: Elsevier, 2010. 16. Coleman SR. Iatrogenic corporeal deformities. In Coleman SR. Structural Fat Grafting. St Louis: Quality Medical Publishing, 2004. 17. Venturi ML, Davison SP, Caprini JA. Prevention of venous thromboembolism in the plastic surgery patient: current guidelines and recommendations. Aesthetic Surg J 29:421-431, 2009.

K23345_Pu_c65_Lipo Trunk_r4_cl_0999-1022.indd 1022

4/3/2015 1:07:38 PM

66 Gluteal Augmentation in Asians

P

David S. Kung

erhaps   no other area of the body is as prone to cultural preferences as the gluteal region. Standards for facial beauty are more universal, largely based on proportion, while accounting for ethnic differences in bone structure and soft issue attributes. Breast shape and size appear to be a more personal preference, notwithstanding the existence of some societal norms among cultures. Although the generally accepted standard for proportional buttocks is 1.4 times the waist circumference, preference for size and shape often refl cts strong cultural ties.1 Among women who explore procedures for buttock augmentation, Hispanic women, particularly those from South America and Latin America, tend to prefer fuller buttocks with moderate fullness in the lateral thigh. Women of African descent, particularly those residing in the Americas, desire greater fullness in both areas. Among white women, some request small, athletic-looking buttocks, with a lateral hollow and medial fullness, whereas others desire the rounded buttocks generally associated with Hispanic or African women. In general, Asian women associate smaller, shapely buttocks with the image of beauty. Th s chapter reviews the anatomy of the gluteal region, discusses available options for augmentation, and provides details and case studies on today’s augmentation procedures of choice for Asian women.

Anatomy The gluteal region encompasses signifi antly more than the buttock, and its anatomic properties must be fully considered before, during, and after any gluteal augmentation procedure. The region is defi ed as the area from the iliac crest of the hip bone to the gluteal fold at the bottom of each buttock. Anteriorly, it extends to the level of the anterior iliac spine; medially from the intergluteal sulcus; and laterally from the anterior superior iliac spine to the tip of the greater trochanter. The anterior superior iliac spine is a landmark that is generally quite visible and easily palpated. The iliac crest may not be so obvious, because it can be covered by tissue. It ends in the posterior superior spine, often identifi d by a dimple, on a level with the second sacral spine, just behind the center of the sacroiliac articulation. The buttock, divided by the deep vertical natal cleft, provides fat-laden padding, primarily to protect the skin, which would otherwise rub on the underlying ischial tuberosity when we sit (Fig. 66-1).

1023

1024

Part IX 

Cosmetic Surgery of the Body and Extremities

Iliac crest Gluteus medius muscle

Gluteus maximus muscle Ischial tuberosity

Gluteus minimus muscle Piriformis muscle Sciatic nerve

Femur

Fig. 66-1  The surface anatomy of the gluteal region in conjunction with deeper structures as it relates to procedures to augment the buttocks.

The primary muscles of the gluteal region include the gluteus maximus, which works with the semitendinosus, semimembranosus, and biceps femoris for hip extension; and the gluteus medius and gluteus minimus, both hip abductors. A number of smaller deep muscles are primarily involved in hip rotation. Any discussion of intramuscular implants and injections must emphasize the importance of knowing the gluteal anatomy, with particular caution in avoiding the sciatic nerve. The longest nerve in the body, the sciatic nerve runs a course between muscle layers of the gluteal region. The nerve is deep, anterior to the gluteus maximus, and is superfic al, posterior to the inner muscle layers, including the superior and inferior gemellus, obturator internus and quadratus femoris muscles.

Indications There are various reasons that an individual might explore gluteal augmentation. The aging process can shift he soft issue of the buttocks, causing skin and the buttocks’ fullness to hang over the gluteal fold. The patient may desire more youthful, lifted, and tightened buttocks. Weight gain and loss can make the skin appear stretched and loose. Larger, fuller, or shapelier buttocks may be desired by a woman of any age, either because her buttocks are naturally flat, or she simply desires an enhanced or different shape.

Consultation and Preoperative Assessment It is important to recognize that individuals who request consultation for gluteal augmentation may have limited knowledge about the options available. Or he or she may be aware of a particular surgical or nonsurgical technique, with or without an understanding of the extent of the procedure, the associated healing time, and the risks. Before the surgeon begins a full discussion of the options, it is wise to evaluate the patient’s desires, expectations, and physical anatomy. Any discussion that follows can then be based on that patient’s individual profile, and appropriate alternatives can be outlined (Fig. 66-2).

Chapter 66 

Gluteal Augmentation in Asians

1025

Fig. 66-2  The physical fi dings of gluteal soft tissue deficie cy in a patient with superior and lateral volume deficie cy. Listening to the patient is a vital aspect of any evaluation. What is the person’s specific desired result? Are the patient’s expectations reasonable? Does she understand that any gluteal augmentation is an involved medical procedure, which even when performed with a minimally invasive technique has associated risks? The surgeon must discuss the patient’s ability to follow postprocedure instructions, including the option to take a few weeks off from work or other obligations that would require extended periods of sitting. The patient’s tolerance for inconvenience, pain, a long recovery period, and potentially delayed results must be explored. And fi ally, it must be determined whether there is any medical condition or necessary medications that eliminate the individual as a candidate for some or all appropriate gluteal augmentation procedures, such as a condition that would make general anesthesia too risky, a bleeding disorder or anticoagulant therapy, or allergies to anesthetic agents. The physical examination should take a whole-body approach. The patient’s physical size, proportion, and body symmetry are assessed. The existence of excess fat in the stomach, back, or other areas that potentially could serve as harvest sites for autologous fat transfer is evaluated. A very small person with minimal body fat is not a good candidate for fat grafting and would be better evaluated for potential gluteal implants. Moving to the gluteal area, the surgeon evaluates the presence and extent of excess fat, sagging skin, the general shape of the buttocks, defin tion of the buttocks from the gluteal crease, and separation from the natal cleft Th s initial consultation will conclude with a discussion of fi dings based on the evaluation, as well as recommended procedures. The treatment choices must not only meet the desires and reasonable expectations of the patient, but must also be a good match to the individual’s anatomic characteristics. Of critical importance is planning a procedure that will not lead to interference with necessary function. Th s often means choosing an appropriate amount of augmentation to match the tissue envelope. Th s is the time for an extended question-and-answer period so the practitioner and patient both leave with confide ce that only an educated decision moves the process forward. For example, if fat grafting is chosen as the preferred treatment option, the surgeon must discuss the average rate of fat resorption after surgery and the possibility that a second procedure could be necessary to achieve the desired augmentation. If implants are chosen, the surgeon must discuss implant sizing in relation to the constraints of the patient’s anatomy.

K23345_Pu_c66 67_Gluteal Aug_r5_cl.indd 1025

4/3/2015 1:09:15 PM

1026

Part IX 

Cosmetic Surgery of the Body and Extremities

Table 66-1  Gluteal Augmentation With Autologous Fat Grafting Compared With Gluteal Implants Augmentation Gluteoplasty

Autologous Fat

Gluteal Implants

Composition

Natural tissue from the patient’s body

Synthetic filler material

Longevity

Resorption rate up to 50%-75%

Permanent

Additional surgical site

Required

Not required

Associated benefits

Improved contour of donor site

No donor site morbidity

Size of augmentation

Limited by amount of donor fat

Limited by size of implant

Surgery

Minimally invasive

Invasive

Complications

Contour irregularity

Infection, extrusion, hardness

FAT INJECTION AND FAT GRAFTING Th s chapter will discuss current options for gluteal augmentation, with emphasis on autologous fat grafting and gluteal implants. Table 66-1 compares the two techniques.

Surgical Technique Acknowledging the preference in surgery for “like with like” makes fat grafting the preferred procedure for gluteal augmentation, when possible. The use of a patient’s own tissue in autologous augmentation signifi antly reduces the risk of infection and rejection and results in the most natural-looking and normalfeeling augmentation possible. Also called fat transfer, fat transplant, liposculpture, or the Brazilian butt lift, autologous fat grafting to the gluteal region is not possible if the patient is too lean, with no visible excess fat, because donor sites must contain enough fat for safe harvesting and adequate results. On average, 250 to 350 cc of purifi d fat is needed for each buttock, or 700 cc total, the equivalent to approximately 1∕2 to 3∕4 pound of fat. Th primary donor sites are the abdomen, the flanks, the lower back, the lateral thighs, and the medial thighs. Th s procedure then has the added benefit of trimming unwanted fat from these donor site areas. Th s can add to the overall shape of the buttocks, because reducing the “frame” of the gluteal region has a dramatic impact on shape. Th ough gentle liposuction with a standard or powered cannula, autologous fat is removed from the donor sites, purifi d, and then injected into the buttocks in multiple layers. Th ough small incisions of about 1 ∕8 inch each, small parcels of fat are evenly injected throughout the tissue, with careful regard for the desired result. By implanting multiple microfat grafts hroughout the thickness of the gluteal muscle and the subcutaneous tissue, each fat cell has an improved chance of establishing an adequate blood supply. In addition, fat takes on the characteristics of its surroundings, and when injected into a fatty area such as the buttock, it will feel natural. The steps in fat grafting include anesthesia, harvesting of adipose tissue, preparation of harvested tissue, and injection (see also Chapters 11and 54 for details on harvesting and processing autologous fat).

Chapter 66 

Gluteal Augmentation in Asians

Anes thes ia

General anesthesia is preferred for autologous fat grafting, primarily for patient comfort. Intramuscular manipulation is quite painful, and although less complex than traditional surgical gluteoplasty, fat grafting remains a painful procedure. Tumescent solution can help control bleeding and assist in postoperative pain management. Tumescent solutions containing 1% lidocaine and epinephrine (1:1000) are standard. Intramuscular infiltration of a long-acting anesthetic such as bupivacaine will last several hours after the procedure.

Har ves ting Adipos e Tiss ue

The key to successful fat grafting is atraumatic harvest of adipose tissue. Minimizing trauma to the harvested tissue enhances the viability of the cells for implantation. Minimum-pressure suction is important not only to reduce damage to the cells, but also for patient safety, specifi ally to minimize bruising to surrounding tissues. Tissue harvest can be accomplished by hand, with a 3 to 4 mm blunt cannula and a traditional low-strength vacuum liposuction device, or with the aid of specifi ally designed harvesting equipment, the development of which continues to advance. Recent improvements in autologous fat harvesting have included the HydraSolve tissue liquefaction system, the Body-Jet water-assisted system, and the Revolve system. These modalities boast minimal disruption of surrounding tissue, with harvested fat that is already washed and ready for transplantation. These medical devices may standardize and simplify the process by both purifying and concentrating the fat for direct injection.

Tiss ue Pr epara tio n

To avoid contamination and maximize tissue viability, exposure to air and mechanical damage should be minimized. In addition, viable adipocytes should be purifi d, which includes separating them from blood, serum, and damaged cells through centrifugation (3000 rpm for 3 minutes, according to several studies).2 My experience is that the use of such techniques, which clean the fat of blood, unnecessary fluid, and toxic free lipids, increases the success rate of transplanted cells, significantly raising the percentage of sustained, unabsorbed fat. My preferred method is the use of a closed, sterile “no-touch” collection system that allows decanting and separation of fat cells for direct injection.

Injectio n Techniq ues

The surgeon’s technique and experience are the greatest indicators for successful, long-lasting grafting. To optimize the viability of the transplanted cells and for augmentation that meets the patient’s and practitioner’s goals, it is recommended that a practitioner receive considerable training and assisted experience before conducting the procedure on his or her own. As a part of patient assessment, preprocedure markings should be made topographically, illustrating the sizing and proportion desired and the injection sites. Th s creates a clear plan to follow during the procedure. Injections are intramuscular, subcutaneous, and/or submuscular, with a choice of injection techniques. Fat cells can be placed into several planes to achieve a larger correction. Generally, fat is transplanted by placing very small parcels in multiple layers in a latticelike approach to increase the surface area for fat cells to develop a new blood supply. Care must be taken to avoid deposit of a large amount in any one

1027

1028

Part IX 

Cosmetic Surgery of the Body and Extremities

A

B

Serial puncture

Linear threading

E D C 1

3

2

5 4

7 9 6 8 Crosshatching

Fanning

Pyramidal

Fig. 66-3  Various techniques are used for injecting the fat. The operator must master the technique of depositing the fat parcel as the cannula is withdrawn, not when it is injected.

area, since a large clump is likely to cause fat necrosis or the formation of fatty cysts. Graft i jections are typically performed with a 3 to 4 mm blunt-tipped cannula or similar blunt needle. Specific echniques include the following (Fig. 66-3): • Serial puncture and linear threading: Injections are done in a tunneling manner beneath the area of the buttocks to be augmented. • Fanning: Injections are arrayed in a fan shape to maximize coverage. • Crosshatching: Injections form a grid, with multiple threads injected perpendicular to each other. • Pyramidal: Injection is deep and perpendicular, with fat cells deposited in a pyramid or cone shape. More parcels of fat are placed deeply and less as the subcutaneous layers are reached.

Aut ol o go us Fat Grafting

Techniq ue

Steps for safe, effective autologous fat grafting include the following: 1. Before the procedure, the patient is marked topographically for both harvest and graft recipient sites in a standing position (Fig. 66-4, A). 2. General anesthesia is administered with intramuscular infiltration of a long-lasting anesthetic. 3. The harvest sites are prepared with epinephrine and/or lidocaine. 4. The recipient sites are pretunneled with a blunt-tipped cannula creating pockets for fat grafts. 5. Fatty tissue is carefully extracted from donor sites, either by hand or with a gentle, low-vacuum liposuction device (Fig. 66-4, B).

Chapter 66 

Gluteal Augmentation in Asians

A

B

C

D

Fig. 66-4  Procedure for autologous fat grafting. A, Preoperative markings. B, Donor tissue is extracted with low-vacuum  liposuction. C, The harvested fat is washed and centrifuged to separate viable adipose cells for injection. D, Tiny parcels of fat are injected by cannula in predetermined patterns for maximum coverage.



6. The harvested fat is washed and purifi d, with adipose cells separated through a microcentrifuge or a self-contained, multistep system (Fig. 66-4, C). 7. Tiny fat parcels are injected in layers (Fig. 66-4, D), using the proven techniques illustrated in Fig. 66-3. 8. A compression garment is placed to combat initial swelling and to shape the graft sites.

Pos t opera tive Instr uctio ns

The patient’s postoperative compliance is as important to the success of autologous fat grafting and the reduction of complications as the practitioner’s technique and surgical precautions. Postoperative measures include the following: • Wearing a compression garment to help support the gluteal region for 4 to 6 weeks, depending on healing, as determined by examination • Avoidance of sitting directly on the gluteal region for 10 days postoperatively • Sleeping in the prone position • Minimizing physical activity for the fi st 2 to 3 weeks • Biweekly follow-up examinations for the fi st 6 weeks, followed by monthly follow-up for the fi st year

1029

1030

Part IX 

Cosmetic Surgery of the Body and Extremities

Results All procedures in the cases presented here were performed with the patient under general anesthesia.

Fig. 66-5 This 35-year-old Asian woman desired increased volume to correct her “flat” buttocks. Examination showed a mild to moderate superior and lateral gluteal contour deficie cy. Augmentation gluteoplasty was performed with autologous fat transfer from her abdomen, flanks, and medial thighs. The total fat graft included 555 cc in the right buttock and 540 cc in the left uttock. Fat transfer was performed in multiple layers using deep pyramidal and linear threading injection techniques. At 12 months postoperatively, her contour improvement in the superior and lateral gluteal region is stable.

K23345_Pu_c66 67_Gluteal Aug_r5_cl.indd 1030

4/3/2015 1:09:17 PM

Chapter 66 

Gluteal Augmentation in Asians

1031

Fig. 66-6 Th s 53-year-old Asian woman requested improvement in the shape of her buttocks. Examination indicated a mild contour deficie cy in the lateral and superior gluteal region. The patient was marked preoperatively (- - -, fat donor sites; X, fat injection sites). Augmentation gluteoplasty was performed by autologous fat transfer from the abdomen, flanks, and medial thighs. The total graft i cluded 365 cc in the right buttock and 365 cc in the left uttock. Both deep pyramidal and linear threading techniques were used. At 12 months postoperatively, multiple contour improvements are evident, particularly in the upper flanks and inner thighs. The patient’s figu e resembles an hourglass rather than a cylinder. Contour improvement is stable in the superior and lateral gluteal region.

K23345_Pu_c66 67_Gluteal Aug_r5_cl.indd 1031

4/3/2015 1:09:18 PM

1032

Part IX 

Cosmetic Surgery of the Body and Extremities

Fig. 66-7 This 27-year-old Asian woman desired improved shape in the gluteal region. Examination showed a showed mild superior gluteal contour deficie cy. Augmentation gluteoplasty was performed by autologous fat transfer from the abdomen, flanks, and medial thighs. The total graft included 440 cc in each buttock. Both deep pyramidal and linear threading techniques were used. At 12 months postoperatively, her contour improvement is stable in the superior and lateral gluteal region. Improvement extends to the posterior flanks and medial thighs, which now have a more balanced and shapelier contour.

Prevention and Management of Complications The complications associated with gluteal fat grafting and their prevention are summarized in Table 66-2.

Table 66-2  Complications Associated With Gluteal Fat Grafting and How to Avoid Them Complication

Prevention

Infection

Sterile technique, bowel preparation

Fat necrosis

Atraumatic manipulation of fat, minimal exposure of adipocytes to air, use of small parcel graft

Fat embolism

Use of small parcel graft

Tissue necrosis

Avoidance of hemoconcentration with appropriate fluid balance

Gluteal erythema

Avoidance of overinjection

Contour

Use of blunt-tipped cannulas away from the skin

Irregularity

Use of appropriate technique over a large area, injecting in layers; patient is placed in a contouring garment to wear for a postoperative period

Chapter 66 

1033

Gluteal Augmentation in Asians

GLUTEAL IMPLANTS The primary advantage of implants is in their use for individuals with little or no fat available as donor sites for autologous fat grafting. Additionally, implant surgery may be preferred over fat grafting when a very large augmentation is desired or when the patient does not want to risk resorption of fat, desiring instead the reliable, more immediate results provided by implants.

Implant Selection Table 66-3 summarizes the different types of gluteal implants that are available and the indications for their use. Implant contours are shown in Fig. 66-8.

Table 66-3  Type of Gluteal Implants and Indications for Use Gluteal Implant

Advantages

Disadvantages

Indications

Hard solid

Form stable

Very fi m, palpable

Rarely used in light of newer implant choices

Elastomeric soft solid

Flexible, will not rupture

Can be palpable

Used when softer implants are not available

Cohesive gel

Very soft, more pliable than soft solid implant

Can rupture, deform

Used when softer implants are not available

Round or nondirectional (Fig. 66-8, A)

Uniform projection, no implant rotation deformity

Limited in long gluteal shape

Square gluteal shape

Oval/anatomic or directional (Fig. 66-8, B)

Precise contour improvement with specific placement and directional orientation

Implant malposition deformity

Ovoid or long gluteal shape

Custom

Patient-specific mirror augmentation with right and left implants

Extremely positionsensitive results

Specific individual needs

Composition

Shape

A

B

Fig. 66-8  A, Round gluteal implant. B, Oval or anatomic gluteal implant.

1034

Part IX 

Cosmetic Surgery of the Body and Extremities

Implant Placement Gluteal implants can be placed subfascially, submuscularly, or intramuscularly (Fig. 66-9). The choice is one based on a combination of surgeon experience and patient anatomy. Table 66-4 summarizes the indications for each technique.

Subfascial

Submuscular

Intramuscular

Fig. 66-9  Optional placement of gluteal implants.

Table 66-4  Indications for Gluteal Implants Implant Placement

Anatomic Position

Advantages

Disadvantages

Indications

Subfascial

Between gluteus maximus and overlying fascia

Decreased muscle disruption

Palpable; risk of unnatural contour high; prone to malposition

Desired fullness in lower half of the buttocks

Submuscular

Deep to gluteus maximus

Excellent tissue cover of implant

Increased morbidity and nerve damage; not useful for flat lower buttocks

Desired fullness in upper half of the buttocks

Intramuscular

In between muscle layers of gluteus maximus

Adequate tissue cover to prevent palpable implants; decreased risk to nerves

Implant sizing is restricted by muscle dimensions

Smaller, thinner patients, common among Asians

Chapter 66 

1035

Gluteal Augmentation in Asians

Intergluteal incision Access for intramuscular pocket Pocket dissection

Fig. 66-10  Placement and the most common route of access for gluteal implants.

Surgical Technique Access for implant placement is usually at the intergluteal crease, which will provide excellent surgical access with the least visible scar. With this technique, only one incision is made, in the intergluteal cleft between the buttocks. Both implants can be inserted from this incision, and the resulting scar is completely concealed (Fig. 66-10). A supragluteal approach from the flank area of the waistline is less common but is surgically effective. Because scars will be more visible, this technique is rarely preferred.

Intramuscul ar Impl ant Sur ger y Thr ough the Inter gl uteal Cr eas e

The steps for performing implant surgery are as follows: 1. Preoperative marking: The gluteal region is divided from the iliac crest to the infragluteal fold into three equal parts. The upper third is left undisturbed. The middle third is marked for implant placement. The lateral extent of the implant should be 4 cm from the intergluteal sulcus bilaterally. The lower third, which is the support zone, is left undisturbed. 2. Access: A 6 to 7 cm linear incision is made in the intergluteal sulcus, 4 cm above the anus or 2 cm above the mucocutaneous union. 3. Dissection: Access is then deepened through the subcutaneous fat to the level of the presacral fascia. Dissection continues superfic al to the fascia for 3 to 4 cm until the gluteus maximus muscle is reached. 4. Pocket formation: A 6 to 7 cm incision is made in the aponeurosis of the gluteus maximus muscle. A gluteal dissector is used to create a space between the muscle fascicles in this intramuscular space. The pocket is developed in the middle of the muscle mass at a depth of 2 to 3 cm with muscle fibers forming the anterior, posterior, and lateral walls. 5. Implant insertion: The lower pole or thicker dimension of the implant is folded on itself, and this is introduced through the incision into the intramuscular space; then the upper pole of the implant is introduced into the pocket. The entire implant is now covered by muscle fibers. 6. Closure: A suction drain is placed in the intramuscular space, along the implant. All dissection planes (muscle, fat, and dermis) are closed in layers with 3-0 and 4-0 nonabsorbable sutures and affixed to the presacral fascia to reconstitute the intergluteal sulcus.

1036

Part IX 

Cosmetic Surgery of the Body and Extremities

Results

Fig. 66-11 Th s 21-year-old Asian woman requested an increase in the projection and width of her gluteal region. Examination showed mild gluteal hypoplasia with lateral hollowing. General anesthesia was administered, and augmentation gluteoplasty was performed with intramuscular placement of anatomic textured implants. The implants were 420 cc Silimed Vergara style prostheses. Access and placement was through the intergluteal crease incision. For additional postoperative pain relief, the patient received intramuscular injections of 0.25% bupivacaine mixed with 60 mg of ketorolac (Toradol) while still under general anesthesia. Increased gluteal projection and volume enhancement were evident immediately after the procedure and as shown at 12 months. Long-term stability was confi med when she was seen 5 years postoperatively.

Prevention and Management of Complications The advantage of gluteal augmentation with implants is that the prosthesis itself is long-lasting. However, while some of the complications associated with gluteal implants have been eliminated with improved implant materials and a greater assortment of sizes and shapes, potential complications are still numerous (Table 66-5).

Chapter 66 

Gluteal Augmentation in Asians

Table 66-5  Complications, Prevention, and Management of Gluteal Augmentation Using Implants Complication

Prevention/Management

Pain

Managed with intramuscular injection of a long-lasting local anesthetic (such as 0.25% bupivacaine with ketorolac)

Infection

Can occur with insertion of any prosthesis; prevention involves use of prophylactic antibiotic therapy, sterile technique, and no-touch delivery of the implant

Rupture/extrusion

Requires implant removal; prevention involves proper surgical placement and implant selection

Seroma

Occurs with implant motion; prevention involves placement of suction drains; managed by aspiration, local irrigation with sclerosant

Bleeding/hematoma

Requires evacuation and exploration; prevention involves sound surgical technique, gentle tissue manipulation

Nerve injury

Prolonged dysesthesia beyond 2 weeks should be explored; prevention involves knowledge of anatomy and procedural training

Contour irregularity

Occurs from implant malposition, implant-recipient site mismatch, capsular contracture, often requires surgical revision; prevention involves proper preoperative evaluation and surgical technique

Discussion Fat transfer procedures have historically been associated with high rates of fat resorption. Anecdotal evidence shows a wide range of experience, with fat resorption ranging from 50% to 75%. However, an experienced practitioner today using advanced technology to harvest fat atraumatically and proven techniques for fat grafting can signifi antly reduce the amount of fat resorption. Wolf et al3 used magnetic resonance imaging to measure fat absorption before and after grafting. In patient studies 2 weeks and 3 months after a fat grafting procedure, these practitioners reported a resorption range of 24% to 36%. In general, the amount of fat and shape that is present 6 months after fat grafting is what will last long term, since the grafted fat parcels will have developed their own blood supply in this time frame. Although the literature yields minimal research on fat grafting in the gluteal region, the general consensus among experts who have reviewed autologous fat grafting to the breast agree that overall, complication rates associated with fat grafting are not unduly high, considering the level of invasiveness. The 2007 ASPS Fat Graft Task Force2 had this to say about autologous fat grafting: “Although fat grafts may be considered for use in the breast and other sites, the specific techniques of graft harvesting, preparation, and injection are not standardized. The results, therefore, may vary, depending on the surgeon’s technique and experience with the procedure.” In a retrospective study of clinical experience with gluteal implants over 15 years, Vergara and Amezcua4 reported on intramuscular gluteal implants in 160 cases, either with silicone gel or silicone elastomeric implants, depending on each patient’s muscle tone. They noted: “The best results in gluteoplasty augmentation are achieved when the implants are placed in the intramuscular space, because they can be covered with a musculocutaneous flap that maintains the implant’s position and creates aesthetically pleasing

1037

1038

Part IX 

Cosmetic Surgery of the Body and Extremities

harmonious, soft c ntours without irregularities. By contrast, implantation in the subcutaneous space is associated with complications, such as seromas, capsular contraction, visible implant edges, and displacement of the implants.” They also noted the difficulty of avoiding the sciatic nerve in the submuscular plane and the limitation that this space permits placement of only small implants in only the highest positions.

Revis io ns or Subs eq uent Pr o ced ur es

Gluteal augmentation, whether achieved by autologous fat grafting or the placement of gluteal implants, often requires revision. Repeat fat grafting to the buttocks is useful for the correction of volume loss from fat resorption, for additional volume enhancement, and for the correction of contour irregularities. Secondary implant surgery is often necessitated by the patient’s desire to change implant size or shape or a request to remove the implant because of implant fi mness.

Al ter native Devel opment s in Gl uteal Augment atio n Autodermal Grafting

If a gluteal augmentation procedure is being performed in conjunction with another body-contouring procedure, such as a lower body lift, an autologous gluteal augmentation procedure using a pedicled dermal flap can be performed. The main advantage of this type of augmentation is decreased tissue resorption, because the flap has its own blood supply. There usually is adequate donor volume for a satisfactory enhancement, and no additional scars are added beyond the body-contouring scars.

Suture Suspension Gluteal Lift The closed gluteal suspension technique involves placing sutures, by needle perforations only, to affi movable fascia to nonmovable skeletal structures. The appeal of this procedure is that it leaves no visible scars. Results are immediate and reversible. Recovery time and complication rates are signifi antly reduced compared with those of traditional surgical gluteoplasty.5 The longevity of results is unclear.

Gluteal Augmentation With Fillers Various nonautologous fillers composed of polymethylmethacrilate (PMMA) and medical grade silicone have been used to enhance the gluteal region without surgery. Nonsurgical augmentation of this type, although appealing, has been fraught with complications, including death, and should be avoided.

Pearls for Success • Patient evaluation is the key to choosing the best procedure for the patient’s anatomy, tolerance, and recovery time. The surgeon must not be afraid to say “no.” • Knowing the anatomy of the gluteal region is essential to avoiding complications. Training and experience are critical to both fat grafting and implant procedures. • During any fat grafting procedure, a pocket should be created for the fat graft to survive by pretunneling the site with a blunt-tipped cannula. • A conservative estimate is appropriate in determining the quantity of fat to be grafted or implant size. It should be remembered that among Asian women, shape is desired over size. • The time spent explaining to the patient the importance of adherence to postoperative care will signifi antly reduce the time spent treating complications.

Chapter 66 

Gluteal Augmentation in Asians

1039

Refer ences 1. Bryant R. Buttock augmentation: latest cosmetic trend. Cosm Surg Times 8:4, 2005. 2. Gutowski KA. Current applications and safety of autologous fat grafts: a report of the ASPS Fat Graft Task Force. Plast Reconstr Surg 124:272-280, 2009. 3. Wolf GA, Gallego S, Patrón AS, et al. Magnetic resonance imaging assessment of gluteal fat grafts. Aesthetic Plast Surg 30:460-468, 2006. 4. Vergara R, Amezcua H. Intramuscular implants: 15 years’ experience. Aesthet Surg J 23:86-91, 2003. 5. Serdev N. Scarless buttock lift y Serdev suture and combinations elongation and beautifi ation with ultrasonic assisted liposuction. Int J Cosmet Surg 8:30-103, 2008.

K23345_Pu_c66 67_Gluteal Aug_r5_cl.indd 1039

4/3/2015 1:09:22 PM

K23345_Pu_c66 67_Gluteal Aug_r5_cl.indd 1040

4/3/2015 1:09:22 PM

67 Cosmetic Calf Reduction Feng-Chou Tsai

B

eautiful legs have always been a signifi ant concern, especially in Asian women with short stature and chubby, muscular legs.1 In Western and Eastern cultures, the ideal contour of the calf has been defi ed as relatively long and slender on the medial upper third, then gradually tapering toward the ankle. Several methods of leg sculpture have been developed to target specific compositions: muscle (temporary or nonspecific: botulinum toxin injection, radiofrequency; permanent or specific: total or subtotal muscle resection and selective neurectomy), fat (liposuction) and vein (varicose vein surgery) as shown in Table 67-1.2-8 These techniques draw on clinical experience from reconstructive surgery showing that sacrific of the gastrocnemius and soleus muscles have negligible consequences. Neurectomy and myomectomy directly resect the nerve and muscle, respectively, while botulinum toxin denervates muscle by temporarily inhibiting the release of acetylcholine at the neuromuscular junction.9 Both botulinum toxin and neurectomy are classifi d as denervation. Radiofrequency damages the nerve or muscle through heat; however, it does this in a nonspecific anner, so the outcome is not only limited but also impossible to anticipate with precision. The advantage of muscle resection is that it deals directly with the oversized muscle deformity. Myomectomy does have its shortcomings, including multiple and often large incisions, long recovery times, bloody operative dissection, technical challenges intraoperatively, uneven contour, and a painful

Table 67-1  Methods of Calf Reduction Muscle

Fat

Vein

Temporary or nonspecifi

Botulinum toxin injection Radiofrequency

Mesotherapy

—

Permanent or specifi

Selective neurectomy Muscle resection, total Muscle resection, subtotal

Liposuction

Varicose vein surgery

1041

1042

Part IX 

Cosmetic Surgery of the Body and Extremities

Fig. 67-1  Beautiful, aesthetic calves are slim and show no chubby muscle bulge, regardless of body posture.

postoperative period. All of these factors make myomectomy procedures less than ideal for patients seeking a simple cosmetic solution. The ideal cosmetic operation should be simple, quick, and easily reproducible, and it must result in a good outcome. I have been investigating denervation muscle atrophy, biomathematical models, and their clinical implications over an extended period in more than 1000 cases. The advantages of combined procedures, such as selective neurectomy and liposuction, are a short operative and recovery time, even and symmetrical atrophy, and inconspicuous scarring. In this chapter I will describe my techniques and information gleaned from long experience. Muscle atrophy is also discussed for clinical applications, with the results pertaining to this issue. Recently, I introduced the appropriate multidisciplinary principles (biochemistry, biomathematics, clinical experience, and so on) to not only explore various phenomena of interest, but also to develop novel and powerful techniques for cosmetic leg sculpture.

Ideal Leg Contour Although no absolute standard of “ideal” legs actually exists, there is some consensus across cultures about what “beautiful” legs look like, compared with “ugly” legs (Fig. 67-1). Preferences vary dramatically and subjectively according to such factors as culture and typical stature. Thus a relative quantifi ation of ideal leg contour is more practical: • Ratio: 20% of a person’s height or maximal calf circumference (MCC)—approximately 32 cm • Smooth contour: No obvious muscle bulges • No anomalies: Varicosity, pigmentation, scars • Symmetry

Anatomy Skeletal muscle constitutes more than 40% of the human body and plays a major role in body physiology and contours. The triceps surae (from the Latin caput and sura, “three-headed calf muscle”), composed of the medial and lateral gastrocnemius and soleus muscles, is responsible for plantar flexi n and ankle stabilization.9

Chapter 67 

Nerves to toes

Nerve to lateral gastrocnemius muscle

1043

Cosmetic Calf Reduction

Lateral gastrocnemius muscle Nerve to lateral gastrocnemius muscle Nerve to soleus muscle

Nerve to soleus muscle Nerve to medial gastrocnemius muscle

Nerve to medial gastrocnemius muscle

Medial gastrocnemius muscle

Fig. 67-2  The anatomy of the calf visualized through a small incision.

My experience has led to the following fi dings from cadaver dissection and more than 1000 clinical cases: 1. The nerve to the soleus muscle has two branches: medial and lateral. 2. Nerve diameter correlates with muscle bulk and is in a way similar to the principles of electric theory. Namely, the number of motor units is correlated with the corresponding nerve fascicles. The nerve impulse travels like an electrical current. Therefore a nerve stimulator can be applied to identify whether any residual nerve remains. 3. The shape of the male medial gastrocnemius muscle was found to be similar to the appendage of the soleus muscle in terms of its bulky and tendinous appearance. 4. The more bulging the muscle (especially where MCC is greater than 40 cm), the deeper the nerve attached to the underneath side of the muscle. Fig. 67-2 indicates the relationship between the different components of calves. 5. Compensation is a normal and inevitable physiological phenomenon after destructive surgery. Thus there is always compensatory hypertrophy of residual muscle for maintenance of “acceptable” activities after any calf reduction procedure. Because in my technique all nerves to the triceps surae are aggressively resected with acceptable functional recovery, residual toe muscle volume and function cannot compensate to a signifi ant degree. The surgical outcome depends on the balance between the atrophic and residual muscle. Since Gutmann10 established the foundation of muscle research in the 1950s and 1960s, many advances have been made in this fi ld. Transmission electron microscopy (TEM) has shown that neurectomy induces irreversible progressive alterations of myofibrils involving the staggering and disorientation of Z-discs with sarcomere disarray and interfiber widening.11

Bio chemis tr y

Apoptosis-inducing factor (AIF)–mediated caspase-independent apoptosis (cell death) appears to result in permanent denervated muscle atrophy after neurectomy. By contrast, no signifi ant changes in apoptosis or survival signaling are seen in the reversible muscle atrophy that occurs after botulinum toxin injection. Some unknown mechanisms may circumvent the apoptotic and long-lasting effect of botulinum toxin compared with neurectomy.

1044

Part IX 

Cosmetic Surgery of the Body and Extremities

Apoptosis results in the elimination of individual myonuclei (myonuclear apoptosis) and the related portion of sarcoplasm, without demise of the entire fiber. In other words, denervation may reduce the size of myofibers without completely destroying the multinucleated fibers, enabling muscle weight recovery in a manner similar to a balloon being deflated or inflated.

Mathema tics or Bio phy sics

My basic studies disclosed the symmetry and pattern of process between skeletal muscle growth (expanding state) and atrophy (contracting or dissipative state), as shown in Fig. 67-3, A. Th s time-reversal symmetry of proteins and surface morphology implies that it is possible to manipulate the different biologic states. The reversible course of botulinum toxin A is an obvious example of both the expanding (recovery) and contracting (atrophic) states (Fig. 67-3, B). The molecular expression pattern of muscle, especially the integrins and myofiber surface complexities, are biphasic (initial increase, later decay) and coherent. In fact, other tissues and even cancers also express

A

Ratio e1

c1

C

1

e2 c2

1

E e1 e2

c1 c2 Time III

II

I II

III

Muscle weight ratio

B 1.0 0.8 First dose

Second dose Third dose

Botulinum toxin

Neurectomy

0.1 1 mo

6 mo

1 yr Time

Fig. 67-3  A, Expression curve in different biologic states (I, Stationary state; II, expanding state [E]; III, contracting

state [C]). B, Time course of botulinum toxin compared with neurectomy. The continuous injection of botulinum toxins can provide the additive effect with a fi ed ratio of muscle weight reduction.

Chapter 67 

Cosmetic Calf Reduction

a similar molecular Levy distribution pattern.12,13 Th s molecular expression pattern may be generalized to all biological phenomena, and it may set the strategy in the future, especially for longevity and cancer treatment. Selective neurectomy in cosmetic calf reduction also provides a good human model to observe the changes in muscle atrophic states. These novel anatomic and biochemical fi dings may be of use to those seeking ways of prolonging the effects of botulinum toxin or minimizing the negative sequelae of nerve injuries in the future.

Indications and Contraindications As to the ideal leg contour or other aesthetic needs, absolute indications or contraindications are not well established. The subjective guidelines are refl cted by the concerns of most individuals who request calf reduction (Box 67-1).

Preoperative Assessment In my series the patients were measured in the standing position (Fig. 67-4). The midline of the popliteal fossa in the popliteal crease was marked. The following parameters should be recorded: the MCC, with and without toe standing, the calf length, and the gastrocnemius muscle excursion. The frontal, posterior, and lateral views, with or without toe standing, should be documented during the preoperative workup and postoperative follow-up.

Box 67-1  Indications and Contraindications for Calf Reduction Indications • Subjective calf hypertrophy or obvious muscle bulge • Maximal calf circumference larger than 34 cm • Male to female transsexual • Calf asymmetry

Contraindications • Spinal cord injuries • Congenital limb disorders • Knee or ankle joint diseases • Psychological disorders

Popliteal crease

Fig. 67-4  Preoperative markings mainly over the

midline of the popliteal crease for incision placement.

1045

1046

Part IX 

Cosmetic Surgery of the Body and Extremities

Patient Selectio n

There are several patient characteristics that may produce a poor result or that will result in unsatisfactory attempts at calf reduction: • Swollen calves: Th s may indicate that the patient’s calf hypertrophy not only results from muscle or fat hypertrophy, but also from poor venous return. There are so far no cosmetic surgical methods for permanently managing leg edema. • MCC greater than 40 cm or less than 29 cm: A patient with extreme calf hypertrophy always has combined total muscle hypertrophy, including the toe muscles, and a thick tibial bone. Furthermore, it is difficult to achieve the ideal MCC from this level, even when a 6 cm reduction is achieved. On the other hand, for a smaller MCC, the improvement will be too insignifi ant for surgery to be considered a reasonable option.

Surgical Technique The surgical procedure is performed with the patient in the prone position, under general anesthesia. No muscle relaxants are given, because they make accurate intraoperative identifi ation of motor nerves impossible. Although local anesthesia is possible, care should be taken with pain and irritability during the operation. In my practice, general anesthesia is commonly used. A 1.5 cm incision is made starting at the midpoint of the popliteal fossa and extending medially.

Selective

Neur ect omy

After the subcutaneous plane is dissected, the fi st structure encountered is the short saphenous vein. The vein is preserved and retracted medially. The specially designed small self-retractor is used to expose the small operative fi ld. The deep fascia is then cut and blunt dissection performed subfascially to locate the motor nerves. We use the fish hook to retract the medial gastrocnemius muscle to reduce the number of assistants required (Fig. 67-5). Between the medial and lateral points, three small nerves can usually be identifi d: (1) the nerve to the medial gastrocnemius, (2) the nerve to the lateral gastrocnemius, and (3) the nerve to the soleus muscle (Fig. 67-6).

A

B

C

D

Fig. 67-5  Instruments selected or designed for the selective neurectomy during different operative steps. A, Smaller self-retractor for skin and fascia. B, Fish hook for muscle retraction. C, Nerve stimulator. D, Mosquito forceps for grasping nerve ends.

Chapter 67 

Cosmetic Calf Reduction

1047

Assistant side

Nerve to medial gastrocnemius muscle

Operator side

Fig. 67-6  The mosquito forceps holds the cut end of the nerve to the medial gastrocnemius muscle.

These nerves are isolated and their innervations confi med with a nerve stimulator (Vari-Stim III Nerve Locator). Stimulation of the nerve must clearly trigger the contraction of the targeted muscle for a positive identification to be made. Sensory nerves that do not produce muscle contractions must be preserved. Once a positive identifi ation is made, a 1 cm segment neurectomy of all nerve to the triceps surae is performed to prevent spontaneous reinnervation of the muscle as a result of the close proximity of the cut ends. The operative time for neurectomy is about 20 minutes. Liposuction is performed with a long, small cannula. Such cannulas will prevent skin irregularities and will suction out the adipose tissue around the Achilles tendon to re-create the natural hollow. The wound is then closed in layers, and the sutures are removed after 2 weeks.

Postoperative Care Mobilization is encouraged immediately after the procedure, and patients are required to wear compressive stockings on their lower limbs for at least 3 months. Because the strong tension on the neurectomy wound often induces conspicuous hypertrophic and hyperpigmented scarring, the patient is not encouraged to actively exercise for at least 1 month, and wound taping after removal of the sutures should be done for more than 2 months. To help the patient achieve a normal gait after the operation, the wearing of highheeled shoes as a “crutch” during the recovery period is suggested.

Results For the 1032 cases I performed until December 2010, reduction in MCC was 2.97 6 1.95 cm. The average MCC was 31.4 6 1.8 cm. Short-term disability was noted as 20.3% within 6 months, 8.2% within 9 months, and 1.9% within 1 year. Subjective dissatisfaction was only 1.1% and focused primarily on a conspicuous scar and numbness over the lateral ankle. Some representative cases of calf reduction (selective neurectomy and liposuction) are presented here.

K23345_Pu_c67 68_Cosmet Calf Reduc_r3_cl_1041-1054.indd 1047

4/3/2015 1:15:55 PM

1048

Part IX 

Cosmetic Surgery of the Body and Extremities

Fig. 67-7 Th s 25-year-old woman had undergone at least three sessions of botulinum toxin A injections, but she was not satisfi d with the results and was concerned about the ongoing cost of such treatment. She presented requesting a surgical solution. I explained the details of the operation, including the short-term inconvenience of leg weakness. She elected to undergo the calf reduction operation. Her MCC was 34.4 cm (left and right) preoperatively; postoperatively the MCC was 30 cm (left and right) and remains so after 1.5 years of follow-up. She is happy with the result.

K23345_Pu_c67 68_Cosmet Calf Reduc_r3_cl_1041-1054.indd 1048

4/3/2015 1:15:56 PM

Chapter 67 

Cosmetic Calf Reduction

1049

Fig. 67-8 Th s 28-year-old fashion model was especially concerned with having beautifully contoured calves. She always wears high-heeled shoes, which exacerbated her prominent calf muscle bulge. She had sought a number of conventional treatments such as massage, but these did not produce any signifi ant improvement. Her MCC was 34.6 cm (left) and 34.4 cm (right) preoperatively; postoperatively the MCC was 31.4 cm (left) and 31.2 cm (right) after 1 year of follow-up. The results have fulfilled her expectations.

K23345_Pu_c67 68_Cosmet Calf Reduc_r3_cl_1041-1054.indd 1049

4/3/2015 1:15:56 PM

1050

Part IX 

Cosmetic Surgery of the Body and Extremities

Fig. 67-9 Th s 55-year-old woman had been eager to have slim calves since youth. She came to my clinic for consultation when she learned of my calf reduction technique. Although she did not engage in regular exercise, her calves had a strong, masculine appearance. She also requested thigh and calf liposuction. Her MCC was 35.2 cm (left) and 34.7 cm (right) preoperatively; postoperatively it was 31.0 cm (left) and 31.3 cm (right) after 2 years of follow-up. There are no irregularities to her legs after these procedures.

K23345_Pu_c67 68_Cosmet Calf Reduc_r3_cl_1041-1054.indd 1050

4/3/2015 1:15:57 PM

Chapter 67 

Cosmetic Calf Reduction

1051

Fig. 67-10 Th s 35-year-old man, a homosexual, requested that his muscular, asymmetrical calves be feminized. Despite weight loss and other efforts to streamline his legs, he still felt that his calves were ugly. His MCC preoperatively was 38.8 cm (left) and 40.2 cm (right); postoperatively it was 33.5 cm (left) and 34.0 cm (right) after 1 year of follow-up. The patient is pleased with the symmetrical balance and size of both calves.

K23345_Pu_c67 68_Cosmet Calf Reduc_r3_cl_1041-1054.indd 1051

4/3/2015 1:15:57 PM

1052

Part IX 

Cosmetic Surgery of the Body and Extremities

Management of Complications The most common sequela in my series was numbness of the lateral ankle. Spontaneous recovery can be expected, but vitamin B complex and massage may accelerate the course of sensory nerve reinnervation. The worst complications were damage of the nerve to the toe muscles. If there is loss of any toe extension or flexion postoperatively, reexploration and microsurgical anastomosis should be performed as soon as possible, because small muscles are less tolerant of long-term nerve injury. Since the length of nerve resection is greater than 1 cm, iatrogenic neuroma was rarely encountered. In cases of neuroma, a resecting procedure often resolves the problem.

Iss ues fo r Revis io n

If a missed nerve during dissection led to a poor result or signifi ant compensatory hypertrophy of residual muscle, a secondary procedure was suggested. The same incision was performed to explore the previous surgical neurectomy scar. Often the glistening neuroma was easily seen. However, the dissection should be through the healthy surgical plane, as for other secondary procedures. In other words, the surgeon should initially explore all nerves to the toe muscles, avoid damage to these nerves, then separate and cut all the nerves above to the triceps surae. Any irregularities after liposuction can be smoothed by a small cannula if it is run delicately over the whole area. Fluid infiltration should be set to a higher amount than for a routine liposuction procedure.

Discussion Pr ed icted Res ul t s

Time Course and Muscle Weight Reduction Neurectomy induced rapid loss of denervated skeletal muscle in the fi st 2 months of denervation, then approached 11% of the skeletal muscle mass after 6 months. By comparison, botulinum toxin induced a V-shaped recovery curve of muscle weight, with a trough seen at 1 month after each injection (see Fig. 67-3, B).

Maximal Calf Circumference The average MCC goal is about 32 cm. The more obvious the muscle bulge, the more reduction can be expected. At present, the largest MCC reduction is about 6 cm. The exact MCC reduction can be predicted preoperatively. Only the reduction range (1.5 to 6 cm) is informed to the patient.

Additive Effects of Botulinum Toxin Additive effects were obtained through repeated injections of botulinum toxin. The muscle weight ratio after a single full-dose botulinum toxin injection recovered incompletely to 90% of original weight after 1 year. Higher frequency of doses of botulinum toxin injections increased and prolonged the effects of muscle atrophy.

Chapter 67 

Cosmetic Calf Reduction

Functional Recovery Serial functional assessments showed that the neurectomy group exhibited immediate and signifi ant reductions in motor function between 1 and 2 months postoperatively, then showed little additional improvement. At 6 months there was a residual functional defic t (20%). Neurectomy not only results in irreversible muscle mass reduction, but also induces a lasting functional defic t, as previously shown in my 2008 study.3 The new techniques eliminate the disadvantage of the conventional neurectomy (compensatory hypertrophy), with good functional recovery. My clinical studies also showed that electromyographic recruitment ranged from 23 to 24, signifying near-total denervation. Gait analysis and clinical observations also revealed that gait approached that of normal levels after 6 months over the knees and ankles.

Specific Goals of Denervation: Muscle Volume Reduction and Iatrogenic Functional Loss Our previous study revealed that denervation fi st results in loss of motor function, followed by muscle mass reduction.11For clinical purposes, ideally only the motor function or the muscle volume (calf or masseter muscle hypertrophy) should be targeted. To create iatrogenic motor function loss (dynamic wrinkles for wrinkle relief), I try to generalize the biological phenomena related to denervation, which should focus as completely as possible on the muscle that performs a specific function. On the other hand, denervation should target a specifi ally innervated muscle as little as possible to reduce muscle mass with minimal functional deficit. In short, the degree of motor function defi it depends on the extent and number of denervated muscles.

Pearls for Success • All nerves to the triceps surae (gastrocnemius and soleus muscle) should be completely resected in a 1 cm length, at least while the saphenous sensory nerve and nerve to the toe muscles are kept intact. • The territory of liposuction should be as extensive as possible, even around the ankle, by the smallest cannula. • The incision wound should be given high priority because of the potential of conspicuous hypertrophic and hyperpigmented scar. • High-heeled shoes are strongly recommended during the recovery or rehabilitation period to serve as a “crutch.” Th s kind of shoes makes walking look as “normal” as possible during the recovery period.

Refer ences 1. Tsai CC, Lin SD, Lai CS, et al. Aesthetic analysis of the ideal female leg. Aesthetic Plast Surg 24:303, 2000. 2. Lee HJ, Lee DW, Park YH, et al. Botulinum toxin A for aesthetic contouring of enlarged medial gastrocnemius muscle. Dermatol Surg 30:867, 2004. 3. Tsai FC, Mardini S, Fong TH, et al. Selective neurectomy of the gastrocnemius and soleus muscles for calf hypertrophy: an anatomical study and 700 clinical cases. Plast Reconstr Surg 122:178, 2008. 4. Tsai FC, Chen CH, Lin CY, et al. Analysis of the body mass index and leg profiles of Asian women after total leg sculpture. Plast Reconstr Surg 124:643, 2009.

1053

1054

Part IX 

Cosmetic Surgery of the Body and Extremities

5. Fong TH, Wong CH, Lin JY, Liao CK, Ho LY, Tsai FC. Correction of asymmetric calf hypertrophy with differential selective neurectomy. Aesthetic Plast Surg 34:335, 2010. 6. Mladick RA. Advances in liposuction contouring of calves and ankles. Plast Reconstr Surg 104:823, 1999. 7. Watanabe K. Circumferential liposuction of calves and ankles. Aesthetic Plast Surg 14:259, 1990. 8. Lee JT, Wang CH, Cheng LF, et al. Subtotal resection of gastrocnemius muscles for hypertrophic muscular calves in Asians. Plast Reconstr Surg 118:1472, 2006. 9. Kim HS, Hwang JH, Lee PK, et al. Localization of the motor nerve branches and motor points of the triceps surae muscles in Korean cadavers. Am J Phys Med Rehabil 81:765, 2002. 10. Gutmann E, ed. The Denervated Muscle. Prague: Czechoslovak Academy of Sciences, 1962. 11. Tsai FC, Hsieh MS, Chou CM. Comparison between neurectomy and botulinum toxin A injection for denervated skeletal muscle. J Neurotrauma 27:1509, 2010. 12. Tsai FC, Pai MH, Chiu CC, et al. Denervation dynamically regulates integrin alpha-7 signaling pathways and microscopic structures in rats. J Trauma 70:220, 2011. 13. Tsai FC, Pai MH, Chiu CC, et al. Downregulation of the integrin a(v) signaling pathway in uterine leiomyomas. Gynecol Obstet Invest 71:129-135, 2011.

K23345_Pu_c67 68_Cosmet Calf Reduc_r3_cl_1041-1054.indd 1054

4/3/2015 1:15:57 PM

Part X

Other Cosmetic Surgical Procedures

K23345_Pu_c68_Hair Transplan_r4_cl_1055-1076.indd 1055

4/3/2015 2:08:41 PM

K23345_Pu_c68_Hair Transplan_r4_cl_1055-1076.indd 1056

4/3/2015 2:08:41 PM

68 Hair Transplantation

H

Jiping Wang, Jincai Fan

air transplantation to treat hair loss was fi st popularized with the Okuda-Orentreich technique (known as a standard punch graft for about a half-century) and its modifications mainly because of its simplicity and effectiveness.1,2 However, these techniques often resulted in unnatural-looking transplanted hair, because the graft was too big. Results did not meet patients’ desires. Smaller hair grafts (such as micrograft and minigrafts) were developed to improve outcomes of growing hair by splitting a standard punch graft into several pieces or dividing minigrafts and micrografts from a harvested scalp strip.3-6 Because the concept of a follicular unit was fi st published in 1984, the desired outcome of more naturalappearing hair growth was possible through transplantation of these individual units.7 Limmer8 introduced graft d vision through stereomicroscopic dissection from a strip of scalp, and Bernstein and Rassman9,10 proposed a formal technique of follicular-unit grafting. In hair restoration surgery the demand for transplantation of follicular-unit grafts has tremendously increased. However, transplantation of a large number of these grafts is tedious, laborious, and time consuming, especially with a dense-packing fashion. The published survival of grafts nd clinical outcomes vary from clinic to clinic, especially for megasessions (1000 or more grafts per session).11,12 In this chapter, we introduce refi ed techniques of hair transplantation to the scalp, eyebrow, eyelash area, and moustache area. Several successful cases are included in this chapter to demonstrate valuable methods used in hair transplantation.

Anatomy of the Scalp The layers of the scalp from superficial to deep are the skin, subcutaneous tissue, galea aponeurosis, loose areolar tissue, and pericranium (Fig. 68-1). The scalp has special characteristics, including the following: • Between the skin and galea are rich connective tissue fibers that fi mly connect the layers and allow scalp flaps to be less elastic. • The scalp is nourished with five paired arteries: the supratrochlear artery, the supraorbital artery, the superfic al temporal artery, the posterior auricular artery, and the occipital artery. • A large scalp flap can survive with a long, narrow pedicle. • The scalp is mainly innervated from the surrounding area to the top of the head by the paired supratrochlear nerve, supraorbital nerve, auriculotemporal nerve, great auricular nerve, small occipital nerve, great occipital nerve, and third occipital nerve. A nerve block can be easily achieved with good aesthetic results. • The subgaleal layer comprises loose areolar tissue and is easily elevated with minimal bleeding. • The direction of scalp hair growth is angulated toward the scalp surface.

1057

1058

Part X 

Other Cosmetic Surgical Procedures

Fig. 68-1  Anatomic layers of the scalp.

Surgical Technique Scalp Str ip Har ves ting With scalp strip harvesting, the donor area to be harvested is based on the demands of the recipient site, such as its position and surface area, and the characteristics of the donor site, such as hair follicle thickness, hair density, and hair color. For correction of the frontal hairline in a patient with male pattern alopecia, we usually select the lower occipital region as a donor site, because the hair in this region is soft and similar in texture to the hair in the frontal hairline in a person without alopecia.13 The hairs in the donor area are trimmed to longer than 5 mm so that the shafts can be used for identifi ation purposes and for ease of transplanting follicular-unit grafts into the recipient microslits (Fig. 68-2, A). The donor area is infiltrated with a local anesthetic of 0.5% lidocaine with 1:500,000 epinephrine and saline solution (Fig. 68-2, B), and the selected area of donor hair-bearing scalp is cut using a No. 10 surgical blade (Fig. 68-2, C). Strips are harvested with a slicing motion, ensuring that the angle of the blade is always parallel to the direction of the hair shafts (Fig. 68-2, D). The incisions are carried to a depth that includes the hair follicles and some subcutaneous tissue. The scalp strip is then harvested with a sharp, curved scissors above the galeal layer and stored in a petri dish on gauze soaked in 4° C (39° F) saline solution (Fig. 68-2, E). The donor area is closed in two layers: the galea is closed with interrupted, absorbable 2-0 sutures, and the skin is sutured with a continuous, locked 4-0 nylon suture (Fig. 68-2, F).

Pr epara tio n of Follicul ar-U nit Graft s

Follicular-unit grafts re cut with sharp blades under a 1.53 to 2.53 magnifying loop (Fig. 68-3, A) or a 53 stereomicroscope (Fig. 68-3, B) using a slicing motion.4-6,14-16 In our experience, blunt blades and a pressing or chopping motion increases tissue trauma, crushes more hair follicles, and transects the hair follicles, because follicle alignment within the strip is altered.4-6 Our technicians perform this procedure on a stable table. Comfortable seating and suffici t soft lighting are required, and in our unit, soft music is played in the operating room. The harvested strip is transferred to a sterile wooden tongue depressor saturated in normal saline solution. It is positioned lengthwise on the tongue depressor, with the scalp surface on the left side nd the subcutaneous fat on the right side. The depressor can then be rotated clockwise or counterclockwise to the desired angle to position the hair follicles parallel to the blade in a pen-holding position (30 to 45 degrees obliquely).4-6,13 The strip is ready for the next step.

Chapter 68 

A

C

B

D

F

1059

Hair Transplantation

E

G

Fig. 68-2  A, The occipital donor site is prepared; the hair is clipped to a uniform shorter length. B, A local anesthetic

in saline solution is infiltrated in the donor area. C, The angle of the blade is parallel to the direction of the hair shafts D, A strip of scalp is harvested over the galeal layer. E, The strips are placed in a petri dish. F, The donor site is closed. G, Seen 10 months postoperatively, the donor site is virtually undetectable.

A

B

Fig. 68-3  A, Magnifying loops in place for preparing follicular-unit graft . B, An assistant prepares a scalp strip with the use of a stereomicroscope.

K23345_Pu_c68_Hair Transplan_r4_cl_1055-1076.indd 1059

4/3/2015 2:08:43 PM

1060

Part X 

A

C

Other Cosmetic Surgical Procedures

B

D

E

Fig. 68-4  A, A superthin sliver is sliced from the harvested scalp strips. It contains only one row of hair follicles. B, The

slivers are transferred to a petri dish containing 4° C saline-moistened gauze. C, Extra fat tissue is removed, beginning 1 mm below the hair bulb. D, Extra tissue is cut from the sides of the follicular-unit grafts E, The follicular-unit grafts, eady to be inserted, are stored in a petri dish containing 4° C saline-moistened 4 3 4 gauze pads. Single-hair follicular-unit grafts are at the top, two-hair follicular-unit grafts are in the middle, and three-hair follicular-unit grafts are at the bottom.

A series of superthin slivers is made, each approximately 1 mm wide. Each sliver contains only one row of follicular units. These are cut with a slicing motion in the space between the follicular units of the scalp strip. Precision is required in this step. Using a Foerster microforceps, the scalp strip is held with the left hand at the skin edge on the proximal end. The strip is cut parallel to the hair follicles with a sharp blade held in the right hand (Fig. 68-4, A). Great care is required to prevent injury to the follicles. The slivers are stored in a sterile petri dish containing saline solution at about 4° C and are then transferred to the next technician (Fig. 68-4, B). Fat tissue is removed beginning 1 mm below the hair bulb (Fig. 68-4, C). The follicular-unit hair grafts usually contain one to three hairs in most Asians. The grafts are divided from the superthin slivers by slicing off the extra tissue from both sides of each follicular unit (Fig. 68-4, D). The prepared grafts, ow ready for transplantation, are mounted on 4 3 4 gauze pads according to hair numbers in the grafts nd stored in a sterile petri dish containing saline solution at 4° C (Fig. 68-4, E). During the entire procedure, the harvested scalp tissue needs to remain moistened with saline solution.

Pr epara tio n of the Recip ient Ar ea

The recipient area is infiltrated with local anesthetic and 1:500,000 epinephrine in saline solution. Microslits are made with a series of needles14-18 to accommodate the follicular-unit grafts. e use 20-, 19-, and 18-gauge needles (Fig. 68-5) for one-, two-, and three-hair grafts, respectively, in an appropriate angle to the skin. The slits are just deep enough (about 3 to 5 mm) to approximate the galea aponeurotica in the scalp. We do not use dilators in our patients, because we think that they are unnecessary. Instead, our unit currently uses a modifi d technique similar to a punctiform or stick-and-place technique.18-20

Chapter 68 

Hair Transplantation

Fig. 68-5  A series of commercial needles: 20-gauge (top), 19-gauge (middle), and 18-gauge (bottom).

Fig. 68-6  A follicular-unit graft is inserted using a forceps-forceps technique.

Inser tio n of Micr o graft s

A comfortable, well-lit working environment is essential for seeding the grafts. The patient should be well sedated and still. The recipient site is cleaned, and bleeding is minimized by injecting a mixture of epinephrine and saline solution. The surgeon begins as soon as the fi st grafts are prepared to minimize ischemia time. We use a 1.53 to 2.53 magnifying loop. Grafts re placed in the microslits in one of two methods: forceps-forceps or puncturing and seeding.

Forceps-Forceps Method A forceps-forceps technique is used for premade recipient microslits in a clean field with minimal bleeding. The graft are implanted using two Foerster microforceps, one for introduction and the other for placement. The introduction forceps are held in the left hand with the tips at an angle of 15 to 20 degrees to open the microslit. Meanwhile, the placement forceps are in the right hand, holding the graft t the subcutaneous tissue below the hair bulbs and hiding it behind the tips of the forceps. The graft s inserted by sliding it into the bottom of the open microslit, along the uppermost wall of the slit (Fig. 68-6). The introduction forceps are then withdrawn from the slit with the same degree of force used for opening the slit. While the introduction forceps maintain the graft in place, the placing forceps are taken out of the slit by slightly releasing the force placed on them for grasping.5

1061

1062

Part X 

Other Cosmetic Surgical Procedures

Puncture and Seed Method The puncture and seed method is used in fields that tend to bleed easily. Injection needles should be sharp enough to easily penetrate the skin of the recipient bed. Each microhole is made to a depth of about 3 to 5 mm in the angle of the original hair with a needle held in the left and (Fig. 68-7, A). The needle is withdrawn to the level of the skin and used to hold the microhole open. The graft is held with a Foerster microforceps in the right hand at the level of the subcutaneous tissue below the hair bulbs and is immediately seeded into the bottom of the microslit along the uppermost wall of the slit (Fig. 68-7, B). While the graft is held in place with the needle tip, the forceps is removed from the slit by slightly releasing the force used to grasp the graft (Fig. 68-7, C). At the end of the session, the scalp is cleaned with a 4 3 4 gauze medical compress soaked in hydrogen peroxide. The transplanted grafts re carefully checked to confi m their proper position and orientation (Fig. 68-8). A microporous dressing with appropriate pressure is usually worn overnight to maintain graft positioning (Fig. 68-9). A prophylactic antibiotic agent such as cephalosporin is routinely applied perioperatively.

A

B

C

Fig. 68-7  Graft implantation with a puncture and seed technique. A, A microslit is made. B, A graft is seeded. C, Graft seeding is completed.

Chapter 68 

Hair Transplantation

Fig. 68-8  The transplanted grafts are carefully checked to confi m their proper position and orientation.

Fig. 68-9  A microporous dressing is usually applied and left in place overnight to maintain graft positioning.

Results And r o gene tic Al opeci a

In general, Asians and whites have the following specific differences in scalp, hair, and alopecia: • The incidence of androgenetic alopecia in most Asians is lower than in whites. • Most Asians are typically less concerned with androgenetic alopecia than whites. • The hair of most is straight and dark, with relative lightly colored skin. The hair density of Asians (about 100 to 150 hairs/cm2) is usually lower than that of whites (more than 200 hairs/cm2), but the hair shaft d ameter is larger in Asians than in whites (about 100 mm and 70 mm). We think that the anagen hair of Asians may grow longer. Thus, styled hair appears fuller than it actually is. • In most Asians, the frontal hairline is round, wide, and flat, compared with that of whites. The patient and surgeon discuss the hairline design before transplantation. Most Asian women favor a typical “beauty arch” (Fig. 68-10, A), whereas most Asian men prefer an M-shaped arch (Fig. 68-10, B). We usually arrange one- and two-hair grafts in the region about 3 cm behind the hairline for a more natural appearance on frontal view. The area farther back is mainly grafted with two-hair and threehair grafts to make the transplanted hair appear thicker. • The incidence of hypertrophic scars and keloids at the donor site is higher in Asians than in whites. The donor site should be closed in two layers to minimize tension on the wound (Fig. 68-11). • Dense-packing follicular-unit graft procedures are more difficult in Asian patients, because the scalp is thicker, stiffer, and less elastic. Sharp instruments should be used and microslits should be curved to minimize forces on the sides and surrounding area when the graft is placed.

1063

1064

Part X 

A

Other Cosmetic Surgical Procedures

B

Fig. 68-10 The shape of the hairline is discussed by the surgeon and patient. Asian women tend to prefer a hairline with a beauty arch (left . Asian men usually prefer an M-shaped hairline (right).

Fig. 68-11 Appropriate donor wound closure is essential to prevent hypertrophic scars or scar widening. The scalp of the patient on the left w s closed in one layer. The wound of the patient on the right was closed in two layers. Note the differences in the visibility of the donor sites; a two-layer closure is recommended. 

K23345_Pu_c68_Hair Transplan_r4_cl_1055-1076.indd 1064

4/3/2015 2:08:49 PM

Chapter 68 

Hair Transplantation

1065

Fig. 68-12 Th s 53-year-old man with Norwood type IIIa male pattern baldness had follicular-unit graft transplantation with a dense-packing fashion. We seeded 400 grafts, each with one to two hairs, in his frontal hairline region and 1100 grafts, each with two to three hairs, in the top region. At his 11∕2-year follow-up, his grafted hairline appears nearly natural (feathering zone).

K23345_Pu_c68_Hair Transplan_r4_cl_1055-1076.indd 1065

4/3/2015 2:08:49 PM

1066

Part X 

Other Cosmetic Surgical Procedures

Fig. 68-13 Th s 32-year-old man with Norwood type VI male pattern baldness underwent follicular-unit graft transplantation. We transplanted 430 one-hair and two-hair grafts in approximately 3 cm regions of his hairline. Behind these grafts, an additional 1500 two-hair and three-hair grafts were transplanted. After 8 months, the grafted hairs are growing well.

K23345_Pu_c68_Hair Transplan_r4_cl_1055-1076.indd 1066

4/10/2015 7:16:37 AM

Chapter 68 

Hair Transplantation

Scalp Al opeci a Fr om Scar r ing

Any injury to the scalp will cause a degree of scalp alopecia from scarring. Scalp reconstruction usually includes full-thickness soft tissue coverage to maintain function and/or hair restoration for aesthetic purposes. An ideal solution to scalp alopecia is to redistribute the remaining hair-bearing scalp. Traditionally, if hair on the remaining scalp was not suffici t, numerous distant flaps with no hair-bearing tissue were transferred to meet functional requirements. Although a hair-bearing scalp flap, with or without tissue expansion, usually achieves high-density hair growth in the recipient site, its disadvantages include those that can occur with any complex surgery, the risk of flap necrosis, visible incisional scarring, and an unnatural hairline.20 Hair grafting may be an alternative option for treating scar lesions for cosmesis. However, this treatment usually does not work well for unstable scars, defects of skull bone, or thin skin that is grafted on the skull bone, which often breaks down, bleeds, or becomes infected. In our experience, a stable, mature, and noninfected scar lesion with more than 3 to 5 mm of scalp thickness is suffici t for follicular-unit hair transplantation (Fig. 68-14). Hair grafting on a scar lesion is technically very difficult, especially with a dense-packing fashion because of tissue stiffness, the lack of elasticity, and poor blood circulation in the recipient bed. Instead of using sharp instruments, we think that curl-slits made with injection needles are a better technique to accommodate grafts 14-16 Because a scarred bed results in poor blood circulation, the concentration of epinephrine in the local anesthetic should be low. Our unit uses a concentration of less than 1:1,000,000. If scar tissue is very thin, microslits should be made at more acute angles to increase the length of the tunnel to house the graft nd to maximize the possibility of graft ttachment for faster revascularization (Fig. 68-15). Less dense-packing may help to increase hair survival in transplanted grafts, especially for surgeons who have little experience with the technique. Furthermore, a well-trained operating team is essential, because repeated attempts to place a graft in a challenging recipient hole increases trauma to the graft and recipient bed and lengthens ischemia time.

Fig. 68-14 Th s 24-year-old man had scarred sideburn alopecia from a burn. He received 100 single-hair grafts nd 400 two-hair or three-hair grafts in only one session. The hair growth appears quite natural, and hair density is satisfactory.

1067

1068

Part X 

Other Cosmetic Surgical Procedures

Fig. 68-15 Th s 35-year-old man was burned on his right sideburn region. His sideburn hair was restored with 630 one-hair to three-hair grafts. After 19 months, his sideburn has a quite natural appearance.

Eyebr ow Rec onstr uctio n

Eyebrows are a very important cosmetic landmark of the face. Eyebrow loss usually makes the face look unpleasant and unnatural. Reconstruction of an ideal eyebrow has always been a challenge for surgeons. Traditionally, eyebrows were restored with an island scalp flap based on the ipsilateral superfic al temporal artery or a scalp strip–grafting technique. However, the former technique usually created a brush-looking eyebrow because of the rich blood nourishment, whereas the latter often resulted in no hair growth because of the shortage of a blood supply. Moreover, neither technique achieves the desired hair orientation. Single follicular-unit hair graft can produce a more natural eyebrow, because the desired hair density and direction can be achieved by a well-trained surgeon. The shape and size of the eyebrow to be reconstructed is usually chosen by the patient. The donor area is in the lower occipital region, close to the hairline, because the hair in this area is soft nd very similar to eyebrow hair, which is especially important for restoration of a partial eyebrow (Fig. 68-16). In our unit, restoration of a complete eyebrow in an Asian man typically requires 200 to 250 single follicular-unit grafts placed in microslits made with a 20-gauge needle, and 150 to 200 grafts are needed for an eyebrow in most Asian women (Fig. 68-17, A). The angle between the hair shaft nd the skin should be sharp, usually 15 to 30 degrees. At the end of the operation, a microporous dressing with appropriate pressure is applied and left in place for about 1 week to maintain proper positioning of the grafts. Patients will have to trim the hairs regularly (Fig. 68-17, B and C).

Chapter 68 

Hair Transplantation

1069

Fig. 68-16 This 25-year-old man lost part of his left eyebrow in a car accident. It was restored with 68 single follicularunit grafts. His outcome is good.

A

B

C

Fig. 68-17 Th s 28-year-old man’s eyebrows were burned in an accident. He received 165 single follicular-unit grafts on his right brow and 135 on his left. A nearly natural look has been restored to his eyebrows.

K23345_Pu_c68_Hair Transplan_r4_cl_1055-1076.indd 1069

4/3/2015 2:08:55 PM

1070

Part X 

Other Cosmetic Surgical Procedures

Eyel a sh Res t ora tio n

Although eyelash transplantation has been performed since the beginning of the twentieth century, it remains a technical challenge even for the most experienced surgeons. The technical difficulties include an unsteady eyelid, the danger of harming the globe, and difficulty seeding the grafts. The ciliary margin is a mobile and unstable region; therefore it is a technical challenge for transplantation. Stabilization of the upper eyelid is a key requirement to facilitate placement of grafts. The technique requires a coordinated effort between the surgeon and assistant. We think that an overlapping design of the grafts in two rows increases graft d nsity without noticeable thickening of the ciliary border. The incidence of graft extrusion during dense-packing is reduced by decreasing the pressure placed on each follicular unit during implantation. The 30-degree upward curve of the recipient sites is necessary to prevent the grafted hair from interfering with vision, but most patients will require regular maintenance to achieve a normal anatomic curl of the eyelashes because of the hardness of the hair shafts in most Asians. The recipient sites (in the upper eyelid) are usually aligned in two off et rows just above the original eyelashes to accommodate single follicular-unit grafts. After a local anesthetic is administered containing 2% lidocaine and 1:100,000 epinephrine, a corneal protector is placed to protect the globe during the procedure. The eyelid is stabilized with a specialty hook constructed from a 25-gauge needle (Fig. 68-18, A). The hook is inserted into the ciliary margin of the upper eyelid. While an assistant helps to stabilize the eyelid, a series of recipient sites is prepared with a 20-gauge needle curved 30 degrees at the tip (Fig. 68-18, B). The sites are made at a 30-degree upward angle, designed to overlap the original eyelash just above the tarsal plate (Fig. 68-18, C). The average number of recipient sites is 50 to 70 per eyelid, depending on patient request. While a curved needle held in the left hand is used to open already-prepared recipient sites, single-hair grafts re placed into the sites along the inferior border using a curved Foerster microforceps in the right hand. At the conclusion of each session, the grafts re carefully evaluated to confi m their proper orientation and placement (Fig. 68-18, D). The eyes should be kept closed for at least 3 to 5 days postoperatively.

A

B

C

D

Fig. 68-18  A, Specialty hook. B, 20-gauge needles curved 30 degrees at tip. C, Recipient sites are made. D, Grafts re evaluated for proper placement and orientation.

Chapter 68 

Hair Transplantation

Most Asians consider long eyelashes highly desirable, however, they generally have very short eyelashes compared with Westerners. Eyelash reconstruction may be required after trauma, as seen in Fig. 68-19 in a man who had lost part of his eyelid in a splash burn. In addition, cosmetic eyelash elongation is in high demand among many young Asian women, as shown in Fig. 68-20. Th s procedure is performed with single follicular-unit hair grafts. reoperatively, patients determine the length and shape of the eyelashes to be grafted. The donor area is selected from the lower occipital region, close to the hairline. The hair in this area is an ideal match for eyelashes.

Fig. 68-19 Th s 36-year-old man had partial loss of his right eyelid after a splash burn. After the eyelid had been reconstructed with a composite tissue graft of septal cartilage and mucosa, the eyelash was restored with 40 single follicular-unit grafts. The grafted hairs are growing well.

1071

1072

Part X 

Other Cosmetic Surgical Procedures

Fig. 68-20 Th s 28-year-old woman requested longer eyelashes. Single-hair grafts were transplanted in her upper eyelids for eyelash elongation. She received 54 single-hair grafts in her right eyelid and 58 in the left. Thi teen months postoperatively, the grafted hairs are growing well.

Mus t a che Rec onstr uctio n

Mustache restoration is usually performed to camouflage a scar (Fig. 68-21). Hair transplantation to the upper lip usually fails to achieve the same excellent cosmesis as transplantation to the scalp. The technical difficulties include unsteadiness of the upper lip and tissue softness for anchorage of a graft. Furthermore, traditional techniques are usually very difficult to perform on scars because of tissue stiffness and the tendency of grafts o fall out of recipient sites. The unpredictability of hair growth usually becomes the main problem. With the puncture and seed technique used in our unit, recipient slit-making and seed grafting can be completed in one continuous action, minimizing bleeding and slit dilation and the attendant effects. We think that curl-slits made with injection needles may better accommodate the grafts. Moreover, the incidence of graft ex rusion during dense-packing is reduced by decreasing the pressure placed on each follicular-unit graft during implantation. Although not proven, resting the mouth as much as possible for 3 to 5 days postoperatively may increase graft urvival. The most important factor for a good outcome is that transplanted hair meets the requirements of the recipient area.

Chapter 68 

Hair Transplantation

1073

Fig. 68-21 Th mustache area of this 42-year-old man was burned in an accident. We transplanted 220 single follicular-unit grafts in his upper lip to camouflage his unsightly, scarred skin. Fifteen months postoperatively, his transplanted hair is growing well.

Postoperative Care After the grafts are implanted completely, the dressing is applied and usually left on overnight. A nonadhesive compress is used at the recipient site to prevent the dressing from sticking to the grafts. Light pressure should be applied, such as with an elastic net, to help to stop minor bleeding from the wound. The head should be kept higher so that there is less edema. Some pain or discomfort is common after hair transplantation surgery, but it is rarely severe. Only patients with severe pain need to take the prepared pain killers. Antibiotics are used for the fi st 3 days after surgery to prevent infection. The patient can begin washing his or her hair in the shower 1 week after surgery. Suture removal of the donor site is performed 10 to 14 days after surgery. Hair growth occurs in the first 3 months after surgery.

K23345_Pu_c68_Hair Transplan_r4_cl_1055-1076.indd 1073

4/3/2015 2:08:58 PM

1074

Part X 

Other Cosmetic Surgical Procedures

Management of Complications To diminish scarring of the donor site, an interrupted, absorbable suture is placed in the galeal layer to decrease the wound tension, and monofilament, nonabsorbable sutures are placed superfic ally, which are removed 10 to 14 days postoperatively. Obvious scars seldom develop at the recipient site. However, scars in this location can be noticeable if recipient holes are too big or small, too much tissue is lost or surgical trauma occurs, or seeded grafts are improperly positioned. Donor bleeding is easily controlled with sutures in two layers. However, it can be more difficult in patients with a history of hypertension or a bleeding tendency. Patients should be screened before surgery. Bleeding in the recipient site is usually controlled with infiltration of the proper amount of adrenalin in the subcutaneous plane. Bleeding can worsen when a procedure lasts too long (for example, in a megasession), if recipient holes are too big, or if adrenalin is given in an insuffici t dose or in the wrong location. Alternatively, the puncturing and seeding technique can be a better way to control the bleeding. A ring bandage on the head can be helpful. It can be removed and replaced periodically. A cobblestone appearance in the recipient site is prevented with transplantation of small hair grafts (for example, follicular-unit grafts), as opposed to traditional punch grafts. But the recipient scalp can be smoothed signifi antly by making recipient holes of the proper shape, size, and depth to match the grafts and to ensure that they remain in position for several days.

Discussion A follicular-unit hair graft s theoretically a free composite tissue graft hat has been surgically isolated from its native site (Fig. 68-22). Once a scalp strip is harvested, it survives only by anaerobic metabolism and nutrients from its own tissue and the storage medium. After the graft s implanted into the recipient slit, nutrients are supplied by the host bed until permanent blood circulation is reestablished several days later from the vessels in the tissue surrounding the recipient site. Increased trauma, metabolism, and ischemia time during transplantation will influence survival of the transplanted grafts We think that cooling the medium to 4° C can slow metabolism and increase the time before ischemia causes irreversible anaerobic changes that result in cell death. Therefore we store the strips and grafts in a 4° C cold petri dish in normal saline solution to decrease the metabolism of the graft and to prevent cold injury to the graft. Sharp instruments for cutting grafts and making slits limit local tissue trauma. Furthermore, we prefer to prepare grafts ith a slicing motion instead of an up-down pressing motion (which increases the cutting force and tissue damage) or dissection fashion (which requires excess tissue cutting

Fig. 68-22  A series of follicular-unit grafts with different numbers of hairs.

Chapter 68 

Hair Transplantation

time).4-6,8-10,13-16 Any excess gripping of the follicles and surrounding tissues will increase tissue inflammatory reactions and negatively influence graft survival. We grasp the grafts at the subcutaneous tissue below the hair bulbs, whereas others hold the hair shaft or the tissue at the side of the hair bulb.4-6,14-16,21 We do not wash the harvested scalp strips and prepared grafts, ecause we think that this removes supportive nutrients from the grafts. We ensure that both the scalp strips and the grafts are always moist, particularly during preparing and seeding procedures. In our unit, a 1.53 to 2.53 magnifying loop or a 53 stereomicroscope is always used to divide the grafts from the harvested strip, and a lightweight magnifying loop with 1.53 to 23 magnifi ation may be helpful to seed the graft . We do not deepithelialize the grafts when they are divided, because this would greatly increase the risk of complications from piggy-backing (insertion of two or more grafts on top of one another in a single slit). Instead, we preserve about 5 mm of hair shaft bove the skin. Th s can be used to identify the graft uring implantation. We do not perform follicular-unit extraction, because we think that it is more difficult to harvest a large number of grafts with this technique, the risk of hair transection is increased, graft reparation time is longer, and the risk of hypertrophic scars or keloids in Asians is greatly increased. Although a single trained person can perform an entire follicular-unit graft transplantation, a team of at least three people signifi antly reduces the procedure time and therefore the ischemia time of the grafts especially in a megasession. Procedures are continually refi ed to increase speed and ease and to reduce surgical trauma to the hair follicles. A highly trained, highly skilled, and dedicated surgical team is essential for transplanting large numbers of grafts. e also emphasize the importance of a proper working environment for patients and personnel.

Pearls for Success • The instruments and operating room setting should be properly prepared. • All team members need to be well trained. • Surgically induced trauma on the grafts should be minimized. • The entire procedure should be as short as possible. • Grafts are preserved at a low temperature (approximately 4° C). • Grafts are implanted in properly sized holes in the recipient bed. The attachment of the graft should be large, without a severe scar or irradiation. • The blood supply of the tissue in the recipient bed should be enriched. • Surgical bleeding needs to be well controlled. • The grafts should be stabilized after anchored placement.

Refer ences 1. Okuda S. Clinical and experimental studies on hair transplanting of living hair. Jpn Dermatol Urol 46:537-587, 1939. 2. Orentreich N. How it all began: autographs in alopecias and other selected dermatological conditions. Ann NY Acad Sci 83:463-479, 1959. 3. Nordström RE. “Micrograft ” for improvement of the frontal hairline after hair transplantation. Aesthetic Plast Surg 5:97-101, 1981. 4. Fan J, Raposio E, Nordström RE. Minigrafts preparation in surgical hair replacement. Scan J Plast Reconstr Surg Hand 31:83-86, 1997. 5. Fan J, Wang J, Nordström RE. Standardized technique of transplanting micrografts in air restoration surgery. A practical approach. Dermatol Surg 23:829-833, 1997.

1075

1076

Part X 

Other Cosmetic Surgical Procedures

6. Fan J, Wang J, Nordström RE. Rhomboid minigrafts in hair restoration surgery. Dermatol Surg 24:581-585, 1998. 7. Headington JT. Transverse microscopic anatomy of the human scalp. Arch Dermatol 120:449-456, 1984. 8. Limmer BL. Elliptical donor stereoscopically assisted micrografting as an approach to further refi ement in hair transplantation. Dermatol Surg 20:789-793, 1994. 9. Bernstein RM, Rassman WR. Follicular transplantation: patient evaluation and surgical planning. Dermatol Surg 23:771-784, 1997. 10. Bernstein RM, Rassman WR. The aesthetics of follicular transplantation. Dermatol Surg 23:785-799, 1997. 11. Limmer BL. Micrograft survival. In Stough DB, Haber RS, eds. Hair Replacement: Surgical and Medical. St Louis: Mosby–Year Book, 1996. 12. Marritt E. The death of the density debate. Dermatol Surg 25:654-660, 1999. 13. Arnold J. Vertical strip dissection for graft production. In Stough DB, Haber RS, eds. Hair Replacement: Surgical and Medical. St Louis: Mosby–Year Book, 1996. 14. Wang J, Fan J. [Aesthetic eyebrow reconstruction by using follicular-unit hair grafting technique] Zhonghua Zheng Xing Wai Je Za Zhi 18:101-103, 2002. 15. Wang J, Fan J. Cicatricial eyebrow reconstruction with a dense-packing one- to two-hair grafting technique. Plast Reconstr Surg 114:1420-1426, 2004. 16. Wang J, Fan J, Chai J. Aesthetic eyelash elongation for Asians using a dense-packing single-hair grafting technique. Dermatol Surg 36:1155-1160, 2010. 17. Eisenberg EL. A rapid micrograft implantation technique. Dermatol Surg 21:988-989, 1995. 18. Uebel CO. Punctiform technique: hair replacement procedure of over 1000 micrografts and minigrafts. In Unger WP III, ed. Hair Transplantation. New York: Marcel Dekker, 1994. 19. Seager DJ. “Stick and place” method of planting. In Unger WP, Shapiro R, eds. Hair Transplantation, ed 4. New York: Marcel Dekker, 2004. 20. Fan J, Liu L, Tian J, et al. The expanded “flying-wings” scalp flap for aesthetic hemi-scalp alopecia reconstruction in children. Aesthetic Plast Surg 33:361-365, 2009. 21. Wang J, Fan J, Chai J. Aesthetic correction of cicatrical sideburn alopecia using follicular-unit hair grafts. ermatol Surg 39:801-804, 2013.

K23345_Pu_c68_Hair Transplan_r4_cl_1055-1076.indd 1076

4/3/2015 2:08:59 PM

69 Hymenorrhaphy

T

Sunxiang Ma, Hua Lei, Wenyi Huang, Qingfeng Li

he   hymen is a mucosal fold at the introitus of the vagina. It is usually ruptured during the fi st sexual intercourse; therefore in some cultures (for example, Mediterranean, African, Chinese, and Korean) its intact condition is the symbol of virginity or chastity. Repair of the hymen is known as hymenorrhaphy, hymenoplasty, hymen reconstruction, hymenal refashioning, and revirgination. The procedure is illegal in most Arab countries. In Western society, hymenorrhaphy is legal, although some surgeons refuse to perform the procedure. In China, hymenorrhaphy is legal and is nearly as popular as other female genital cosmetic procedures. Many young girls consult plastic surgeons and request hymenorrhaphy. Most journal articles that are published in English regarding hymenorrhaphy discuss the appropriateness of hymenal reconstruction or describe the different cultural beliefs about the procedure in various countries.1-5 Very few reports describe the techniques and results after hymenorrhaphy.6 However, Chinese literature often describes how to reconstruct the hymen and how to improve operative outcomes.7,8 In this chapter, we introduce a technique used in China and report our unique experience with hymenorrhaphy.

Anatomy and Classification The hymen is a thin, annular fold of mucosa consisting of epithelium and connective tissue, relatively few blood vessels, and a small number of nerves, some of which are not part of the sympathetic nervous system.9 The hymen is usually ruptured or torn and bleeds during a woman’s fi st sexual intercourse or various types of trauma. A ruptured hymen never heals by itself. This tearing does not cause physiologic dysfunction. The shape of a ruptured hymen varies. To our knowledge, a correlation between the shape of the tear and the optimal reconstruction has not been reported. McCann et al10 described varied appearances of the hymen after healing in prepubertal and adolescent girls.

1077

1078

Part X 

Other Cosmetic Surgical Procedures

Based on our clinical observation and those reported by McCann et al, we classify the shape of the tear, or cleft, into the following five types (Fig. 69-1): 1. I type: The two edges of the wound are well defi ed with no tissue defects and are closely approximated. The cleft has an I shape. 2. {| type: No tissue defect is present. The laceration extends from the edge to the base of the hymen and continues along the base bilaterally. All edges of the wound are closely approximated. The cleft has a {| shape. 3. V type: A tissue defect is present near the free edge of the hymen. The two edges of the cleft are approximated or connected at the base of the hymen and separated at the free edge. The cleft has a V shape. 4. D type: A tissue defect is present near the base of the hymen. The two edges of the cleft re close together at the free edge and farther apart at the base of the hymen. The cleft has a D shape. 5. U type: A tissue defect is present between the two edges of the cleft. e edges are separated from the free edge to the base of the hymen. The cleft has a U shape.

A

B

|{ type

I type

C

D

V type

E

D type

Fig. 69-1  Hymenal cleft shape classifi ation.

U type

Chapter 69 

Hymenorrhaphy

Th s classifi ation of hymenal laceration refers to the shape of the cleft when the patient is in the lithotomy position and the labia minora are pushed aside as much as possible. One or more defects of various types can be present. In our clinical series, most lacerations extended the entire width of the hymen, especially in women who previously had sexual intercourse (see Fig. 69-1). Some lacerations extended more than half the width of the hymen; few lacerations extended less than half the width of the hymen. We think that lacerations extending less than half the width do not destroy the integrity of the hymenal ring and do not need to be repaired. Therefore we perform hymenorrhaphy mainly for lacerations extending from half the width to the entire width of the hymen. The I and {| shapes were most commonly seen in our series of patients

Indications Women who have a hymenal cleft from sexual intercourse, trauma, vigorous sporting activities, and surgical procedures are candidates for hymenorrhaphy. Women who have had their hymen repaired multiple times and those with a history of vaginal or induced delivery are not candidates, because their hymen has been severely torn and has minimal remnant tissue. The procedure should not be performed in women with medical conditions such as a venereal disease, vaginal infection, and diabetes.

Preoperative Assessment A thorough consultation in the offic is very important for the patient and surgeon. The surgeon should inquire about the patient’s motivation for requesting surgery. The patient’s medical history is obtained, including information about venereal diseases, vaginal infections, and medical conditions such as diabetes. Her history of sexual intercourse, childbearing, and menstruation are discussed. Patients should be informed that hymenorrhaphy does not necessarily lead to bleeding from a ruptured hymen at the fi st intercourse after surgery. Patients who have unrealistic expectations should not have this procedure. Some patients came to our department with a family member, in which case the patient and the family member should be informed together about specific situations. Otherwise, the information is considered confide tial. Careful preoperative assessment of the hymen is critical. Results of reconstruction are better if the preoperative width of the cleft is not more than 3 mm and the thickness of the wound edge is more than 2 mm. Patients with fewer tears generally have better results. The cleft hape affects the result. I- and {|-shaped clefts have better results than V-, D-, and U-shaped clefts (see Fig. 69-1). The procedure should not be performed during the patient’s menstrual and ovulation periods, because vaginal secretions interfere with wound healing. Vaginal and perineal infections should be treated and healed before surgery.

Surgical Technique The patient is placed in the dorsal lithotomy position. The perineal region is prepared with iodophor and draped. Local infiltration is preferred for this operation. At the level of the vaginal introitus, the margin of the labium minus margin and the lateral border of the labium majus border are infiltrated with a local anesthetic solution (0.25% lidocaine with 1:200,000 epinephrine). The labium minus margin is sutured to the labium majus lateral border to fully expose the hymen. Both edges of the hymenal cleft re injected with local anesthetic. Most clefts, especially I and {| types, can be repaired by approximation. The method for approximation involves creating two defects—one on the lateral surface of one cleft dge and one on the medial surface of the other edge—by removing epithelium approximately 2 to 3 mm wide. To prevent

1079

1080

Part X 

Other Cosmetic Surgical Procedures

A

B

C

D

Fig. 69-2  Approximation method. A, Hymenal cleft B, Two defects are created by removing epithelium: one on the lateral surface of one cleft edge and one on the medial surface of the other cleft edge. C and D, The edges are approximated and closed.

injury to the blood supply, the margin of the defect should not be undermined. The edges are approximated with 6-0 absorbable interrupted sutures in the mucosa (Fig. 69-2). The inner connective tissue should not be sutured to decrease wound tension, because it can compromise the already-weak blood supply of the hymen. The laceration along the hymenal base in {|-type clefts does not need surgical repair. When the tissue defect between the edges of the hymenal cleft is wider than 2 mm or when the edge of the hymenal cleft is less than 2 mm thick, approximation alone may not be successful because of the high tension needed to close the wound and the poor blood supply. In these cases, a local transposition flap is needed. In this technique, two defects are created: one on the internal surface of one cleft edge and one on the lateral surface of the other cleft edge. One flap is raised from the internal area (vaginal mucosa) and one from the lateral area (vaginal vestibular mucosa). Both are adjacent to the hymenal base. The long axis of each flap is parallel to the hymenal base border; the superior margin of each flap is along the hymenal base border. The flaps consist of mucosa and submucous tissue, and they are oriented in opposite directions. After the new flap defect for the medial flap is closed, the flap is rotated to cover the medial defect of one cleft edge. The proximal part of the superior margin of the medial flap is sutured to the defect margin of the other cleft edge. The lateral flap is rotated to cover the lateral defect on the other cleft edge, and the proximal part of its superior margin is sutured to the defect margin of the contralateral cleft edge. The middle parts of the superior margin of the two flaps between the two cleft edges are sutured to each other. The new flap defect for the lateral flap is closed directly. A triangular area of mucosa at the tip of the new flap defects is excised to prevent dog-ears (Fig. 69-3). In patients with multiple clefts, we usually repair only two or three clefts. More cleft repairs can induce high wound tension. The hymenal opening after reconstruction is approximately 8 mm in diameter (a minimum of 5 mm) to allow the smooth, unobstructed outfl w of menstrual blood.

Chapter 69 

1081

Hymenorrhaphy

A

B

C

D

E

F

G

H

Fig. 69-3  Closure with transposition flaps. A, U-type hymenal cleft B, Th dashed lines indicate the extent of epithelium

to be removed. C, New defects are created by removal of epithelium on the internal surface of one cleft edge and the lateral surface of the other cleft edge. D, The flaps (black line and dashed line) and redundant mucosa (gray lines) are marked on the vaginal vestibular mucosa and vaginal mucosa. E, The flaps are raised. F, The new flap defects are closed, and the internal flap is rotated to cover the defect on the inner edge of the cleft. G and H, The lateral flap is rotated to cover the defect on the lateral edge of the cleft, and the new flap defect is closed.

K23345_Pu_c69_Hymenorrhaphy_r2_cl.indd 1081

4/3/2015 1:19:34 PM

1082

Part X 

Other Cosmetic Surgical Procedures

Postoperative Care No dressing is required postoperatively. Patients are instructed to softly clean the perineal region, especially the vaginal introitus, with iodophor after urination and defecation. They can begin to bathe on the second day postoperatively. Patients are instructed not to perform vigorous exercise, squatting, straddle movements, and riding activities. Patients follow up on postoperative day 7 for assessment of healing. Typically, no further follow-up is needed. Sutures are absorbable; thus suture removal is not necessary and could tear a weakly healed wound.

Results The result on postoperative day 7 is the basis on which success is determined. Hymenal reconstruction is successful if at least 80% of the cleft r clefts re healed. The overall success rate with the approximation technique is about 30% in our early series (2000 to 2007). To improve the success rate, we have used the transposition flap technique since 2007. The overall successful rate with this technique is approximately 80% in our recent series.

Appr oxima tio n Techniq ue

Fig. 69-4 Th s 24-year-old Chinese woman with an I-type cleft requested hymenal reconstruction. She had a history of sexual intercourse. An approximation technique was performed.

K23345_Pu_c69_Hymenorrhaphy_r2_cl.indd 1082

4/3/2015 1:19:34 PM

Chapter 69 

Hymenorrhaphy

Trans pos itio n Fl ap Techniq ue

Fig. 69-5 Th s 28-year-old Chinese woman requested hymenal reconstruction. She has a D-shaped hymen with a thin edge of the hymenal cleft. The local transposition flap technique was performed.

Management of Complications Complications of hymenorrhaphy are minor and can be managed easily. Occasionally, patients develop odynuria, which is usually caused by irritation of the wound at approximately the 12 o’clock position. Th s resolves soon after the wound heals. Bleeding, severe postoperative pain, infection, uroschesis, rectal fistula, and retention of menses did not occur in our series. Because of the signifi ance of an intact hymen in some cultures, a failed reconstruction of a ruptured hymen can result in depression, anxiety, fear, despair, and an elevated risk of suicide for the patient and parents. Therefore, efforts to improve the success rate of hymenal reconstruction is critical. We have learned from our results that some ruptured hymens cannot be successfully reconstructed by the approximation method, especially thin I- and {|-type clefts, and V-, D-, and U-type clefts because of poor blood supply and higher wound tension on approximation. Therefore we attempted to use flap transposition to enhance the blood supply of the cleft edge and decrease wound tension on approximation.

Discussion The success rate for our most recent 30 cases was improved, because we used the transposition flap technique. But reconstruction in a few ruptured hymens was unsuccessful in our series. Unfortunately, except for one article in English6 that advocates a cerclage method, no reports have been published on how to improve the surgical technique for hymenorrhaphy.

1083

1084

Part X 

Other Cosmetic Surgical Procedures

Patient education is essential. All patients should be informed of the success rate and possible outcomes. For example, patients need to be informed preoperatively that an intact hymen will not necessarily rupture or bleed at the fi st sexual intercourse because of the tissue’s extra elasticity and decreased blood supply, and a reconstructed hymen is similar to an intact hymen.2 Therefore surgeons should advise the patient and her family that not all women bleed during intercourse on their wedding night, regardless of whether they have had hymen repair.

Pearls for Success • A comprehensive preoperative consultation is essential to ensure patient and surgeon satisfaction postoperatively. • Preoperative evaluation of the hymenal tissue, especially the shape of the cleft, s the basis on which a surgical technique is selected. The surgical technique is a determining factor for a successful hymenorrhaphy. • Only one to three clefts re repaired in one ruptured hymen, because as more clefts re closed, wound tension increases. • Because the blood supply of the hymen is decreased compared with that of surrounding tissues, repeated clamping and suturing is avoided, and minimal suturing is performed. • When defects are created on the edge of the cleft, nly epithelium is removed. Defect margins should not be undermined to protect the blood supply. • Only mucosa and minimal submucous tissue are sutured during wound closure. • The lower the wound tension, the better the result. Therefore transposition flaps are helpful for V-, D-, and U-type hymenal clefts • The reconstructed hymenal opening usually is 8 mm in diameter (and not less than 5 mm) to allow menstrual blood outfl w. • Absorbable sutures should be used, because suture removal can tear weakly healed tissue.

Refer ences 1. Paterson-Brown S. Should doctors reconstruct the vaginal introitus of adolescent girls to mimic the virginal state? Education about the hymen is needed. BMJ 316:461, 1998. 2. Rogers DJ, Stark M. The hymen is not necessarily torn after sexual intercourse. BMJ 317:414, 1998. 3. Logmans A, Verhoeff A, aap RB, et al. Should doctors reconstruct the vaginal introitus of adolescent girls to mimic the virginal state? Who wants the procedure and why. BMJ 316:459-460, 1998. 4. Cook RJ, Dickens BM. Hymen reconstruction: ethical and legal issues. Int J Gynaecol Obstet 107:266-269, 2009. 5. Essén B, Blomkvist A, Helström L, et al. The experience and responses of Swedish health professionals to patients requesting virginity restoration (hymen repair). Reprod Health Matters 18:38-46, 2010. 6. Ou MC, Lin CC, Pang CC, et al. A cerclage method for hymenoplasty. Taiwan J Obstet Gynecol 47:355-356, 2008. 7. Li FY, Li Q, Zhou CD, et al. To repair the hymen by splitting the cleft asymmetrically and suturing the cut, respectively. Chinese J Cosmet Med 19:1122-1123, 2010. 8. Wang HY, Zhang YQ, Shen GX, et al. The application of M-Y and M-V plasty in hymen repair. Zhong Guo Mei Rong Yi Xue 15:1354-1356, 2006. 9. Wile IS. The psychology of the hymen. J Nerv Ment Dis 85:143-156, 1937. 10. McCann J, Miyamoto S, Boyle C, et al. Healing of hymenal injuries in prepubertal and adolescent girls: a descriptive study. Pediatrics 119:e1094-e1106, 2007.

70 Labial Reduction

I

Yuguang Zhang

nitially, patients requested labial reduction mainly to correct labial asymmetry or labial hypertrophy and to change the appearance of the vulva. Currently, however, more and more patients desire surgery only for cosmetic reasons and not to correct size and shape abnormalities. Capraro1 and Radman2 fi st introduced labioplasty in the 1970s. By 1984, when Hodgkinson and Hait3 first described labioplasty for entirely aesthetic purposes, the procedure had become well known in the plastic surgery community.4 Traditionally, labia minora hypertrophy was treated by resection of the excess tissue and wedge resection. With advancements in genital cosmetic plastic surgery, new techniques have been developed for labial reduction such as wedge resection, inferior V-shaped resection, W-shaped resection, central deepithelialized reduction labioplasty, and 90-degree Z-plasty.4-6 In this chapter, I describe the anatomy of normal and abnormal labia, a classifi ation system, indications for labial reduction, preoperative assessment, operative techniques, and postoperative care. The selection of the surgical technique, management of complications and revision surgery, and special considerations for labial reduction in Asian women are also discussed.

Anatomy The labia minora are located between the labia majora and have an overall triangular shape. The inner side of the labia minora is covered with pink, shiny mucosa; the outer side is covered with dark skin.

The Ideal Labi a

The normal width of the labia minora is generally 1.5 to 2 cm. A small part of the labia minora is visible when they are closed together between the labia majora (Fig. 70-1). However, the aesthetics of the labia are based on the patient’s perception. Miklos and Moore7,8 conducted a survey of 550 patients who received labial reduction, asking their reason for seeking surgery and postoperative expectations. Results showed that 97.8% of patients preferred the labia minora to be at or below the level of the labia majora, and 96.9% preferred pink edges.

1085

1086

Part X 

Other Cosmetic Surgical Procedures

Fig. 70-1  Normal labia minora.

Fig. 70-2  Hypertrophic labia minora.

Table 70-1  Types of Labial Hypertrophy Type

Labial Width* (cm)

1

,2

2

2 to 4

3

4 to 6

4

.6

*Labial width was measured from the vaginal introitus to the most laterally projecting tip of the labia minora. (From Franco T, Franco D. Hipertrofia de Ninfas. J Bras Ginecol 103:163-165, 1993.)

Labi al Hyper tr ophy

Labia minora hypertrophy can be congenital or acquired. Causes of acquired hypertrophy include the male hormone (testosterone), chronic inflammation, excessive masturbation, stretching from sexual intercourse, early-onset sexual intercourse, multiple pregnancies, and so on (Fig. 70-2). Usually the hypertrophy is bilateral, but it can be limited to one side and can extend from the prepuce to the labial frenulum. Franco and Franco7 classifi d labia minora hypertrophy into four types (Table 70-1).

Indications Rouzier et al10 considered that a labia minora width of 4 cm or more is an indication for reduction surgery; however, not all women in this classifi ation choose to have surgery unless they have discomfort or concerns about their appearance. In actual clinical work, we found that most patients require surgery because of psychological reasons and have their own ideal size in mind. The surgeon can perform the surgery in accordance with the patient’s desire if the function of the labia minora is not damaged. The recommended minimum age for a patient to have surgery is approximately 12 years old, which is the female menstruation menarche age. If the patient does not have this surgery, the hypertrophy of the labia will prevent menstrual discharge and can cause infection of the vulva.

Chapter 70 

1087

Labial Reduction

Common reasons patients request labial reduction include the following11: • Vulvar discomfort, including the inability to wear tight underwear or pants and discomfort while sitting or exercising • Dissatisfaction with genital appearance • Psychological effects, including poor self-esteem, teasing by siblings, and parental concern • Dyspareunia

Preoperative Assessment The best time for labial reduction is 3 to 7 days after menstruation. Therefore the patient’s menstrual period is discussed during the preoperative assessment. A gynecologic examination is performed. Surgery is delayed in patients with acute inflammation of the perineum. The size of the labia is evaluated. The labial width is measured from the vaginal introitus to the most laterally projecting tip of the labia minora. The most important aspect of the preoperative assessment is communication with the patient to understand her expectations and to jointly develop a surgical approach. Th s approach is essential to achieve mutually acceptable and satisfactory postoperative results.

Surgical Technique Infer io r V-Shap ed Res ectio n

For an inferior V-shaped resection, the patient is placed in the lithotomy position, and the vulva is sterilized with 0.5% iodophor. The labia minora are mildly stretched laterally. A V-shaped area of redundant labial tissue is marked. The fi st line is marked on the posterior part of each labium minus, parallel and close to the base. The distance between the upper end of the fi st line and the upper pole cannot be too short to make sure there is enough pedicle. The second line is marked based on the amount of tissue to be resected. The second line crosses the labia minora from the outer edge and intersects the fi st line. The two lines are adjusted to make them long enough. The tissue between the two lines is the area to be resected. The area is infiltrated with a local anesthetic solution of 1% lidocaine with 1:200,000 epinephrine. The tissue within the marked lines is resected full thickness using a scissors in accordance with the design. After hemostasis is maintained, the anterior labial flap is secured to the underlying connective tissue with an interrupted 5-0 absorbable coated Vicryl plus antibacterial suture. The front and back sides of the labia minora, respectively, are sutured. A topical antibiotic is applied on the suture lines (Fig. 70-3).

Fig. 70-3  Design of an inferior V-shaped resection.

1088

Part X 

Other Cosmetic Surgical Procedures

A

A

B

C

B/C

Fig. 70-4  Design of a central deepithelialized reduction labioplasty.

Central

Deep itheli alized Red uctio n Labio pl a st y

For central deepithelialized reduction labioplasty, the patient is placed in the lithotomy position, and the vulva is sterilized with 0.5% iodophor. The labia minora are mildly stretched laterally, and the area to be deepithelialized on the medial side is marked (Fig. 70-4). The marked line A is approximately 1 cm from the outside edge. The marked line AC is parallel to the base of the labium minus, and A is approximately 1 cm from the base. The position of point B is adjusted to ensure that AB is as long as AC. The area to be deepithelialized on the lateral side is then marked. The upper marking is parallel to and approximately 1 cm from the edge of the labia minora. The lower marking is along the gutter between the labia majora and labia minora, ending at point C. Next, the area is infiltrated with a local anesthetic solution of 1% lidocaine with 1:200,000 epinephrine. Th s is injected until the labia minora swell to increase the thickness of the subcutaneous tissue between the medial and lateral skin to facilitate surgery and reduce bleeding. Using a scissors, the surgeon removes the epidermis within the designed area. After complete hemostasis is maintained, the margins of the raw surface are reapproximated with an interrupted 5-0 absorbable coated Vicryl plus antibacterial suture. A topical antibiotic is applied on the suture lines.

Nine t y-Degr ee Z-Pl a st y

For a 90-degree Z-plasty procedure, the patient is placed in the lithotomy position. The vulva is sterilized with 0.5% iodophor. The labia minora are mildly stretched laterally and the amount to be resected is estimated. The incision is marked as a 90-degree Z shape. In the case of unilateral hypertrophy, the excision area is based on the size of the contralateral side. The area is infiltrated with a local anesthetic solution of

Chapter 70 

Labial Reduction

Fig. 70-5  Design of a 90-degree Z-plasty.

1% lidocaine with 1:200,000 epinephrine. The tissue within the marking is resected full thickness with scissors. After hemostasis is maintained, the raw edges are reapproximated with interrupted 3-0 silk suture in a mattress pattern. The labia minora should be at least 1 cm wide to cover the vaginal opening. A topical antibiotic is applied on the suture lines (Fig. 70-5).

Postoperative Care Postoperatively, patients are instructed to apply erythromycin ointment twice a day on the suture lines and to avoid weight-bearing, straddling movements, and sexual intercourse. They should place sterile gauze on the surface of the wound to absorb blood from the wound and vaginal secretions and replace them often to keep the wound dry. The perineal region should be cleaned with 1:5000 potassium permanganate solution after urination and defecation. Patients take an oral antibiotic for 3 days and return to the clinic on postoperative day 7 for suture removal.

Results Most patients who had labia minora reduction were satisfi d with the postoperative appearance. The complications were very minimal. Two patients had delayed wound healing. Only one patient who underwent central deepithelialized reduction labioplasty was unsatisfi d with the appearance and reported that her labia minora remained hypertrophic. A revision procedure was performed.

1089

1090

Part X 

Other Cosmetic Surgical Procedures

Fig. 70-6 Th s 24-year-old woman had excessive vulvar secretions and discomfort wearing tight pants, especially during sports activities. The left side f her labia minora was severely hypertrophic. Her labial width was more than 5 cm. She underwent an inferior V-shaped resection. The patient recovered well, and her uncomfortable symptoms are improved.

Fig. 70-7 Th s 25-year-old woman had enlarged labia minora that seriously affected her self-esteem. She underwent a central deepithelialized reduction labioplasty. The patient recovered well with minimal postoperative discomfort and is very satisfi d with the result.

K23345_Pu_c70 71_Labial Reduc_r2_st_1085-1092.indd 1090

4/3/2015 1:21:01 PM

Chapter 70 

Labial Reduction

Issues for Revision Inadequate resection and asymmetry are common. Patients with these results report that the postoperative outcome does not meet their expectations. Reoperation is the only way to resolve the redundancy and asymmetry. The best way to prevent these complications is to conduct a thorough preoperative assessment and select an appropriate design. Patients who have wound dehiscence or delayed wound healing require reoperation.

Discussion The technique chosen is based on the requirements of the patient and the degree of labia minora hypertrophy. An inferior V-shaped resection can be considered an option for patients with severe labia minora hypertrophy, because more tissue can be resected with this technique. A central deepithelialized reduction labioplasty and 90-degree Z-plasty are better options for patients who have mild hypertrophy. Wound dehiscence is a common postoperative complication, especially in patients who have an inferior V-shaped resection. The extremity of the flap is thin with a poor blood supply, even if the main artery of the labium minus courses along the anterior border and is preserved in the flap.4,12 Wound dehiscence can be managed by a second procedure after a local anesthetic solution is injected. The end result is satisfactory. Some patients develop dyspareunia after the operation, but this resolves at approximately 1 month in most patients. Hematoma, infection, and transient pain can occur after labial reduction. For these complications, symptomatic treatments are needed.

Pearls for Success • Communication with patients preoperatively is essential to determine their needs and postoperative expectations. • The surgical approach is selected based on the patient’s needs and the results from the physical examination. • The design should be reasonable to prevent excessive or insuffici t resection. • Skin sutures are placed with minimal tension to prevent postoperative wound dehiscence. • Postoperatively, patients are instructed to take an oral antibiotic for 3 days, to change the dressing after urination and defecation, and to avoid sexual intercourse for a month.

1091

1092

Part X 

Other Cosmetic Surgical Procedures

Refer ences 1. Capraro VJ. Congenital anomalies. Clin Obstet Gynecol 4:988-1012, 1971. 2. Radman HM. Hypertrophy of the labia minora. Obstet Gynecol 48(1 Suppl):S78-S79, 1976. 3. Hodgkinson DJ, Hait G. Aesthetic vaginal labioplasty. Plast Reconstr Surg 74:414-416, 1984. 4. Mirzabeigi MN, Moore JH Jr, Mericli AF, et al. Current trends in vaginal labioplasty: a survey of plastic surgeons. Ann Plast Surg 68:125-134, 2012. 5. Alter GJ. A new technique for aesthetic labia minora reduction. Ann Plast Surg 40:287-290, 1998. 6. Choi HY, Kim KT. A new method for aesthetic reduction of labia minora (the deepithelialized reduction of labioplasty). Plast Reconstr Surg 105:419-422; discussion 423-424, 2000. 7. Miklos JR, Moore RD. Labiaplasty of the labia minora: patients’ indications for pursuing surgery. J Sex Med 5:1492-1495, 2008. 8. Miklos JR, Moore RD. Postoperative cosmetic expectations for patients considering labiaplasty surgery: our experience with 550 patients. Surg Technol Int 21:170-174, 2011. 9. Franco T, Franco D. Hipertrofia de Ninfas. J Bras Ginecol 103:163-165, 1993. 10. Rouzier R, Louis-Sylvestre C, Paniel BJ, et al. Hypertrophy of labia minora: experience with 163 reductions. Am J Obstet Gynecol 182:35-40, 2000. 11. Ellsworth WA, Rizvi M, Lypka M, et al. Techniques for labia minora reduction: an algorithmic approach. Aesthetic Plast Surg 34:105-110, 2010. 12. Likes WM, Sideri M, Haefner H, et al. Aesthetic practice of labial reduction. J Low Genit Tract Dis 12:210-216, 2008.

K23345_Pu_c70 71_Labial Reduc_r2_st_1085-1092.indd 1092

4/3/2015 1:21:01 PM

71 Vaginal Rejuvenation

V

Yang Liu, Kaixiang Cheng

aginal   rejuvenation, unlike other medical terms, is rather ambiguous in meaning to both professionals and the public. It has been controversial among medical professionals either because of its nomenclature or its safety and effectiveness.1,2 Vaginal rejuvenation might be a single procedure or a combination of various procedures such as labioplasty, vaginoplasty, perineoplasty, vaginal tightening, or colpoperineoplasty. The goal of vaginal rejuvenation is to obtain aesthetically more acceptable genitalia and an enhanced sensation of vaginal tightness and sexual gratifi ation.3,4 In the absence of data supporting the long-term safety and efficacy of vaginal rejuvenation, the American Congress of Obstetricians and Gynecologists (ACOG)1 stated in 2007 that recommending procedures such as vaginal rejuvenation and touting their potential for enhancing sexual performance and gratifi ation was “untenable.” In 2010, Goodman et al3 reported on their large multicenter outcome study of female genital plastic surgery, concluding that many women chose to modify their vulvas and vaginas even though they had been informed that these female genital plastic procedures were not performed to correct “abnormalities,” yet they had an excellent outcome in both general and sexual satisfaction. In this chapter we prefer to use the more standard medical terminology of vaginoplasty and perineoplasty to describe our techniques for restoration of a tighter vagina and enhancement of sexual gratifi ation.

Anatomy and Pathophysiology The vagina is a hollow viscus with a shape that is determined by the structures that surround it and by the attachments of its lateral walls to the pelvic walls. Great variability in the length of the vaginal walls is reported. The average length of the anterior vaginal wall is 7 cm above the pelvic fl or, and the posterior wall is 9 cm above the pelvic fl or; however, the vaginal lumen is much more capacious and distensible. The distal portion of the vagina is constricted by the action of the levator ani muscles. The size of the vaginal lumen at the distal portion is determined by the size of muscular lacuna surrounding the vagina and the contractility of the surrounding muscles. These muscles include the bulbocavernosus muscles, also known as the bulbospongiosus muscles, levator ani muscles, and urethrovaginal sphincter muscles (Fig. 71-1). With normal functioning, the contractility of the bulbocavernosus muscles and the levator ani muscles is stronger and serves as the main reason for the normal tension of the vagina and thus sexual gratifi ation.5

1093

1094

Part X 

Other Cosmetic Surgical Procedures

Cervix Fornix Vaginal wall Vagina

Levator ani muscle

Superior and inferior fascias of urogenital diaphragm

Transverse perineal muscle Superficial (colles) fascia Vestibular bulb Bulbospongiosus muscle

Round ligament Labium majoris

Vestibule

Uterus Cervix Fornix

Bladder

Vaginal wall

Urethra

Vagina

Labium minus

Vestibule

Fig. 71-1  Anatomy of the vagina.

The perineal body is another important structure to strengthen the pelvic fl or and prevent pelvic organ prolapse. It is a mass of fibromuscular tissue found between the distal part of the posterior vaginal wall and the anus. The perineal body is formed by the attachment of several structures such as the bulbocavernosus muscles, superfic al transverse perineal muscles, external anal sphincter muscles, the perineal membrane, levator ani muscles and covering fascia, urethrovaginal sphincter muscles, and distal part of the posterior vaginal wall (Fig. 71-2).

Chapter 71 

1095

Vaginal Rejuvenation

Clitoris

Bulbospongiosus muscle Urethral orifice Ischiocavernosis muscle Inferior fascia of urogenital diaphragm

Vaginal orifice Posterior vaginal wall (perineal body) Ischial tuberosity Central tendon of perineum

Superficial transverse perineal muscle

Anus Levator ani muscle External anal sphincter

Gluteus maximus muscle

Coccyx

Fig. 71-2  Anatomy of the pelvic fl or.

The degenerative changes of the pelvis with aging and the damage of the pelvic fl or muscles by vaginal labor are the main factors leading to the laxity of vagina. During the vaginal delivery process, the pelvic floor muscles and the perineal body are overstretched and in some severe cases might even be lacerated, leading to the damage of the integrity of the pelvic fl or muscles and a decrease of the muscle tones (see Figs. 71-1and 71-2). To correct the sensation of a wide vagina, vaginoplasty and perineoplasty should be performed to restore the integrity of the pelvic fl or muscles, to decrease the muscular lacuna around the vagina, to approximate the lacerated fibromuscular tissue of the perineal body, and to decrease the size of the vaginal orific .

Indications Patients who complain of the sensation of a wide vagina and sexual dissatisfaction together with the physical signs of vagina laxity or perineal body dysfunction are candidates for vaginoplasty and perineoplasty. Patients with vaginitis should receive standard treatment until the routine exam finds no abnormality of leukorrhea before surgery.

Preoperative Assessment The surgeon should assess the severity of the vagina laxity and the function of the perineal body during the pelvic examination by putting the fi gers into the patient’s vagina and asking the patient to contract the vagina and anus. Th s allows the surgeon to measure the width of the vagina at rest, the contractility of pelvic fl or muscles, the elasticity of the vagina, and the function of the perineal body, all of which can be subjectively perceived by the examiner.

1096

Part X 

Other Cosmetic Surgical Procedures

The surgeon should also assess the patient’s psychological state and previous sexual function, although there is no standard questionnaire to evaluate them, the surgeon should pay attention to the patient’s psychological state and previous sexual function during the interview. Patients who reveal psychological problems or classic sexual dysfunctions, such as dyspareunia, primary anorgasmia, sexual partner dysfunction, or a combination of these, should be excluded from or cause a delay of the surgical treatment.

Surgical Technique 1. With the patient in the lithotomy position, the vagina and the perineum are sterilized with iodine tincture. 2. The extent of an ellipse mucosa at the caudal posterior wall of the vagina to be excised is labeled. It could be 3 to 5 cm in width and 4 to 6 cm in length, according to the severity of the laxity and length of the vagina (Fig. 71-3, A). 3. Along the labeled extent, 0.5% lidocaine with epinephrine is injected submucously for anesthesia. The concentration of epinephrine should be less than 1:200,000 if it was added in the lidocaine. 4. The labeled ellipse mucosa is excised by cutting the incisions with a scalpel and removing the mucosa through sharp dissection beneath the mucosa. Suture ligation is used for hemostasis if active bleeding occurs at the wound. 5. The bilateral margin of the residual vaginal mucosa is freed by approximately 0.5 cm in width to decrease the wound tension when the mucosa wound is closed by sutures later. 6. The exposed submucosal tissue together with the underlying muscles at the posterior vaginal wall are approximated toward the midline with 3-0 nonabsorbent sutures through a rectangular suture style (Fig. 71-3, B). Approximately 3 to 4 stitches are made from the cephalic end to the caudal end. 7. In patients who need the perineal body to be strengthened or repaired, the incision is extended to the vestibule area, the excess skin at the area is removed, and 2 to 3 more stitches with 3-0 nonabsorbent sutures are made at the midline to approximate the musculatures. 8. Finally, the mucosa are approximated through the use of interrupted stitches with 4-0 absorbable sutures (Fig. 71-3, C). A

B

C

Fig. 71-3  A, The perineal skin and mucosa at the vestibule area and the posterior junction of the labia minors were excised. B, The perineal muscles were approximated with 3-0 absorbable sutures. C, Postoperative appearance: enhanced perineal body.

Chapter 71 

Vaginal Rejuvenation

1097

Postoperative Care No dressings are placed inside the vagina. Patients are instructed to maintain smooth bowel movements, to avoid excessive physical exercise during the fi st week after surgery, and to avoid sexual intercourse in the fi st 2 months after surgery. Sutures are removed at 10 to 14 days after surgery.

Results Based on our own experience with more than 80 patients who had the procedure, almost all of our patients are very happy with their results immediately after vaginoplasty, although the true enhancement of their sexual function remains unknown and is hard to assess objectively. Overall complications are minimal and less serious after surgery. All of our patients experienced a smooth healing process without severe complications. Delayed wound healing may develop occasionally, but it can be managed easily with proper wound care.

Fig. 71-4 Th s 38-year-old woman suffered vaginal laxity and decreased sexual satisfaction after two vaginal deliveries. Physical examination revealed depression of the perineal body, a flattened vestibule area, a widened vagina permitting the insertion of at least three fi gers, decreased elasticity and contractility of the vaginal lateral walls, and an obvious sulcus that was palpated at the bilateral posterior vaginal wall and became deeper with the contraction of the anus. Two weeks after vaginoplasty and perineoplasty, the vaginal introitus became smaller and only two fi gers could be inserted into the vagina, the perineal body became longer with increased contractility of the anus and vagina, there was no obvious scar on the vaginal wall, and the sulcus at the bilateral posterior vaginal wall was no longer palpated. She started sexual activity 2 months postoperatively, and both she and her husband had signifi antly enhanced sexual pleasure.

K23345_Pu_c71_Vaginal Rejuv_r2_cl.indd 1097

4/3/2015 1:24:07 PM

1098

Part X 

Other Cosmetic Surgical Procedures

Fig. 71-5 Th s 34-year-old woman presented with the complaints of anal incontinence and vaginal laxity together with right labia minor malformation. Physical examination found complete laceration of the perineal body, the exposure of partial rectus mucosa and vaginal mucosa, and laceration of the anal sphincter and right labia minor. Two months after perineoplasty, her symptoms of anal incontinence resolved completely, and the appearance of the perineum became normal with an integrated perineal body, constricted anus, vaginal introitus, and nearly symmetrical labia minors. In addition, her sexual pleasure was enhanced signifi antly.

Discussion The traditional anterior colporrhaphy, posterior colporrhaphy, excision of the lateral vaginal mucosa, or a combination of these are commonly used procedures for vaginoplasty in cosmetic patients with the sensation of a wide vagina. Although some authors6-8 advocate lateral colporrhaphies, because they believe that it is more effective in reducing the size of the vagina without placing scars within the area of highest sensitivity, we chose to use the posterior colporrhaphy in all our patients, because it could be performed together with perineoplasty in the same extended incision at the posterior vaginal wall. Previously, we had not encountered the complaint of decreased sensitivity from the patients. Although bleeding, infection, altered sensation, dyspareunia, adhesions, and scarring are the reported potential complications of vaginoplasty, we have not encountered any such complications during our practice.1,3,9 Some patients reported having wound dehiscence, which we think might be mainly caused by the poor suturing and tightening of the perineal muscles. With good suturing and tightening of the muscle layer, the tension over the incision at the mucous layer should decrease and the wound dehiscence could be avoided.

Chapter 71 

Vaginal Rejuvenation

Because of incomplete follow-up, the data on the postoperative functional improvement is difficult to evaluate accurately. However, most of our patients indicated that they experienced moderate to signifi ant functional improvement after the operation; therefore we believe that the vaginal tightening operation is effective in creating functional improvement. Vaginoplasty itself has become popular even among Asian women, because when combined with perineoplasty, it can be a safe and effective procedure in achieving enhanced sensation of vaginal tightness and possible sexual gratifi ation without any severe complications. Our own experience and other reports3,8,9 have proven that vaginoplasty and perineoplasty are very effective in treating the sensation of a wide vagina. However, it is still unknown how long the results of vaginal tightening will last and the implications for patients who elect to have children after the procedures. Therefore we now recommend that these patients avoid having vaginal delivery.

Pearls for Success • Injecting saline containing lidocaine and epinephrine at the submucous layer is very important, because it helps with the dissection of the vaginal mucous and decreases bleeding. • The surgeon must avoid damaging the rectal venous plexus during mucous dissection through careful and precise operation and avoid dissection that is too deep and too close to the cervix. • Precise hemostasis should be performed through suture ligation of the active bleeding points. • Using reliable sutures on the submucous and muscle layers is the key step to ensuring functional improvement after surgery. • Vaginoplasty and perineoplasty are safe and effective procedures in treating the sensation of a wide vagina without causing any severe complications.

Refer ences 1. American College of Obstetricians and Gynecologists, Committee on Gynecologic Practice. ACOG Committee Opinion No. 378: vaginal “rejuvenation” and cosmetic vaginal procedures. Obstet Gynecol 110:737-738, 2007. 2. Mirzabeigi MN, Jandali S, Mettel RK, et al. The nomenclature of “vaginal rejuvenation” and elective vulvovaginal plastic surgery. Aesthet Surg J 31:723-724, 2011. 3. Goodman MP, Placik OJ, Benson RH III, et al. A large multicenter outcome study of female genital plastic surgery. J Sex Med 7(4 Pt 1):1565-1577, 2010. 4. Goodman MP. Female cosmetic genital surgery. Obstet Gynecol 113:154-159, 2009. 5. Hoffman BL, Schorge JO, Schaffer JI, eds. Williams Gynecology. New York: The McGraw-Hill Companies, 2008. 6. Alzate H, Londoño ML. Vaginal erotic sensitivity. J Sex Marital Ther 10:49-56, 1984. 7. Alzate H. Vaginal eroticism: a replication study. Arch Sex Behav 14:529-537, 1985. 8. Adamo C, Corvi M. Cosmetic mucosal vaginal tightening (lateral colporrhaphy): improving sexual sensitivity in women with a sensation of wide vagina. Plast Reconstr Surg 123:212e-213e, 2009. 9. Pardo JS, Solà VD, Ricci PA. Colpoperineoplasty in women with a sensation of a wide vagina. Acta Obstet Gynecol Scand 85:1125-1127, 2006.

1099

K23345_Pu_c71_Vaginal Rejuv_r2_cl.indd 1100

4/3/2015 1:24:07 PM

72 Penile Enhancement

P

Yang Liu, Kaixiang Cheng

enile   enhancement surgery is still highly controversial, because no one surgical technique has been universally accepted. Moreover, there is no standardization of surgical techniques. Male perception of adequate penile size does not necessarily coincide with the true dimensions of the organ. Indeed, complex social and psychological implications may affect the degree to which a person accepts his own body image. Patients with hypoplasia of the penis may be satisfi d with their sex life, whereas others whose penis is considered to be of normal size may want enhancement surgery because of an altered perception of the size of the organ (penile dysmorphophobia).1,2 Dysmorphophobia can be defi ed as an aesthetic or cosmetic issue, in which the penis is normal size, but the patient is dissatisfi d with its dimensions in the flaccid state. Alternatively, it can be viewed as a functional issue, in which the patient has a normal penis but is dissatisfi d with its erection size. Enhancement phalloplasty, whether aesthetic or functional, in patients with dysmorphophobia is cosmetic surgery. Furthermore, patients with this penile dysmorphic disorder require intensive psychological counseling before surgery. Penile enhancement to improve length can be performed in patients who have realistic expectations. Despite the numerous surgical techniques, penile enhancement can generally be divided into two types: relative enhancement and penile lengthening with autograft tissue or artific al materials.

Anatomy The penis is a pendulous organ that is suspended from the front and sides of the pubic arch and contains the greater part of the urethra. In the flaccid state, it is cylindric, but when erect it is a triangular prism with rounded angles. One side of the prism forms the dorsum3 (Figs. 72-1 and 72-2).

1101

1102

Part X 

Other Cosmetic Surgical Procedures

The penile shaft is composed of three erectile columns: two corpora cavernosa and the corpus spongiosum, which are surrounded by the deep penile (Buck’s) fascia, Dartos fascia, and penile skin4 (Fig. 72-3). The root of the penis lies in the perineum between the inferior fascia of the urogenital diaphragm and Colles fascia. In addition to its attachment to the fascia and the pubic rami, it is attached to the front of the symphysis pubis by the fundiform and suspensory ligaments. The fundiform ligament springs from the front of the sheath of the rectus abdominis and linea alba. It splits into two fasciculi that encircle the root

Fundiform ligament Rectus sheath Spermatic cord Superficial fascia of penis (Dartos fascia)

Fig. 72-1  The penile ligaments.

Fig. 72-2  Penile anatomy.

Fig. 72-3  The three erectile columns of the penile shaft

Chapter 72 

Penile Enhancement

of the penis. The upper fibers of the suspensory ligament pass downward from the lower end of the linea alba and the lower fibers from the symphysis pubis. Together they form a strong fibrous band that extends to the upper surface of the root, where it blends with the fascial sheath of the organ. The fundiform and suspensory ligaments, which are composed of primarily elastic fibers, support the penis at its base. The suspensory ligament of the penis is attached to the pubic symphysis, which holds the penis close to the pubic bone and supports it when erect5,6 (see Figs. 72-1 and 72-2).

Preoperative Assessment We propose that only men with a flaccid length of less than 4 cm or a stretched or erect length of less than 7.5 cm should be considered candidates for penile lengthening.7 However, the defin tion of micropenis has a different reference range of penile length, depending on the patient’s age and nationality. Multiple etiologic factors, including congenital and endocrinologic causes, and pathologic conditions such as trauma and genital cancer, may lead to a stunted penis. Despite variations in most Asian countries, the worship of genitalia brings attention to penile length. When justifi d, penile extenders used under medical supervision must be the first-line treatment option for patients seeking a penile lengthening procedure. If this treatment is unsuccessful, enlargement surgery can then be considered. The traditional techniques for penile lengthening mainly involved dissection of the penile ligaments and the application of a penile traction extender, which increases both penile length and circumference.8-10 Anthropometric measurements and an analysis of preoperative and postoperative penile length are performed. The term penis length refers to the maximum length of the flaccid penis, as measured along the dorsal surface of the penis from the symphysis pubis to the distal end of the glans. The surgeon should record both flaccid and erection length data. Subjective perception of the sexual evaluation questionnaire, such as the International Index of Erectile Function (IIEF) and the Self-Esteem and Relationship (SEAR) inventory, is recommended before surgery. Measurements of the glans and penile shaft or sensation assessment, which include an assessment of pain, temperature, static two-point discrimination, and vibratory threshold, should also be conducted for the trauma-related patients.

Surgical Techniques Penile Lengthening Pr o ced ur e Indications and Patient Selection

There is no consensus on the size below which a man should accept or want to modify the size of the penis. An assessment of men requesting penile enlargement must include a psychosexologic or psychiatric evaluation to identify dysmorphophobia or another psychiatric condition. Most men who request surgical penile enhancement have a normal-size and fully functioning penis, but they perceive their penises as small (psychological dysmorphism). In our experience, patients with a flaccid length of less than 4 cm or a stretched or erect length of less than 7.5 cm can be considered candidates for penile lengthening. Behavioral therapy and psychotherapy are recommended before surgery.

Technique The mainstay of penile lengthening procedures is a combination of release of the suspensory ligament of the penis with an inverted V-Y penopubic skin advancement.8,9 The technique has drawbacks, such as the possibility of the penis reattaching to the pubis and a residual scar (Fig. 72-4).

1103

1104

Part X 

Other Cosmetic Surgical Procedures

Fig. 72-4  Complication of V-Y penile enhancement surgery. Note the scarring.

B

A

Fig. 72-5  Penile enhancement surgery of a patient with a microphallus. A, Before surgery. B, Immediately after surgery.

A

B

Fig. 72-6  Penile enhancement surgery of a patient with a normal-size penis. A, Before surgery. B, Immediately after surgery.

K23345_Pu_c72 73_Penile Enhance_r3_cl_1101-1110.indd 1104

4/3/2015 1:39:13 PM

Chapter 72 

Penile Enhancement

For penile lengthening, we use a multiple Z-plasty flap technique to overcome these drawbacks and to minimize the loss of gained length. The technique most commonly used for penile lengthening is the release of the suspensory ligament in combination with an inverted skin plasty (Fig. 72-5). However, an alteration in the angle of the erection may also occur, which should be fully understood by patients. The suspensory ligament is released through a multiple Z-plasty incision of the mons pubis. In addition, the lateral section of the penile fundiform ligament is further released to increase penile length. While stretched, Buck’s fascia is sutured to the surrounding tissue to prevent the penis from pulling back. The subcutaneous fat flap is pulled into the incision gap between the base of the penis and pubis, and it is secured in position by suturing its deep surface and lower edge to the pubis. The incision is closed as a double Z (Fig. 72-6). A urinary catheter is inserted.

Par ti al Phall opl a st y With Gor e-Tex

The transfer of the free radial forearm flap is the treatment of choice for penile reconstruction. However, given the considerable donor-site damage, the transfer of a free radial forearm flap in patients with only partial penile necrosis may be controversial.11,12 Otherwise, the forearm flap is recommended as the procedure of choice for penile reconstruction for transsexual surgery or total penile absence. An artific al graft, such as expanded polytetrafluoroethylene, or ePTFE ( Gore-Tex), is a superior choice that causes no donor-site lesions and affords excellent biocompatibility for functional recovery and aesthetic outcome.13,14 Th s graft has reliable mechanical strength, and ideal tissue adaptation.15,16

Indications For patients with a congenital microphallus or partial penis necrosis, we perform a glanuloplasty with GoreTex. Th s treatment option results in satisfactory shape and function of the reconstructed penis without any functional and aesthetic donor-site damage. It is particularly suitable for patients who cannot accept scars or complications in the forearm region.

Technique We recommend that patients receive penile elongation at the proximal end with penile suspensory ligament release before grafting. In trauma patients, the partially lost glans is reconstructed by resculpturing the scrotal flap, and a penile prosthesis is implanted 6 months later. All patients receive a glanuloplasty with a penile prosthesis (Gore-Tex) implant. The surgical procedure results in increased penile length. However, the original penile length (that is, before injury) may not be achieved. The Gore-Tex biomaterial is sculpted to form two thirds of a dome structure that is wrapped with a thin dermal flap. The combination of the Gore-Tex and dermal flap is implanted at the distal part of the neophallus under the scrotal skin flap.

Results Penile Lengthening

Pr o ced ur e

In our series of 33 patients, the postoperative course was uneventful with minor complications. The mean increase in penile length (flaccid to stretched penis) was 1.804 cm (range 1.5 to 2.5 cm). In general, penile enhancement surgery can cause a moderate increase of 2.5 to 3.5 cm in penile length (see Fig. 72-6). There were no injuries to the neurovascular bundle or urethra and no erectile dysfunction. All patients reported painless sexual intercourse. They reported signifi ant improvement (20% to 53%) in sexual self-esteem and functioning.

1105

1106

Part X 

Other Cosmetic Surgical Procedures

Twelve months after surgery, there was no loss in the additional length. The angle of the erection was altered by about 10 degrees compared with that before the procedure. The skin incisions left no hump, and a faint scar was covered by pubic hair.

A

B

C

Fig. 72-7 Th s 32-year-old man, who complained of insuffici t penile length both in the flaccid and erectile states, requested penile enhancement surgery. A physical examination showed that the length of his penis was 6 cm in the flaccid state (Fig. 72-7, A). Immediately after ligament dissection, the length of the penis was 9 cm in the flaccid state (Fig. 72-7, B). The incision healed uneventfully. One year later, the length of the penis was still 9 cm in the flaccid state. The incisional scar was faint and hidden in the pubic hair, and there was no erectile dysfunction or change to the erection angle (Fig. 72-7, C). The patient started sexual activity 1 month after surgery. He was satisfi d with the result and felt more confide t during sexual activity.

Penile Phall opl a st y With a Gor e-Tex Impl ant

In our series penis length was almost completely restored to the original penis length, and patients were basically satisfi d with the postoperative penile appearance. The preoperative and postoperative anthropometric measurements of penile length in 33 patients showed an overall increase in penile length after surgery (3.16 [0.54] versus 5.73 [0.54)]; p ,0.01). Phalloplasty with Gore-Tex resulted in an average extended penile length of 2.57 cm. All of the patients reported superior experiences of sexual intercourse and had higher sexual satisfaction. In contrast, compared with preinjury, we observed lower sensitivity in trauma patients.

Chapter 72 

Penile Enhancement

A

B

C

D

E

Fig. 72-8 Th s 29-year-old man developed partial penile necrosis as a result of iatrogenic damage when he underwent foreskin circumcision in a private clinic (Fig. 72-8, A). He was initially treated with complete debridement of the gangrenous tissue, and the residual cavernous body was embedded in the scrotum. One month later, the scrotal flap covering the residual stump was elevated, and the donor site was closed with direct suturing. Six months later, traditional penile enhancement surgery was performed and a sculptured Gore-Tex implant was positioned at the distal part of the residual stump. The patient is shown immediately after surgery (Fig. 72-8, B). During the procedure, the sculpted Gore-Tex was wrapped by a piece of autologous dermis, which was ready for implantation at the distal part of the residual stump (Fig. 72-8, C). After surgery, a 16 Fr Foley catheter was inserted into the bladder and remained for 3 days (Fig. 72-8, D). The postoperative course was uneventful, with no erectile dysfunction, but a mild change in the erection angle occurred. Penile length reached 7 cm in the flaccid state and 10 cm when erect. The patient is shown 14 days after the procedure (Fig. 72-8, E). He started sexual activity 1 month later and was satisfi d with the result.

1107

1108

Part X 

Other Cosmetic Surgical Procedures

Discussion To date, the use of cosmetic surgery to enlarge the penis is highly controversial. There is no standardization of procedures, and the indications and outcome measures are poorly defi ed.17 In reality, the alteration in penile size is not signifi ant and does not always satisfy every patient’s high expectations. However, despite the substantial clinical course, the benefits of signifi ant improvement in sexual self-esteem and function and the highly accepted outcome by most patients, penile enhancement is a reasonable treatment option for the management of penile dysmorphophobia in strictly selected and thoroughly informed young adult men. Recent studies have reported that the complications of penile lengthening with an autograft r allograft included penile deformity, paradoxic penile shortening, unacceptable scarring, granuloma formation, migration of injected material, and sexual dysfunction.17 Disappointing short-term and long-term patient satisfaction rates were also reported after these procedures in most studies.17 Relative enhancement without a graft is a better choice, with preferable curative results. Penile lengthening surgery not only achieves superior appearance but also improves male sexual function in many cases. Morphologic and functional repair of a penile defect remains a challenge, mostly because of the lack of an ideal graft. Gore-Tex grafting may be an ideal reconstructive method for a partial penile defect. In patients with a partially necrotic penis or congenital microphallus, we recommend Gore-Tex glanuloplasty to rebuild the partially necrotic penis. Th s technique can achieve a normal penile shape and restore sexual function, along with an acceptable complication rate, in most patients. In addition to the improved appearance, most of our patients regained their basic tactile sensitivity and erogenous sensation after 6 months. In more than 88% of cases, patients reported an improvement in sexual performance, and their partners experienced greater sexual satisfaction and more ease in reaching an orgasm. The rigidity of the implanted Gore-Tex increased neoglans hardness, which may be the major reason the partner achieved an orgasm. In 9.1% of our patients, the Gore-Tex material was removed because of infection, which resulted in delayed reimplantation of a new prosthesis. Partial scrotal flap necrosis occurred in 6.1% of patients. A urethral fistula was found in 3% of patients who required further urethroplasty.

Pearls for Success • Penile lengthening surgery leads to only a 2.5 to 3.5 cm increase in penile length. • To prevent excessive alteration in erection angle, the surgeon should not release the deep suspensory ligament to achieve an additional gain in penile length. • To maintain the increase in penile length, the surgeon should use the surrounding tissue to fill up the gap. Suturing the fascia secures the penis in position. • To avoid infection, Gore-Tex implants should be fully covered by the flap. Any exposure may increase the incidence of infection and should be revised as soon as possible.

Chapter 72 

Penile Enhancement

1109

Refer ences 1. Lehman P. Running Scared: Masculinity and the Representation of the Male Body. Philadelphia: Temple University Press, 1993. 2. Woodhouse CR. The sexual and reproductive consequences of congenital genitourinary anomalies. J Urol 152(2 Pt 2):645-651, 1994. 3. Gray H. Anatomy of the Human Body. Philadelphia: Lea & Febiger, 1918. 4. Belman A, King L. Urethra. In Kelalis P, King L, Belman A, eds. Clinical Pediatric Urology, vol 1. Philadelphia: WB Saunders, 1976. 5. Park J. Normal development of the urogenital system. In Wein A, Kavoussi L, Novick A, et al, eds. CampbellWalsh Urology, vol 4. Philadelphia: Saunders Elsevier, 2007. 6. Brooks JD. Anatomy of the lower urinary tract and male genitalia. In Wein A, Kavoussi L, Novick A, et al, eds. Campbell-Walsh Urology, vol 4. Philadelphia: Saunders Elsevier, 2007. 7. Long DC. Elongation of the penis. Chin J Plastic Surg Burns 6:17-19, 1990. 8. Roos H, Lissoos I. Penis lengthening. Int J Aesthetic Restorative Surg 2:89-96, 1994. 9. Wessells H, Lue TF, McAninch JW. Penile length in the flaccid and erect states: guidelines for penile augmentation. J Urol 156:995-997, 1996. 10. Nikoobakht M, Shahnazari A, Rezaeidanesh M, et al. Effect of penile-extender device in increasing penile size in men with shortened penis: preliminary results. J Sex Med 8:3188-3192, 2011. 11. Perovic SV, Djinovic RP, Bumbasirevic MZ, et al. Severe penile injuries: a problem of severity and reconstruction. BJU Int 104:676-687, 2009. 12. Roche NA, Vermeulen BT, Blondeel PN, et al. Technical recommendations for penile replantation based on lessons learned from penile reconstruction. J Reconstr Microsurg 28:247-250, 2012. 13. Butera G, Gaio G, Carminati M. Redilation of e-PTFE covered CP stents. Catheter Cardiovasc Interv 72:273-277, 2008. 14. Fontana F, Santoro F, Maiorana C, et al. Clinical and histologic evaluation of allogeneic bone matrix versus autogenous bone chips associated with titanium-reinforced e-PTFE membrane for vertical ridge augmentation: a prospective pilot study. Int J Oral Maxillofac Implants 23:1003-1012, 2008. 15. Toygar HU, Guzeldemir E, Cilasun U, et al. Long-term clinical evaluation and SEM analysis of the e-PTFE and titanium membranes in guided tissue regeneration. J Biomed Mater Res B Appl Biomater 91:772-779, 2009. 16. Verardi S, Simion M. Management of the exposure of e-PTFE membranes in guided bone regeneration. Pract Proced Aesthet Dent 19:111-11 7, 2007. 17. Vardi Y, Har-Shai Y, Gil T, et al. A critical analysis of penile enhancement procedures for patients with normal penile size: surgical techniques, success, and complications. Eur Urol 54:1042-1050, 2008.

K23345_Pu_c72 73_Penile Enhance_r3_cl_1101-1110.indd 1109

4/3/2015 1:39:13 PM

K23345_Pu_c72 73_Penile Enhance_r3_cl_1101-1110.indd 1110

4/3/2015 1:39:13 PM

73 Correction of Varicose Veins With Endovascular Laser

C

Cheng-Jen Chang

hronic venous insuffici cy, or varicose veins, of the lower extremities is a common condition.1 Varicose veins are subcutaneous dilated veins greater than or equal to 3 mm in diameter, as measured in the upright position. Approximately 20% to 25% of women and 10% to 15% of men over the age of 15 have visible tortuous varicose veins.2 Minor degrees of varicosis (for example, reticular veins) are more common, affecting 50% of women and 45% of men.3 The risk factors for such conditions include age, sex (female), pregnancy, geographic location, and race.2 The main cause of primary varicose veins is the failure of a single valve in a critical location, whereas secondary varicose veins occur mainly when deep system and perforator valve damage is caused by thrombophlebitis. Other secondary causes of varicose veins include pregnancy, gravity, tumor compression, obesity, and trauma. Patients with varicose veins display an array of nonspecific s mptoms, including pain, soreness, swelling, itching, aching, burning, throbbing, muscle fatigue, cramping, and restless leg. The sequelae of varicose veins include long-term pain and edema, pigmentation, recurrent cellulites and dermatitis, lipodermatosclerosis, nonhealing leg ulcers (ulcer crura), cutaneous infarction (atrophy blanche), superfic al thrombophlebitis, hemorrhage from varices, pulmonary embolism, deep vein thrombosis (DVT), and even malignant transformation.4 Treatment of varicose veins focuses on eliminating the symptoms, improving one’s appearance, and preventing additional deterioration. The multiple treatment options available include the use of compression stockings, sclerotherapy, ambulatory phlebectomy, surgical ligation, surgical stripping, and radiofrequency ablation—either in isolation or in combination.5-11Surgical treatment for varicose veins has evolved from a major surgical procedure to minimally invasive approaches. The safe and effective use of lasers in angioplasty12 and lasers for the treatment of hemangiomas and vascular lesions has been widely reported.13-16 Endovascular laser photocoagulation (EVLP) is becoming the preferred treatment for varicose veins of the lower extremities because of its simplicity and success.17

1111

1112

Part X 

Other Cosmetic Surgical Procedures

Classification of Varicose Veins and Physical Examination Greater saphenous vein (GSV) primary varicosis is graded using Hach’s classifi ation system: • Grade 4 Varices about the groin • Grade 3 Varices about the midthigh • Grade 2 Varices about the middle to upper calf • Grade 1 Varices about the ankle • Grade 0 No varices visible Classifi ation is based on physical examination using the single Trendelenburg test, double Trendelenburg test, and Perthes test. A history of thrombophlebitis in the deep or superfic al veins and hemorrhage is noted in this checklist. All patients receive duplex ultrasonographic imaging at a vascular laboratory. A duplex ultrasound scan typically showing normal saphenofemoral valvular function can actually compare an abnormal valvular function on the contralateral side (Fig. 73-1). I recommend EVLP when there is an indication of axial reflux in the saphenous veins, large varicosities, varicosities in the medial or anterior thigh, and/or a combination of these indications, along with other cosmetic reconstruction.

Indications EVLP is indicated for the treatment of varicose veins and varicosities with superficial reflux of the GSV, based on the age of the patient or the seriousness of the disease, and for the treatment of incompetent refluxing veins in the superfic al venous system in the lower limb.

A

B

Fig. 73-1  A, Normal saphenofemoral valvular function. B, Abnormal saphenofemoral valvular function.

Chapter 73 

Correction of Varicose Veins With Endovascular Laser

Fig. 73-2  Preoperative marking of the varices.

Contraindications Patients with the following conditions should not undergo EVLP: • Th ombus in the vein segment to be treated • An inability to ambulate • Severe arterial disease • DVT or a history of DVT • Pregnant or breastfeeding women • General poor health Other contraindications may be raised by the individual physician at the time of treatment.

Preoperative Preparation In the operating room, the varices are marked preoperatively, and photographs are taken with the patient standing upright. Any incompetent perforators should be identifi d by duplex ultrasonography before surgery (Fig. 73-2).

Selected Lasers for EVLP After its introduction in 1999, the radiofrequency endovenous ablation system has been used because of its thermal destruction of venous tissues using electrical energy passing through tissue in the form of a highfrequency alternating current generated by the VNUS RF (radiofrequency) ablation system. Th s current is converted into heat, which causes irreversible localized tissue damage. A special catheter with deployable electrodes at the tip is used to deliver radiofrequency energy; the electrodes touch the vein walls and deliver energy directly into the tissues without coagulating blood.18

1113

1114

Part X 

Other Cosmetic Surgical Procedures

Box 73-1  EVLP System Wavelengths: Absorption Characteristics • The 810 nm wavelength is specific for hemoglobin absorption. • The 940 nm wavelength provides a balanced ratio between the light irradiated into the tissue and the absorption by water and hemoglobin. • The 980 nm wavelength is specific for water and hemoglobin. • The 1319 nm/1320 nm wavelength is specific or water absorption, targeting collagen in the vein wall. • The 1470 nm wavelength features an absorption coeffici t in water that is 40 times greater than the absorption coeffici t at the 810 nm and 980 nm wavelengths.

Table 73-1  Application for Endovascular Lasers Wavelength (nm) 81019

94019

98019

106419

132020

147021

Diode

Diode

Diode

Nd:YAG

Nd:YAG

Diode

Optical fiver (mm)

600

600

600

600

600

600

Power watt (W)

14

15

11

10 or 15

8

15

49.3

23.4

45.9

Not provided

63

90

Type

Mean unit energy (J/cm)

Data from Kim HS, Yoo JY, Cho KH, et al. Topical photodynamic therapy using intense pulsed light for treatment of actinic keratosis: clinical and histopathologic evaluation. Dermatol Surg 31:33-37, 200519; Proebstle TM, Moehler T, Gül D, et al. Endovenous treatment of the great saphenous vein using a 1,320 nm Nd:YAG laser causes fewer side effects than using a 940 nm diode laser. Dermatol Surg 31:1678-1684, 200520; and Pannier F, Rabe E, Maurins U. First results with a new 1470-nm diode laser for endovenous ablation of incompetent saphenous veins. Phlebology 24:26-30, 2009.21

One of the most prominent evolutions of EVLP systems is the introduction of numerous wavelengths, each of which has unique absorption characteristics (Box 73-1). Thermal ablation leaders have divided endovenous lasers into two categories based on their hypothetical mechanisms of action: (1) hemoglobin-specific aser wavelengths (HSLWs) and (2) water-specific aser wavelengths (WSLWs) (Table 73-1). HSLWs are thought to produce thermal damage by using intravascular blood as a chromophore to absorb laser energy and create steam bubbles. Lasers that target hemoglobin absorption include 810 nm, 940 nm, and 980 nm lasers, with the lowest wavelength having the highest specific ty for hemoglobin. The HSLW lasers create bubbles from boiling blood because of the absorption of laser energy by hemoglobin. These bubbles can disburse throughout the vein and cause heat damage to the inner vein wall all the way up to the remote site from the fiber tip. Perforation also occurs from the direct contact of the fiber tip with the vein wall when there is no blood in the vein. In addition, carbonization of the vein wall is caused at the perforation site by the uncontrollably high temperature. It is widely thought that WSLWs infli t vein wall damage by targeting the interstitial fluid in the vein wall. The 1064 nm, 1320 nm, and 1470 nm lasers are thought to produce thermal damage with this mechanism, with higher wavelengths showing a greater affi ty for water absorption. The WSLWs penetrate the blood and are absorbed by collagen in the vein wall, causing contraction of the collagen and thermal shrinkage of the vein wall in a similar manner to radiofrequency closure. The vein diameter decreases and occludes with a small amount of thrombus formation. Controlled heating of the vein wall causes vein lumen diameter shrinkage, shortening and thickening of the collagen fibers, and fibrotic sealing of the vessel.22

Chapter 73 

Correction of Varicose Veins With Endovascular Laser

In our laser center, both HSLWs and WSLWs have been used for EVLP. Because many factors must be considered to achieve successful results, one of the most important factors affecting EVLP is the rising temperature in the blood fl w induced by energy transfer when in contact with the vein wall. Other factors affecting EVLP are the anatomic location (saphenofemoral junctions [SFJs], side branches, or perforators) for treatment and the vein diameter.23

Endovascular Procedures Ster ile Setup

Instruments that are used for cutting in the vein procedure include the following: • 2 small vein retractors • 1 right-angle clamp • 1 fi e DeBakey vascular forceps • 1 needle holder • 4 curved mosquito clamps • 1 No. 8, No. 9, or No. 10 crochet hook • 1 pair curved Metzenbaum scissors (5-inch) • 1 Adson forceps with teeth (5-inch) • 1 short tumescent cannula • 1 long tumescent cannula • 1 No. 3 knife handle • 1 small towel clip Meanwhile, the supplies for sterile setup (stab avulsion/ligation veins) include the following: • 1 Mayo stand and stand cover • 3-0 silk ties • 5 sterile towels • 3∕4 sheet (for under the leg) and 1∕2 sheet (to cover the sterile setup) • Steri-Strips • 250 ml normal saline solution for irrigation • 25-gauge and 21-gauge needles • 10 ml syringe (for tumescent) • Sterile IV tubing with a control clamp and no injection ports • Instrument set ȤȤ 1 No. 11knife blade ȤȤ 10 gauze sponges (4 3 4) ȤȤ 1 bowl (500 ml) ȤȤ Sterile gowns and sterile gloves

Anes thes ia

The use of a tumescent anesthetic is an advisable option, because the risk is minimal, no conscious sedation is required, and it is well tolerated by the patient. We administer a general anesthetic or spinal anesthetic for extensive areas or for individuals with low pain tolerance. The steps for preparation of tumescent solution are as follows: 1. 60 ml of tumescent solution is removed from a 500 ml bag of 0.9% normal saline solution. 2. 16 ml of sodium bicarbonate is added to the solution. 3. 60 ml of 1% lidocaine with epinephrine (1:100,000) is added to the solution.

1115

1116

Part X 

Other Cosmetic Surgical Procedures

Th s gives a lidocaine concentration of 5 to 6 mg/kg in a 70 kg patient. Epinephrine reduces bleeding by causing vasoconstriction, and it reduces lidocaine absorption into circulation. Sodium bicarbonate buffers lidocaine and reduces the burning sensation that the patient has during administration of a tumescent solution. For patients with extensive varicose veins or in some special cases, a spinal or general anesthetic is indicated.

Sur gical Pr o ced ur es

A 2 cm long skin incision is made over the saphenofemoral junctions (SFJs) at the groin crease. Using blunt dissection, the SFJs and all of the terminal tributaries draining into the GSV are identifi d and flushligated with nonabsorbable sutures. In a similar manner, the distal end of the GSV is identifi d and ligated through a small incision anterior to the medial malleolus. Using a No. 11 blade, the surgeon creates a 2 mm longitudinal venotomy of the distal GSV just proximal to the ligature. A bare 600 mm optic fiber connected to a laser system is inserted into the lumen of the GSV and threaded upward along its course toward the SFJ. The passage of the optic fiber can be identifi d through the transillumination of the overlying skin provided by the helium-neon guide light at the fiber tip through ultrasound and visualization of the aiming beam. A successful passage up the GSV will steady the guide light at the SFJ. In 10 of our patients for whom a complete upward passage of the laser was not possible (because of a severely sinuous axial vein), the optic fiber was passed in a retrograde fashion from the SFJ. The laser system is calibrated to deliver laser with proper energy and pulse duration on each trigger by a foot pedal. The optic fiber is gradually retracted at a speed of 10 sec/cm (Fig. 73-3). Using the pulse mode when delivering the laser energy enables the surgeon to have more control than he or she could have with a continuous wave. Overheating of the overlying skin is avoided through the use of a continuous fl w of chilled water at 4° C and the surgeon’s hand being placed over the treatment area. Visible shrinkage and a palpable fi mness of the varices signal the treatment endpoint. The proximal and distal ends of the treated GSV are then doubly ligated and divided.

Fig. 73-3  The optic fiber delivers the laser energy

within the GSV, and an 18-gauge needle is used to puncture the local lesion and lead the optic fiber into the nidus for photocoagulation.

Chapter 73 

Correction of Varicose Veins With Endovascular Laser

1117

Along with the axial GSV, the varices of its branches are also treated by laser photocoagulation. At each of these sites, percutaneous cannulation of the varices or perforators is achieved with the use of an 18-gauge metallic vascular cannula (Angiocath). A backfl w of blood or a resistance offered by the deep fascia confi ms the accurate placement of the cannula for the varices and perforators, respectively. The optic fiber is inserted into the cannula, and the tip is identifi d by the guide light. The cannula is withdrawn from the skin to prevent inadvertent thermal injury to the skin by heat conducted from the fiber to the cannula during treatment. Laser pulses are then conveyed in a similar manner as described previously. The entire procedure is performed under duplex monographic guidance. On completion of the laser photocoagulation, the skin incisions are closed with sutures, and external compression is applied to the entire lower extremity with loose gauze and elastic bandages. The total energy delivered is calculated as a product of the power (W), pulse duration (seconds), and the total number of pulses. Th s value is recorded in the operative notes.

Postoperative Care Preparation of the postoperative dressing includes the following: • Unsterile cotton balls • 3 absorbent (abdominal) pads (5 3 9-inch ) to hold the cotton balls in place over the avulsion sites • 2 extra-long sanitary pads adhered back to back and placed next to the skin over the ablated saphenous vein • 1 extra-long sanitary pad cut in half lengthwise and adhered back to back for any needed additional length to cover the ablated saphenous vein • 1 extra-long sanitary pad also cut in half lengthwise and not adhered but placed at the ankle over the Achilles tendon to prevent the Ace bandage from rubbing against the skin • 2 rolls of Kerlix bandages to hold the sanitary pads in place • 1 roll of Coban self-adhering wrap placed over the Kerlix bandage to provide additional compression over the saphenous vein • Steri-Strips • 1 Ace bandage wrap (4-inch) • 2 Ace bandage wraps (6-inch) • Benzoin spray to hold Steri-Strips in place • 1 large bandage scissors to cut the Coban self-adhering wrap After a stable condition is reached, a stocking can be used to replace the dressings. Patients are encouraged to ambulate, and when in bed, to elevate the treated limb or limbs. Cold pack compresses are applied to the lower limbs for the fi st 72 hours after treatment. Most patients are discharged on the day after treatment. The compression dressings are maintained until the fi st outpatient reviews on the third or fourth postoperative day. Thereafter, the patient wears gradient compression stockings (24 to 26 mm Hg) for 6 weeks. Medical compression stockings are used based on these classifi ations: • Class 1 20 to 30 mm Hg with a mild superfic al effect • Class 2 30 to 40 mm Hg with a medium effect • Class 3 40 to 50 mm Hg with a superfic al and deep effect • Class 4  50 mm Hg or greater with a pronounced deep effect All patients are seen and photographed at regular intervals in the outpatient clinic. Reticular veins and telangiectasia are treated by outpatient sclerotherapy, a flashlamp-pumped pulse dye laser (ScleroPLUS), and an Nd:YAG laser (GentleYAG).

K23345_Pu_c73_Cx Varicose Veins_r2_cl_1111-1122.indd 1117

4/3/2015 1:40:44 PM

1118

Part X 

Other Cosmetic Surgical Procedures

Results In my practice, only patients with primary varicose veins and saphenofemoral reflux documented by duplex ultrasound were treated. All patients received surgical ligation of the SFJ. EVLP was performed using a 1064 nm Nd:YAG laser, delivered with a 600 mm optical fiber. Laser power was set at 10W or 15W, delivered with a pulse duration of 10 seconds. The outcome was compared before and after EVLP, based on the score of severity of the varicose veins according to Hach’s classifi ation. The results showed a range of the total delivered energy from 9200 J to 20,100 J. The entire procedure was completed in 95 to 175 minutes (mean 122.33 minutes) for bilateral procedures, and in 65 to 100 minutes (mean 81.07 minutes) for unilateral procedures. The follow-up period ranged from 12 to 28 months with a mean of 19 months; 141 patients with 244 legs involved (96.8%) showed remarkable improvement (p ,0.05). The common early complications observed at 3 weeks after surgery were local paresthesia of the treated area in 92 legs (36.5%), ecchymosis and dyschromia in 58 legs (23.0%), superfic al burn injury in 12 legs (4.8%), superfic al phlebitis in four legs (1.6%), and localized hematoma in two legs (0.8%). There were no signifi ant signs of morbidity or mortality. All patients recovered completely.

Fig. 73-4 Th s 66-year-old woman had severe varicose veins (grade 3) at her right medial thigh and leg. Her symptoms had completely resolved 20 months after one EVLP treatment with an 810 nm diode laser.

K23345_Pu_c73_Cx Varicose Veins_r2_cl_1111-1122.indd 1118

4/3/2015 1:40:45 PM

Chapter 73 

Correction of Varicose Veins With Endovascular Laser

1119

Fig. 73-5 Th s 71-year-old man had severe varicose veins (grade 3) at his left medial thigh and leg. He had complete resolution of his symptoms 12 months after one treatment with an 810 nm diode laser.

Fig. 73-6 Th s 72-year-old woman had varicose veins (grade 2) on her left knee and leg. She had complete resolution of her symptoms 15 months after having one EVLP treatment with an 810 nm diode laser.

K23345_Pu_c73_Cx Varicose Veins_r2_cl_1111-1122.indd 1119

4/3/2015 1:40:49 PM

1120

Part X 

Other Cosmetic Surgical Procedures

Fig. 73-7 Th s 49-year-old woman had varicose veins (grade 2) on her left nee and leg. She had complete resolution of her symptoms after one EVLP treatment with an 810 nm diode laser.

Discussion When delivered to a target tissue, a laser may be absorbed, refl cted, refracted, scattered, or transmitted. The immediate tissue effect depends on the absorption spectrum and thermal properties of the tissue, and the energy and wavelength of the laser. Common tissue effects include photocoagulation, photodisruption, and photovaporization. These tissue effects may be harnessed to achieve the desired therapeutic effects. Cutaneous lasers are restricted by poor tissue penetration and are ineffective against varicosities within the superfic al fascia. Direct application through the skin may cause nonselective thermal injury. My method of intravenous photocoagulation delivers the Nd:YAG laser beam through a bare optic fiber into the varices. The optic fiber overcomes the lack of adequate tissue penetration and skin burns by transmitting the laser beam directly into the varices. Immediately after EVLP, the vessel and its surrounding tissues coagulate. EVLP likely affects intravascular thrombogenesis and photocoagulation of vessels and the surrounding tissues, leading to fibrosis, ischemia, sclerosis, thrombus blockade, and ultimately the obliteration of the varices and their tributaries. Among the early complications in my patients, I did not observe any wound infections or DVT. In the follow-up period, all of my patients recovered completely. I think that all of the previously mentioned complications are caused by the direct thermal effects of laser treatment. Heat injury of the sensory nerve caused sensory impairment. Positioning the optic fiber too superfic ally was the likely cause of burns on the overlying skin; in addition, delivering too much laser energy too slowly could be responsible. During the procedure and the application of cold packs for the fi st 72 hours after EVLP, the temperature at the

K23345_Pu_c73_Cx Varicose Veins_r2_cl_1111-1122.indd 1120

4/3/2015 1:40:53 PM

Chapter 73 

Correction of Varicose Veins With Endovascular Laser

Fig. 73-8  The pulsed dye laser is effective in treating residual vessels.

varices can be controlled through cooling with chilled water. Applying compression bandages on the patient when in the operating room is also critical to prevent hematoma formation. Sustained compression is also important, because it reduces intravascular thrombus formation, encourages fibrosis of the collapsed vessel, and prevents DVT. In addition, keeping the patients ambulant helps to avoid DVT. Although venous lesions found on the legs can be categorized as either varicose veins or leg veins, they can be treated with EVLP instead of ligation and stripping according to the concept and use of the laser in angioplasty. Frequently, however, small leg veins (those with a diameter less than 200 mm) still worry patients for cosmetic reasons. An alternative method to treat spider and reticular veins is to use a combined therapy of sclerotherapy and laser therapy using a hypertonic solution and foam sclerosing agents. According to the concept of selective photothermolysis, a long pulsed 1064 nm Nd:YAG laser (GentleYAG) and a flashlamp-pumped pulsed dye laser (ScleroPLUS) with longer wavelengths are often selected to treat small leg veins and spider veins (Fig. 73-8).

Pearls for Success • HSLW specifi ally targets hemoglobin within the blood and includes 810 nm, 940 nm, 980 nm, and 1064 nm wavelengths. • WSLW specifi ally targets water within the vein wall and includes 1320 nm and 1470 nm wavelengths. • EVLP is undoubtedly of great benefit in the treatment of varicose veins, because it is a less invasive method that can minimize the complications of conventional surgery. • Although a long pulsed dye laser can be effective in the clearance of leg telangiectasia, the combination of EVLP and a flashlamp-pumped pulsed dye laser creates the most effective and safest method to treat varicose veins. • After being treated with EVLP 1064 nm and EVLP 810 nm, all of my patients made good or excellent improvement. Improvement was greater in the Diode laser group. • Inadvertent contact of bare-tip fibers with the vein wall is unavoidable, regardless of the wavelength. • With ongoing improvements in EVLP use, there will undoubtedly be even greater results in the future for patients seeking treatment of varicose veins or varicosis.

1121

1122

Part X 

Other Cosmetic Surgical Procedures

Refer ences 1. Callam MJ. Prevalence of chronic leg ulceration and severe venous disease in western countries. Phlebology 7(Suppl):6-12, 1992. 2. Callam MJ. Epidemiology of varicose veins. Br J Surg 81:167-173, 1994. 3. Hirai M, Naiki K, Nakayama R. Prevalence and risk factors of varicose veins in Japanese women. Angiology 3:228-232, 1990. 4. Weiss RA, Feied CF, Weiss MA, eds. Vein Diagnosis & Treatment: A Comprehensive Approach. New York: McGraw-Hill, 2001. 5. Fegan G. Varicose Veins: Compression Sclerotherapy. London: Heinemann, 1967. 6. Lin SD, Tai CC, Lin TM, et al. Endoscope-assisted correction of primary varicose veins. Ann Plast Surg 44:241249, 2000. 7. Goren G, Yellin AE. Invaginated axial saphenectomy by a semirigid stripper: perforate-invaginate stripping. J Vasc Surg 20:970-977, 1994. 8. Goren G, Yellin AE. Ambulatory stab avulsion phlebectomy for truncal varicose veins. Am J Surg 162:166-174, 1991. 9. Walsh JC, Bergan JJ, Beeman S, et al. Femoral venous reflux abolished by greater saphenous vein stripping. Ann Vasc Surg 8:566-570, 1994. 10. Campbell WB, Ridler BM. Varicose vein surgery and deep vein thrombosis. Br J Surg 82:1494-1497, 1995. 11. Harris EJ. Radiofrequency ablation of the long saphenous vein without high ligation versus high ligation and stripping for primary varicose veins: pros and cons. Semin Vasc Surg 15:34-38, 2002. 12. Ashley S, Kester RC. Laser angioplasty. Br J Surg 80:550-551, 1993. 13. Alani HM, Warren RM. Percutaneous photocoagulation of deep vascular lesions using a fiberoptic laser wand. Ann Plast Surg 29:143-148, 1992. 14. Chang CJ, Fisher DM, Chen YR. Intralesional photocoagulation of vascular anomalies of the tongue. Br J Plast Surg 52:178-181, 1999. 15. Fisher DM, Chang CJ, Chau JJ, Chen YR, Achauer BM. Potential complications of intralesional laser photocoagulation for extensive vascular malformations. Ann Plast Surg 47:252-256, 2001. 16. Achauer BM, Chang CJ, VanderKam VM, et al. Intralesional photocoagulation of periorbital hemangiomas. Plast Reconstr Surg 103:11-16; discussion 17-19, 1999. 17. Chang CJ, Chua JJ. Endovenous laser photocoagulation (EVLP) for varicose veins. Lasers Surg Med 31:257-262, 2002. 18. Lurie F, Creton D, Eklof B, et al. Prospective randomized study of endovenous radiofrequency obliteration (closure procedure) versus ligation and stripping in a selected patient population (EVOLVeS Study). J Vasc Surg 38:207-214, 2003. 19. Kim HS, Yoo JY, Cho KH, et al. Topical photodynamic therapy using intense pulsed light for treatment of actinic keratosis: clinical and histopathologic evaluation. Dermatol Surg 31:33-37, 2005. 20. Proebstle TM, Moehler T, Gül D, et al. Endovenous treatment of the great saphenous vein using a 1,320 nm Nd:YAG laser causes fewer side effects than using a 940 nm diode laser. Dermatol Surg 31:1678-1684, 2005. 21. Pannier F, Rabe E, Maurins U. First results with a new 1470-nm diode laser for endovenous ablation of incompetent saphenous veins. Phlebology 24:26-30, 2009. 22. Almeida JI, Kaufman J, Göckeritz O, et al. Radiofrequency endovenous ClosureFAST versus laser ablation for the treatment of great saphenous reflux: a multicenter, single-blinded, randomized study (RECOVERY study). J Vasc Interv Radiol 20:752-759, 2009. 23. Calcagno D, Rossi JA, Ha C. Effect of saphenous vein diameter on closure rate with ClosureFAST radiofrequency catheter. Vasc Endovasc Surg 43:567-570, 2009.

K23345_Pu_c73_Cx Varicose Veins_r2_cl_1111-1122.indd 1122

4/3/2015 1:40:53 PM

74 Correction of Osmidrosis

O  

David Daehwan Park

smidrosis refers to foul-smelling perspiration caused by abnormalities in sweat glands in the axillary region. It is also called fetid sweat, axillary odor, and bromhidrosis. Because many Westerners have osmidrosis to some extent, it is not commonly treated surgically in these patients. However, it is generally considered an abnormality in Asians and is thought to be responsible for problems in marital relations and social interactions, including employment seeking. Osmidrosis is a source of distress for many Asians and a common reason for social isolation. Therefore these patients are often treated surgically to restore emotional and mental health and to help them resume daily social activities. It is performed in men and women. In my experience, the incidence of osmidrosis surgery in men has recently increased remarkably. Although many osmidrosis treatment methods are available, complete treatments have not yet been developed. In this chapter I will describe aspects of osmidrosis, ranging from the pathologic basis of its development to clinical patterns, diagnosis, and the evolution of nonsurgical and surgical treatments.

Epidemiology Beginning in adolescence, all humans emit odors from their axillas because of abnormalities in their apocrine glands, which are connected with axillary hair. These are associated with sex hormones. The presence of strong osmidrosis that is unpleasant for others varies greatly among races. In general, most Westerners have osmidrosis, whereas very few Asians have it; thus it is typically treated as a disease in Asians. According to the literature, 100% of blacks and 70% to 90% of other Westerners have osmidrosis. Among Asians, 10% to 15% of Japanese and only 3% to 5% of Koreans have osmidrosis. The reason for a higher incidence in Westerners has not been established. It is thought that they have numerous apocrine glands and large amounts of secretions from sebaceous glands, inducing bacterial propagation and malodor. Because it is less common in Korea and can lead to rejection by others, it has a stronger psychological effect and can cause anthropophobia. In the West, the word osmidrosis is used synonymously with axillary hyperhidrosis, which is treated with surgery to reduce sweat production but not specifi ally to eliminate malodor. On the other hand, in Asian countries, axillary hyperhidrosis refers to the production of large amounts of sweat by the axillas, and axillary odors, or osmidrosis, is a distinctly different phenomenon.

1123 K23345_Pu_c74_Crx of Osmidrosis_r2_cl_1123-1138.indd 1123

4/3/2015 1:42:33 PM

1124

Part X 

Other Cosmetic Surgical Procedures

Papillary muscle Sebaceous gland

Stratum corneum Stratum lucidum Stratum granulosum Stratum spinosum Stratum basal

Epidermis

Papillary dermis

Meissner’s corpuscle

Reticular dermis

Dermis

Hair follicle Hypodermis Papilla of hair follicle

Sweat glands

Sensory nerve Artery Vein

Elastic fibers

Fig. 74-1  The relationship of skin appendages, such as apocrine sweat glands, sebaceous glands, and hair follicles, to the epidermis, dermis, and subcutaneous tissue.

Pathophysiology Osmidrosis is associated with sweat glands located under the axillas. There are two types of sweat glands: apocrine and eccrine. The apocrine glands are just below dermis, and the eccrine glands are in the middle of dermis. Apocrine glands are large enough to be identifi d by the eye. These are also called large sweat glands and are located at the outlets of hairs (Fig. 74-1). Both gland types are concentrated on the dome region in the center of axillae, and central eccrine glands account for around 70% to 80% of axillary sweating. Many scholars have studied the unique odors of osmidrosis and have reported various theories. Although no fi m conclusion has been made, the following six hypotheses have been proposed: (1) the nature of the odors is determined by the amount of apocrine glands, (2) the nature of the odors is determined by the composition of the apocrine glands’ secretions, (3) the nature of the smells is determined by the composition of the sebaceous glands’ secretions, (4) bacteria are the cause of the odors, (5) bacteria and sebaceous glands act on apocrine sweat to produce odors, and (6) the odors are produced by sex hormones to attract members of the opposite sex.

Clinical

Pat ter ns

The clinical manifestations of axillary osmidrosis include unpleasant odors and axillary sweat. People with osmidrosis are not necessarily aware that they have this problem, and many are informed by family members or others. Generally, parents bring their children to the clinic for assessment and surgery. Not all patients with osmidrosis sweat excessively. Some report that their white undershirts have a permanent yellow discoloration in the axillary area.

Chapter 74 

Correction of Osmidrosis

Whether osmidrosis is affected by seasonal weather variations is controversial.1-3 Some think that it becomes more severe in summer as sweat increases, whereas others insist that osmidrosis decreases somewhat in the summer, because thin clothes facilitate evaporation of sweat. Some claim that osmidrosis is not frequently accompanied by axillary hyperhidrosis, because the precursors and secretions generated in apocrine glands that produce odoriferous substances through bacterial actions are diluted by sweat. Patients typically request surgery for osmidrosis mainly because other people avoid them. Some patients report that they do not like their own body odors. However, most patients undergo the surgery to resume or improve their relationships with others. The age at which osmidrosis develops ranges from preadolescence to 70 years of age. Most patients who have surgery are 18 to 25 years of age. Although osmidrosis frequently occurs in men, in my experience, twice as many women have osmidrosis surgery.

Assessment and Diagnosis Because the cause of osmidrosis is not completely understood, the best way to diagnose it has not been established. Osmidrosis generally develops in both axillas simultaneously in adolescence or later, and many patients have a family history of the disease. In Asians, it should be carefully distinguished from hyperhidrosis, which refers to the production of large amounts of sweat from the axillas. If osmidrosis is accompanied by hyperhidrosis, it should be carefully differentiated from various systemic diseases that induce hyperhidrosis. Sweat tests are conducted using special solutions. The Minor test (the iodine-starch test) involves elevating both of the patient’s arms and applying Minor solution (made by mixing 1.5 g of iodine, 10 ml of castor oil, and 100 ml of 95% alcohol) to the axillary regions. The axillas are dried for approximately 5 minutes, and a thin layer of starch is applied. The axillas are then illuminated with two 500 W light bulbs at a distance of 50 cm for 3 minutes to induce sweating. Sweat is revealed as black areas, because it causes white starch to change to black (Fig. 74-2). With this test, sweating regions can be identified through discolored skin.4 However, this is not an accurate method, because it does not distinguish apocrine secretions from eccrine secretions. Osmidrosis is an abnormality of the apocrine gland rather than the eccrine gland.

A

B

Fig. 74-2  Diagnosis of osmidrosis using the sweat test. A, Starch is discolored as blackish brown in this osmidrosis patient. B, No color change occurs in patients who do not have osmidrosis.

1125

1126

Part X 

Other Cosmetic Surgical Procedures

Nonsurgical Techniques Temporary treatment is offered for patients who want to eliminate osmidrosis for a short period, such as during the rainy season or for a date on the next day. It is generally thought that the sweat from the apocrine glands in the axilla and the secretions from the sebaceous glands mix with cells on the skin’s surfaces to produce osmidrosis. The resulting odors are diffused by the axillary hairs. Nonsurgical treatment aims at preventing sweat and sebum secretion from apocrine glands and sebaceous glands, respectively, preventing bacterial propagation on the skin and removing hairs.

Topical Tr ea t ment

The simplest method for temporary treatment of osmidrosis is to apply ointment or spray products to the axillary skin. These include adiaphoretics to reduce sweat secretion and bactericides to suppress bacterial propagation. A solution of 20% aluminum chloride hexahydrate in anhydrous ethyl alcohol (Drysol) is the safest and most effective local agent of those currently used.5 It is the fi st treatment used in most patients. The mechanism of this medicine is to plug the holes of the eccrine glands in the epithelium. 5 The aluminum and boric acid powder therapy shows high efficacy and 83% to 98% patient satisfaction if applied appropriately.6-9 However, Rayner et al10 reported that this therapy was not effective in 26 of 38 patients, who later elected surgical treatment. Although local anticholinergic drugs are not frequently used because of their lack of efficacy and adverse effects, 0.025% benzoyl scopolamine hydrobromide solution is reported to reduce sweating without systemic or local adverse effects. Treatments such as glutaraldehyde and formaldehyde are effective but are not frequently used because of adverse effects.7,11All of these treatments block eccrine glands in the horny layer to prevent sweat and odors.12 Although these products can reduce odors to some extent, they do not effectively control the problem of excessive axillary sweat.

Rad io therap y

Radiotherapy that is effective only at high doses did not prove to be a satisfactory alternative. Th s therapy was found to destroy tissue through x-ray irradiation and radium irradiation and induce dangerous adverse effects, such as ulcers and dermatitis. Th s therapy is no longer used.

Iont opho r es is

Iontophoresis involves the fl w of electrical currents through a patient’s palms, soles, or directly through the axillas. Th s is performed while the patient is in contact with an aqueous ion solution. These currents transfer ions from the solution to the patient’s skin to plug sweat gland ducts, thereby suppressing sweating.7,13,14 In several studies, sweating was reduced by at least 50% within 3 weeks in most patients; however, compared with the palms and soles, which were quite responsive, the axillas did not respond well.6,8,12,15

Systemic Tr ea t ment

To achieve greater effects, oral anticholinergic sedatives can be used in combination with local ointments.7 Although benzodiazepine sedatives can decrease sweating triggered by emotions or stress by suppressing sympathetic nerves while reducing the emotional stimuli, they tend to induce drug tolerance and dependence.5 Anticholinergics are effective in most cases, but their use is limited because of adverse effects. Their

Chapter 74 

1127

Correction of Osmidrosis

use is recommended in combination with glycopyrrolate (Robinul) or phenobarbital for the treatment of hyperhidrosis and emotional sweating.7

Surgical Techniques Surgery is a permanent treatment for osmidrosis and can be performed in indicated patients when local chemical therapies have failed. Patients are selected based on their personality, physical health, social environment, desired level of improvement, and the degree of distress caused by the disease. A thorough examination is needed preoperatively to suffici tly understand each of these factors in each case. Surgery should only be performed on mentally stable individuals.

Anat omy of the Axill ar y Regio n

Thorough knowledge of the anatomy of the axillary region is essential in the surgical treatment of osmidrosis (Fig. 74-3). Deep axillary fasciae exist immediately below the skin and subcutaneous fat in the axillary region. Below this layer are the lateral cutaneous branch of the superior intercostal nerve and the axillary vein. Below the axillary vein are the brachial plexus and the axillary artery,16 whose pulse can be palpated on the surface of the skin when the upper extremity is abducted. These structures should not be damaged during surgery in the axillary region. To prevent injury to the motor nerves that course from the fi h and sixth cervical nerves and innervate the shoulder muscles, the upper arm should not be abducted more than 90 to 120 degrees while the patient is anesthetized.17,18 The postoperative osmidrosis axillae position could cause ulnar neuropathy associated with excessive strain of the ulnar nerve during prolonged flexi n of the elbow.17-19

Sternocleidomastoid muscle Phrenic nerve

Trapezius muscle Acromion

Transverse cervical artery

Musculocutaneous nerve Deltoid muscle

Median nerve Subclavian artery and vein Medial antebrachial cutaneous nerve

Pectoralis major muscle

Teres major muscle Long thoracic artery and nerve Latissimus dorsi muscle

Fig. 74-3  Anatomy of the axillary region.

1128

Part X 

Other Cosmetic Surgical Procedures

Selectio n of Sur gical Techniq ue

Selection of a surgical method requires understanding the type of sweating, the degree of osmidrosis, the degree of sweating reduction desired by the patient, and the patient’s preferences regarding scars and axillary hair removal. For patients who are more concerned about scar visibility than the degree of sweating present postoperatively, subcutaneous tissue excision through small incisions or modifi d liposuction is appropriate. Patients who are not concerned about scars but insist on preserving axillary hair and have severe osmidrosis are treated by excising only severely sweating regions or by detaching these regions and excising them together with surrounding subcutaneous tissue. Imprudent excision of subcutaneous tissue can destroy follicles and cause partial or total atrichia in the axillary region. Patients who want total axillary anhidrosis and do not care about atrichia or large scars are treated with either a bat-shaped excision or complete excision of a double rotation flap of hair-bearing axilla, followed by a wide-ranged incision such as a Z-plasty. Although the choice of treatment for each patient can be difficult and is sometimes controversial, the method that is the simplest, results in minimal damage, and controls symptoms should be selected fi st. If a patient is not satisfi d with the degree of reduced axillary sweating, the method can be repeated or a different procedure can be performed.

Compar iso n of Sur gical Techniq ues

The goals of surgery for osmidrosis are to adequately remove sweat glands for long-lasting reduction of malodor and to eliminate other adverse effects with a minimal healing time. Many surgical methods for removing axillary sweat glands in osmidrosis patients have been developed. Most techniques can be categorized as one of the following: (1) methods to remove only subcutaneous tissue, (2) methods to excise the skin and subcutaneous tissue, or (3) a combination of both. Another classifi ation describes two types of techniques: (1) removal of apocrine glands with direct visualization (mechanical method) and (2) removal of apocrine glands without direct visualization (with equipment). Th ee methods involve directly viewing the apocrine glands: (1) removal of the skin, (2) removal of only the apocrine glands with preservation of the skin, and (3) removal of both skin and apocrine glands (Box 74-1).

Box 74-1  Classifi ation of Surgical Methods for Treatment of Osmidrosis Visualization • Direct visualization ȤȤ Removal of the skin ȤȤ Removal of only apocrine glands and preservation of the skin ȤȤ Removal of skin and apocrine glands • Visualization through equipment Methods • Subcutaneous excision • Direct skin excision • A combination of subcutaneous and direct skin excision

Chapter 74 

1129

Correction of Osmidrosis

Rad ical Excis io n

Traditional osmidrosis surgery, or radical excision, involves direct visualization and excision of the entire area of skin with axillary hair, including the subcutaneous tissue (Figs. 74-4 and 74-5). This method has several disadvantages. The average width of the range of axillary hairs in most Asians is quite large. Complete excision and closure places tension on the subcutaneous nerves and blood vessels and results in a scar longer than 10 cm20 (Fig. 74-6).

A

B

D

E

C

F

Fig. 74-4  Various designs for radical excision. Stay sutures will be placed at the end of the procedure to secure a bandage. A, Horizontal oval excision. B, Vertical oval excision. C, A combined horizontal oval excision with a Z-plasty. D, A combined vertical oval excision with a Z-plasty. E, Z-shaped excision. F, W-shaped excision.

Fig. 74-5  Various designs for radical excision marked on the skin.

1130

Part X 

Other Cosmetic Surgical Procedures

Fig. 74-6  Th s patient has a visible scar after having a radical excision.

A

B

Fig. 74-7  Subdermal shaving. A, A vertical

oval incision is marked. The dots indicate the location of the extent of undermining. B, The incision is made. C, The tissue is undermined. D, The skin is everted with a fi ger. E, Apocrine and sebaceous glands are removed with scissors.

C

Modified W-pl a st y

D

E

Dermal shaving is a surgical approach for removal of only subcutaneous tissue without excision of the skin. One of several types of incisions is made several centimeters long on the axillary skin. The surgeon uses his or her fi gers to invert the skin and removes the apocrine glands and sebaceous glands with scissors, effectively shaving the skin. Because this is the most reliable surgical method for removing only the parts that should be removed, it is currently the most commonly performed technique (Figs. 74-7 and 74-8).

Chapter 74 

A

C

F

1131

Correction of Osmidrosis

B

D

E

G

H

Fig. 74-8  Subdermal shaving (bipedicled flap method). A, The patient is marked preoperatively. B, The skin is incised.

C, Medial flap elevation. D, Central flap elevation. E, Lateral flap elevation. F, Subdermal shaving. G, Draining and quilting suture. H, Tie-over dressing.

In 1966 Hurley and Shelley2 reported a combined technique that incorporated the advantages of both the excision method and the dermal shaving method. Excision is performed in the central region of the axilla, where sweat and odors are produced, and dermal shaving is performed in the peripheral areas. The disadvantages include large scars and high recurrence rates. Th ee methods are available for removal of apocrine glands through direct visualization: (1) subcutaneous tissue curettage, (2) shaving, and (3) suction. Subcutaneous tissue curettage removes apocrine glands through the smallest possible incisions. In this method, a specially designed curette is inserted through subcutaneous incision holes, as with surgery, to remove apocrine glands. Currently, this method is not commonly used because of difficulties in sharpening the instrument’s blade and the unpredictable effects of the procedure. Similarly, subcutaneous tissue shaving involves insertion of an instrument through a small incision to remove the tissue; the instrument resembles a razor blade and a roller (Fig. 74-9).

1132

Part X 

A

Other Cosmetic Surgical Procedures

B

C

D

Fig. 74-9  Subdermal curettage and resection (Inaba method). A, Curettage instrument. B, Curettage instruments in place intraoperatively. C, Subcutaneous tissue shaving instrument. D, Shaving curettage tool in place intraoperatively.

A

B

C

D

E

F

Fig. 74-10  Subdermal curettage and aspiration. A, Design. B, Incision and dissection. C, Checking the thickness of the skin. D, The instrument used for curettage and aspiration. E, Curettage and aspiration. F, Result.

K23345_Pu_c74_Crx of Osmidrosis_r2_cl_1123-1138.indd 1132

4/3/2015 1:42:38 PM

Chapter 74 

Correction of Osmidrosis

The concept of subcutaneous tissue suction is similar to that of liposuction. Apocrine glands are very fi mly attached to the dermal layer of the skin. Measures such as ultrasonic wave removal only partially remove glandular tissue, allowing regeneration of apocrine glands. Ultrasound removal can be compared with subdermal curettage and aspiration by needle biopsy after surgery. Ultrasound removal must be performed through one small hole. Ultrasound removal is not as good as subdermal shaving with the manual method, which is more effici t and permanent. Moreover, this method does not remove eccrine glands; thus it does not reduce sweating (Fig. 74-10). All three of the methods presented involve insertion of an instrument through small incisions to remove subcutaneous tissue. Subcutaneous tissue shaving provides the most complete removal of tissue, and the instrument is most reliable. Th s method is widely used. Many instruments have become available for use recently, and their surgical effects are good. However, this method has several drawbacks. The degree of shaving is not based on apocrine glands; the goal is to preserve a thin layer of skin to expose sebaceous glands on the skin’s surface. It is difficult to insert the instrument properly between fat layers and apocrine gland layers, and the instrument is not easily operated by anyone other than skilled doctors.

Postoperative Care Careful hemorrhage control is essential to the success of a procedure, regardless of surgical technique.21 It is the only way to minimize the risk of hematoma formation, infection, and related complications, such as dermonecrosis and delayed wound healing. When a large amount of skin has been detached or a considerable amount of serous secretions is produced, Penrose drains are placed and maintained for several days, until the discharge decreases. In general, hematoma or seroma development is prevented by placing compressive dressings over the axillas. The sutured axilla is covered with gauze. Th s is covered with gauze soaked in physiologic saline solution and another layer of dry gauze. The dressing is secured with size 5 white silk at 8 to 10 points around the axilla and covered with a compression bandage that is wound in a figure-of-eight pattern over the surgery sites and both shoulders (Fig. 74-11). The dressing is worn for several days postoperatively. Postoperatively, antibiotics are given for 1 week, and the dressing is worn for 5 days. Sutures are removed 1 to 2 weeks after surgery. If a hematoma is suspected, the compression dressing is unwound to allow assessment of the site and then is replaced. To minimize tension in the wound, the patient is advised to refrain from abducting the arms for several weeks. Reinnervation from the sympathetic nerves occurs approximately 6 to 12 weeks postoperatively, causing increased axillary sweating. Therefore the effectiveness of the surgery should not be determined until after this time. A

B

Fig. 74-11  A and B, Compression dressings after an osmidrosis surgery.

1133

1134

Part X 

Other Cosmetic Surgical Procedures

Results Regardless of the surgical procedure performed, most patients are satisfied with their results, which include diminished foul odor and sweating and increased self-confide ce. From January 1986 to September 2011,I treated 593 osmidrosis patients (570 bilateral sides and 23 unilateral sides, for a total of 1163 sides). Techniques included subdermal shaving, radical excision, and other instrument-assisted treatments. Complications occurred in 163 sides (14.0%). Hematomas developed in 58 sides (5.0%), wound disruption occurred in 41 sides (3.5%), skin necrosis was observed in 19 sides (1.6%), and wound infections were diagnosed in 18 sides (1.5%). Osmidrosis recurred in 24 sides (2.0%).

Fig. 74-12 Th s 14-year-old patient had osmidrosis in both axillas. A radical excision was performed. On postoperative day 10, the wound dehisced. We debrided the area and closed the wound. The incision was 1 inch long. One month after debridement, the wounds had healed and scars were evident on both axillas.

K23345_Pu_c74_Crx of Osmidrosis_r2_cl_1123-1138.indd 1134

4/3/2015 1:42:40 PM

Chapter 74 

Correction of Osmidrosis

1135

Fig. 74-13 Th s 15-year-old patient had osmidrosis in both axillas. We performed bipedicled subdermal shaving. The patient is shown 7 months postoperatively. No complications have been observed.

Fig. 74-14 Th s 23-year-old patient had osmidrosis in both axillas. We performed bipedicled subdermal shaving to correct the problem. On postoperative day 20, the skin necrosed between the incisions. We decided to allow the wound to heal by secondary intention. It takes approximately 1 month for the wound to heal completely.

K23345_Pu_c74_Crx of Osmidrosis_r2_cl_1123-1138.indd 1135

4/3/2015 1:42:41 PM

1136

Part X 

Other Cosmetic Surgical Procedures

Fig. 74-15 Th s 34-year-old patient had osmidrosis in both axillas. We performed the Inaba method. The patient is shown 12 months postoperatively. No complications have been observed.

Management of Complications The various treatment methods for osmidrosis can lead to postoperative complications, including the following: • Hematoma • Infection cyst • Skin necrosis • Wound dehiscence • Inclusion • Milia • Brachial plexus injury • Recurrence Hematoma is the most common complication. It can develop despite complete, meticulous intraoperative coagulation and is indicated by the presence of petechiae and sensory pain. If a hematoma is diagnosed, it should be drained and a compression dressing applied. The importance of restraining from activities that involve arm movements needs to be explained to all patients. To help prevent hematoma recurrence, a drain is inserted in the wound, or multiple 2 to 3 mm stab incisions are made and left open. Skin necrosis can develop if the elevated flap is too thin, if the pedicle of skin flap is small, and as a secondary effect of hematoma. Complete skin necrosis requires debridement. If necessary, a skin graft an be used to close the wound. However, skin necrosis that is less than 1 cm in diameter allows secondary intention healing after debridement. Wound disruption, infection, and scar contracture are possible complications. The wound disruption means that there is breaking of the wound margin. Scars can be tender for as long as 3 months after surgery. Scar management through steroid injection with the use of a Silastic sheet is needed for patients who have a tendency to develop keloids.

K23345_Pu_c74_Crx of Osmidrosis_r2_cl_1123-1138.indd 1136

4/3/2015 1:42:41 PM

Chapter 74 

Correction of Osmidrosis

1137

The rate of recurrence varies. It is indicated by the presence of foul odors and remnant axillary hair. Management of recurrence is guided by the following criteria: • If areas of hair are present postoperatively, manual dermal shaving locally is indicated. • If a large portion of hair is present postoperatively, repeat dermal shaving is indicated. • If severe scars or large areas of fibrotic tissue develop, radical excision is indicated.

Pearls for Success • Selection of an appropriate procedure to meet each patient’s needs is crucial to the success of the treatment. • Patients need to be thoroughly informed of the importance of postoperative compliance. • The areas peripheral to the treatment region should be adequately shaved. • Glandular tissue is completely removed from the upper flap and the soft tissue bed. • Glandular tissues embedded in the reticular dermis need to be removed. • The removal of glandular tissue converts the upper flap to a split-thickness skin flap. The healing process is the same as that of a split-thickness skin graft • Gentle manipulation is needed to prevent tissue trauma. Surgeons should practice this technique. • Establishing hemostasis is essential.

Refer ences 1. Hurley HJ, Shelley WB. A simple surgical approach to the management of axillary hyperhidrosis. JAMA 186:109112, 1963. 2. Hurley HJ, Shelley WB. Axillary hyperhidrosis. Clinical features and local surgical management. Br J Dermatol 78:127-140, 1966. 3. Sato K, Kang WH, Sato KT. Biology of sweat glands and their disorders. II. Disorders of sweat gland function. J Am Acad Dermatol 20:713-726, 1989. 4. Hwang DH, Ki Ahn KY, Park DH. The comparative study of the surgical treatment of axillary osmidrosis by Inaba’s manual and combined subcutaneous tissue shaving method. J Korean Soc Plast Reconstr Surg 20:13101316, 1993. 5. Shelley WB, Hurley HJ Jr. Studies on topical antiperspirant control of axillary hyperhidrosis. Acta Derm Venereol l55:241-260, 1975. 6. Lilis PJ, Coleman WP III. Liposuction for treatment of axillary hyperhidrosis. Dermatol Clin 8:479-482, 1990. 7. White JW. Treatment of primary hyperhidrosis. Mayo Clin Proc 61:951-956, 1986. 8. Ellis H, Scurr JH. Axillary hyperhidrosis: topical treatment with aluminum chloride hexahydrate. Postgrad Med J 55:868-869, 1979. 9. Scholes K, Crow K, Willis JP. Axillary hyperhidrosis treated with alcoholic solution of aluminum chloride hexahydrate. Br Med J 2:84-85, 1978. 10. Rayner CR, Ritchie KD, Stark GP. Axillary hyperhidrosis, 20% aluminum chloride hexahydrate, and surgery. Br Med J 280:1168, 1980. 11. Cullen SJ. Topical methenamine therapy for hyperhidrosis. Arch Dermatol 111:115 8-1160, 1975. 12. Sato K, Dobson RL. Mechanism of the antiperspirant effect of topical glutaraldehyde. Arch Dermatol 100:564569, 1969. 13. Akins DL, Meisenheimer JL, Dobson RL. Efficacy of the Drionic unit in the treatment of hyperhidrosis. J Am Acad Dermatol 16:828-832, 1987. 14. Elgart M, Fuchs G. Tapwater, iontophoresis in the treatment of hyperhidrosis. Use of the Drionic device. Int J Dermatol 26:194-197, 1987.

K23345_Pu_c74_Crx of Osmidrosis_r2_cl_1123-1138.indd 1137

4/3/2015 1:42:41 PM

1138

Part X 

Other Cosmetic Surgical Procedures

1 5. Midtgaard K. A new device for the treatment of hyperhidrosis by iontophoresis. Br J Dermatol 114:485-488, 1986. 16. Healy JE, Seybold WD, eds. Synopsis of Clinical Anatomy. Philadelphia: WB Saunders, 1969. 17. Sabatier H, Picaud AJ. The surgical treatment of axillary hyperhidrosis. J Dermatol Surg 2:331-332, 1976. 18. Shaw MH. A serious complication of an operation for axillary hyperhidrosis. Br J Plast Surg 27:196-197, 1974. 19. Jung SN, Lim JH, Kwon H, et al. Ulnar neuropathy at elbow after flap to graft conversion method for osmidrosis axillae. J Korean Soc Plast Reconstr Surg 31:249-252, 2004. 20. Atkins JL, Butler PE. Hyperhidrosis: a review of current management. Plast Reconstr Surg 110:222-228, 2002. 21. Kwon SS, Yoon HH, Jeong DS, et al. Dressing with a splint in osmidrosis. J Korean Soc Plast Reconstr Surg 31:422426, 2004.

K23345_Pu_c74_Crx of Osmidrosis_r2_cl_1123-1138.indd 1138

4/3/2015 1:42:41 PM

Index

A Abdominoplasty anatomy in, 983-984 in Asian patients, 996-997 complications in, 996-997 full, 987-989 indications for, 984-985 mini, 990-991 patient selection for, 986-987 postoperative care for, 991 preoperative assessment in, 985-987 results with, 992-995 surgical technique for, 987-991 Ablative laser therapy; see Laser therapy Accent RF, 194; see also Radiofrequency (RF) treatment Acceptance, of cosmetic surgery, 18-19 Acne active, treatment modalities for, 74-77 androgens and, 75-76, 77 antibiotics for, 77 antisymptomatic treatments for, 72 carbon dioxide laser drilling for, 77 chemical peel for, 77 inhibitory treatments for, 72 isotretinoin for, 73, 74, 75, 81 oral contraceptives for, 73, 76 retinoids for, 74-75 severity scale, 72, 73 spironolactone for, 73, 76, 82 treatment strategy for, 72-73 Acne scarring chemical peel for, 80, 82 classification of, 78-79 dermabrasion for, 79-80 fillers for, 80

laser abrasion for, 80 laser resurfacing for, 80, 93 pathophysiology of, 71-72 punch excision for, 80 retinoids for, 79 steroid injection for, 81 subcision for, 80-81 treatment of, 79-81 Acquired dermal melanocytosis (ADM), 58-59, 66 AdatoSil 5000, 99 Adhesive, 37 Adipose stromal cells (ASCs), 849 Advancement projection control suture, 570 Age eyebrow shape and, 152 mandibular contouring and, 693 in medical assessment, 3 osmidrosis and, 1125 in physical examination, 6 as risk factor, 11, 12 venous thromboembolism and, 12 Aging of Asian face, 217-220 in Asians, 264-266 bone resorption in, 265, 266 buttocks in, 1024 corrugator and, 263 early, 222 eyebrows in, 263 in forehead and brow complex, 222-223 forehead in, 264 frontal, 264-266, 267 of lower eyelid, 444-446 of midface, 278-280, 448-449 mild, 218 moderate, 218, 222 muscles in, 263, 264

I-1

I-2

Index

Aging—cont’d nasolabial folds in, 212, 220, 263 periorbital, 497-499 severe, 220, 222 tear trough in, 425-426, 428 in whites versus Asians, 220-221, 239 Alar base reduction, 593 Alar-columellar discrepancies, 580-586 Alar extension graft, 580-582, 589 Alar retraction, 580-582 Alar spreader graft, 580 Allergy(ies) chemosis and, 369 dermatitis with, 91 fillers and, 98, 99, 114 herbal supplements and, 6 in medical assessment, 3, 4 scarring and, 31, 33, 624 spironolactone and, 76 testing, 98-99, 100 Alloplastic material, 533-534 Alloplasts; see Implant(s) Alopecia androgenic, 1063-1066 in brow lift, 231, 236, 293 in forehead contouring, 674 hair transplantation for androgenic, 1063-1066 in midface lift, 303 from scarring, 1067-1068 Aluma, 191; see also Radiofrequency (RF) treatment Alveolar process, 102 American Society of Anesthesiologists (ASA) patient classification, 6-7 Androgenic alopecia, 1063-1066 Androgens, in acne, 73, 75-76, 77 Anesthesia for Botox, 152 for brow lift, open, 230-231 for endoscopic procedures, 285 in face lift, short-recovery, 253, 261 for fillers, 106-107 in genioplasty, 711 for gluteal augmentation, 1027 for laser resurfacing, 88-89 in liposuction, 1004 in mandibular contouring, 694 for orthognathic surgery, 748 for radiofrequency energy, 191 in varicose vein treatment, 1115-1116 for Woffles lift, 209 Angle(s) columellar-lobular, 576, 577, 580 columellolabial, 568, 577 nasofrontal, 557, 671

nasolabial, 557, 576, 577, 744, 745 zygomatic, 657-658, 660, 664 Angle-splitting osteotomy, 692, 693, 696-697, 700 Anterior segmental osteotomy (ASO), 752 Anterior septal angle alar retraction and, 581 nasal tip surgery and, 569, 570, 571, 587 Antibiotics, for acne, 77 Antihelical fold, 627, 630, 638 Antisocial patients, 25, 26 Apoptosis, calf reduction and, 1043-1044 APTOS thread, 203 Aquamid, 99 Arcus marginalis, 265 Areolar fascia, 276 Argiform, 99 Arms fat distribution in, 1000-1001 liposuction in, 1009 Artefill, 99 Asian patients; see also Chinese patients; Japanese patients; Korean patients; Taiwanese women abdominoplasty in, 996-997 acne scarring pathophysiology in, 71-72 aesthetic preferences of, 18 aging of, 217-220, 239, 264-266 androgenic alopecia in, 1063-1066 beauty standards and, 15-17 body mass index in, 976 breast reconstruction in, 947 breasts in, 763, 764 cephalometric point in, 660 changing ideals for, 567 chin in, 706-707 ear in, 613-618 eyelids in, 337-344 facial anatomy of, 217-218 facial proportions in, 661 facial skeleton in, 657-664 facial skeleton patterns in, 18-19 female, white versus, 764 forehead in, 225-226, 229-230 hyperpigmentation in, 54, 55 mental health and culture of, 27 midface in, 217 nasal tip in, 569 nipple in, 895 nose in, 523-524, 556, 557, 567-569 orbits in, 661 palpebral aperture in, 467 scarring in, 980 soft issues in, 664 sweating in, 1123 teeth procumbancy in, 660 undesirable features in, 151 white face versus, 150, 217, 220-221

I-3

Index

Atopic dermatitis breast augmentation and, 804 MRSA and, 625 rippled hyperpigmentation in, 56, 57, 58 scarring and, 372, 624, 803 Attractiveness, 15-17; see also Beauty Augmentation rhinoplasty, 590-591 anatomy in, 556, 557 common prostheses in, 555-556 complications in, 564-565 postoperative care for, 561 preoperative assessment for, 557, 558 results with, 562-564 surgical technique for, 558-561 Auricular boutonnière face lift, 268-270 Auricular cartilage, 541-543, 573 Autologen, 99 Autologous collagen, 99 Autologous grafts, implants versus, in rhinoplasty, 536 Avoidant personality disorder, 25, 26 Axillary anatomy, 1127 B Baldness, brow lift nd; see Alopecia Bandages, 38 Barbed-suture technology, 203-213; see also Thread lift Beauty, 15-17, 150, 239, 664-665 Bigonial distance, 172, 173, 174 Bilateral sagittal split osteotomy (BSSO), 748-750 Bimaxillary protrusion, 162, 660, 748 Bio-Alcamid, 99 Biocompatibility, 533-534 Birth control, acne and, 73, 76 Bizygomatic distance, 172 Blacks lateral crus in, 580 masseteric hypertrophy in, 156 osmidrosis in, 1123 Bleaching, 59-62, 66, 67, 68 Bleeding disorders, 11-12 Blepharochalasis, 499 Blepharoplasty; see also Eyelids; Medial epicanthoplasty; Periorbital rejuvenation asymmetry after, 343 chemosis after, 369 complications with, 341-344 corneal exposure after, 369 ectropion in, 272, 342, 343, 421, 440, 449, 455, 456, 462, 466 in face lift, 267 hematoma after, 341, 342, 368-369, 422, 440, 460, 461 hypertrophic scarring after, 370-371

infection in, 369, 370 lower, 268 anatomy in, 443-444 asymmetry after, 463 complications with, 460-463 eyelid malposition after, 440, 461 fat redistribution in, 464-466 lateral canthoplasty in, 455 lowering the lower lid (LLL) procedure in complications in, 479 eye prominence in, 472 indications for, 467, 470-471 postoperative care for, 475-476 results with, 476-479 revision surgery in, 479 surgical technique for, 472-476 tone of lower eyelids in, 471 orbital fat removal and rearrangement in, 452454 postoperative care for, 458 preoperative assessment for, 450-451 recurrence of malar festoons after, 462 results with, 459-460 scarring after, 463 skin flaps versus skin-muscle flaps in, 451 surgical options for, 450 surgical technique for, 451-458 undercorrection in, 463 in multimodal approaches, 267-268 in periorbital rejuvenation, 505-509 in short-recovery face lift, 252-253, 256-257 sunken eyelids after, 484 for tear trough deformity, 434-441 upper, 268, 345-376 blepharoptosis after, 384, 385, 388 brow lift ith, 519 buried suture method in, 346-347, 354-357, 358359, 372-373 complications with, 368-371, 378-385 fat grafting in, 375 Fernandez method in, 358-359 incision methods for, 347, 348, 358-360 indications for, 347-348 levator shortening in, 375-376 ligation sutures for adhesion induction in, 360 multiplicative deformities after, 384 nonburied suture method in, 345-347 nonincision methods for, 345-348, 352-357 partial incision methods for, 348, 360-363 postoperative care for, 363 preoperative assessment for, 348-351, 372, 378 results with, 364-368, 389-391 secondary, 377-392 subbrow resection in, 374 supratarsal depression after, 388-389 supratarsal fold asymmetry after, 380-382, 387

I-4

Index

Blepharoplasty—cont’d upper—cont’d supratarsal fold loosening after, 379-380, 386 supratarsal fold narrowing after, 382, 387 supratarsal fold widening after, 382-384, 385, 387, 390 surgical techniques for, 352-363, 386-389 suture above tarsal plate in, 352 suture through tarsal plate in, 352-353 tissue dissection for adhesion induction in, 360 width reduction in, 373-374 Blepharoptosis after blepharoplasty, 370, 384, 385, 388 aponeurotic, 407, 408 asymmetrical, 410 categories of, 407 classification of, 405-408 congenital, 410 evaluation of, 405-408 frontalis orbicularis oculi muscle flap shortening operation for, 414, 415, 416, 420 frontalis sling operation for, 413 history in, 408-410 levator aponeurosis plication for, 411-412, 417, 418 levator function measurement for, 405-407 levator in, 405-407 levator/Müller’s muscle advancement operation for, 412-413, 419 mechanical, 407 mixed, 407 myogenic, 407 neurogenic, 407 physical examination in, 408-410 severity, 406, 407 surgical correction of, 411-422 surgical correction of upper, 411-422 Blue nevus, 56, 59 Body contouring; see also Liposuction abdominoplasty in, 983-998 body image and, 975-978 body mass index and, 975-977 calf reduction in, 1041-1053 gluteal augmentation in, 1023-1038 invasiveness of, 980 patient selection in, 977-978 scarring in, 979 treatment frequency in, 980 treatment options in, 978-979 Body dysmorphic disorder (BDD), 8, 18, 23 BodyFX, 191; see also Radiofrequency (RF) treatment Body image, 975-977 Body image evaluation, 8 Body image orientation, 8 Body mass index (BMI); see also Obesity body contouring and, 975-977 as risk factor, 11

BodyTite, 189-191; see also Radiofrequency (RF) treatment Bone graft cartilage versus, 539, 540 in genioplasty, 725 in mandibular contouring, 699, 701 in midface contouring, 679, 681 in orthognathic surgery, 749, 750 in secondary cleft hinoplasty, 602 types of, 539 Bone resorption in aging, 265, 266 procedures for, 267 Borderline personality disorder (BPD), 25-26 Bossing frontal, 229, 233, 236, 668, 670, 671, 673, 674 supraorbital, 669, 673 Botulinum toxin A brow lift ith, 151, 152-155, 163 in calf reduction, 1041, 1048, 1052 complications in, 181 dilution of, 152 for facial contouring, 171-182 for facial rejuvenation and reshaping, 149-167 facial slimming with, 151, 156-159 for gummy smile, 162, 165 intradermal, 159-162 for masseteric hypertrophy, 156-158, 163, 171-172, 173-182 for mentalis strain, 162 microbotox, 159-162 in neck, 161 for parotid gland hypertrophy, 158-159, 164, 174 for periorbital rejuvenation, 509, 512 physiologic changes after, 179-180 for popply chin, 150, 151, 162, 165 problems targeted by, 267 professionals performing, 149 for submandibular gland hypertrophy, 158-159, 164 for tear trough deformity, 430-433 techniques with, 151-152 types of, 175 for undereye lines, 162 Bovine collagen, 98 Boxcar acne scar, 78-79 Boxy face, 156, 171 Breast(s); see also Nipple in Asians, 763, 764, 783-784 augmentation of, 764-765 anatomy in, 837-838 capsular contracture after, 800-801, 821 cell-assisted lipotransfer in, 849-863 complications in, 798-801 cyst formation in, 845 fat grafting in, 837-847

Index

galactorrhea after, 798 hematoma in, 775, 777, 778 implant malposition in, 830-835 indications for, 785 infection in, 777, 778, 788, 798 inframammary approach for, 803-822 malposition in, 799 patient dissatisfaction with, 846 patient selection for, 805 postoperative care for, 816 preoperative assessment for, 805-814, 838 results with, 794-798, 817-820, 841-844 rippling with, 820 rupture of implants in, 799 scarring in, 803-804 transmaxillary approach for, 783-801 in mastopexy, 765 measurements, 786 in physical examination, 7 reconstruction, 766-768 anatomy in, 911-914, 931-933 in Asian patients, 947 complications in, 923-927, 928-929, 942-944, 957-959 contraindications for, 915 contralateral balancing procedures in, 958 delayed, 948, 954 fat necrosis in, 928 hematoma in, 957 immediate, 948 with implants, 947-959 indications for, 914-915, 933-934 infection in, 923, 958 in irradiated breast, 949 mastectomies and, 948 nipple-areola reconstruction in, 961-971 nipple reconstruction in, 959 patient satisfaction with, 924 postmastectomy radiation and, 949-950 postoperative care for, 923, 938, 954 preoperative assessment for, 915, 934-935 results with, 923-927, 938-942, 954-957 surgical technique for, 916-922, 935-938, 950-954 reduction, 765-766 anatomy in, 881-882 complications in, 892 hematoma in, 892 indications for, 882-883 inframammary fold in, 883, 884, 886, 893 markings in, 884-885 medial pedicle, 881-893 patient selection for, 882-883 postoperative care for, 887 preoperative assessment for, 883-884 results with, 887-891 surgical technique for, 885-887

shape, 783 size of, 784 symmetry, 784 Breast cancer, 766-767; see also Breast(s), reconstruction Breast footprint, 786 Breast-soft issue envelope, 785-786 Brow; see also Eyebrows in aging, 263 position, 225-226 tattoos, 501 Brow-eyelid complex, 226 Brow lift; see also Periorbital rejuvenation alopecia after, 293 with Botox, 151, 152-155, 163 dysesthesia in, 228 endoscopic, 285-294 hematoma in, 236, 237 open, 225-237 anatomy in, 226-228 anesthesia in, 230-231 complications with, 236 fixation points in, 233 hair control in, 230, 231 indications for, 228 postoperative care for, 234 preoperative assessment for, 229-230 results with, 235 revision, 237 surgical technique for, 230-234 pruritus in, 293 with upper blepharoplasty, 518, 519 Brow ptosis, 499, 510 Bruxism, 171 Buccal branch, of facial nerve, 281 Buccal fat, 220 Buccinator, 102, 705 Bulbospongiosus muscles, 1093, 1094 C Calf reduction anatomy in, 1042-1045 biochemistry in, 1043-1044 complications in, 1052 contraindications for, 1045 indications for, 1045 methods, 1041 patient selection in, 1046 postoperative care for, 1047 preoperative assessment for, 1045-1046 results with, 1047-1051 revision surgery, 1052 selective neurectomy in, 1046-1057 Calprotectin, 823-824 Calvarial bone, in secondary cleft hinoplasty, 602

I-5

I-6

Index

Canthal tilt, 468, 470 Canthoplasty, lateral, 455 Capsular contracture, in breast augmentation classification of, 824 indications for treatment of, 825 in inframammary approach, 821 pathophysiology of, 823-824 posterior capsulectomy for, 827 results with treatment of, 827-829 in transaxillary approach, 800-801 Capsulopalpebral fascia (CPF), 469 Capsulopalpebral ligament, 443 Capsulopalpebral repair, 456, 457 Carbon dioxide laser drilling, for acne, 77 Cardiovascular conditions, as risk factor, 11 Cartilage; see also Lateral cartilages diced absorption of, 540 complications with, 531 dorsal augmentation with, 526, 528, 530, 591, 602 in secondary cleft rhinoplasty, 602-603, 605 for short nose, 592 for warped cartilage graft, 552 harvesting, 541-543, 545 in nose, 524 in rhinoplasty, 524-525 Cartilage graft in otoplasty, 642-643, 646-649, 651 in rhinoplasty advantages of, 540 auricular, 541-543, 573 costal, 545 implants versus, 539-540 secondary cleft, 601, 602-603 septal, 544-545 warping of, 552-553 Caudal rotation graft, 573-574, 587 Caudal septal hypoplasia, 583-584 Cell-assisted lipotransfer (CAL), in breast augmentation adipose stromal cells and, 849 complications in, 862-863 indications for, 850-852 postoperative care for, 858 preoperative assessment for, 852-853 results with, 858-861 surgical technique for, 853-857 Central necrosis, 130, 133 Cephalometric point, 660 Cervical point, 319 Cervicomental angle, 319 Cheek, drooping, 446, 447 Cheekbones, high, 218, 298, 658, 677 Cheek droop, in midface contouring, 688 Cheek ptosis, 449 “Cheese-wiring,” 204

Chemical peel for acne, 77 for acne scarring, 80, 82 Chemosis, 369, 479 Chin; see also Genioplasty analysis of, 705-710, 739 angular, 710 in appearance, 703 blunt, 710 broad, 710 in Chinese patients, 709 deformity classification, 706 in mandibular contouring, 693 pear-shaped, 710 pointed, 710 popply, 150, 151, 162, 165 shapes, 710 trapezoid, 710 Chin augmentation; see also Genioplasty in facial rejuvenation, 223 implants in, 731 indications for, 732 in multimodal approaches, 270 preoperative assessment for, 732 results with, 734-735 surgical technique for, 732-734 Chinese patients body mass index in, 976 breast reconstruction in, 970 breast reduction in, 889, 890, 891 chin in, 709 Confucian morality and, 337 ear in, 628 epicanthal folds in, 395 face width in, 661 facial aging in, 218 hymenorrhaphy in, 1077, 1082, 1083 ideas of beauty in, 15-16 masseteric hypertrophy in, 156 neck rejuvenation in, 327, 331, 332 teeth procumbancy in, 660 temple augmentation in, 118 Chin protrusion, dermal fillers and, 101 Chin ptosis, after genioplasty, 726 Chloasma, 56, 58 Chondritis, in otoplasty, 637 Chondroitin, 6 Chronic progressive external ophthalmoplegia (CPEO), 406 Cicatricial lower eyelid bowing, 462 Classic face lift; see Face lift, classic Cleft ar, 619, 620 Cleft ip, in secondary cleft hinoplasty, 596, 597 Cleft rhinoplasty, secondary complications in, 608 indications for, 596

Index

lining deficiency in, 599-600 pathology in, 595 postoperative care for, 605 results with, 606-607 surgical technique for, 597-605 Closed approach; see Endoscopic procedures Cohesive gel implants, 780 Collagen in acne scarring, 71 in capsular contracture, 824 as dermal filler, 98, 99 fillers, 106 injections, 166 in laser skin resurfacing, 86, 87, 89, 92 in radiofrequency treatment, 184, 185, 188, 192, 195, 200 in varicose vein treatment, 1114 Collagenase, 849, 850, 854, 856 Columellar-lobular angle, 576, 577, 580 Columellar retraction, 583-584, 585-586, 589 Columellar-septal suture, 571, 572 Columellolabial angle, 568, 577 Compensated brow ptosis, 229-230 Complications in abdominoplasty, 996-997 in augmentation rhinoplasty, 564-565 in blepharoplasty, 341-344 lower, 460-463 upper, 368-371, 378-385 with Botox, 181 in breast augmentation, 798-801 in breast reconstruction, 923-927, 928-929, 942-944 in breast reduction, 892 in brow lift endoscopic, 292-293 open, 236 in calf reduction, 1052 in cell-assisted lipotransfer, for breast augmentation, 862-863 in cleft hinoplasty, secondary, 608 in face lift classic, 246, 250-251 short-recovery, 261 with fillers, 114 in forehead contouring, 674 in genioplasty, 724-727 in gluteal augmentation, 1032, 1036-1037 in hair transplantation, 1074 in hymenorrhaphy, 1083 in laser resurfacing, 91-93 in lowering of lower lid, 479 in mandibular contouring, 700 in mastopexy, 879-880 in midface contouring, 688 in midface lift, endoscopic, 303

in multimodal approaches, 272 in neck lift, 327 in nipple surgery, 907-908 in osmidrosis treatment, 1137 in otoplasty, 637-638, 645, 650, 652 in penile enhancement, 1108 in ptosis correction, 421-422 reoperations and, 45-46 in rhinoplasty, 531-532 in sunken eyelid correction, 491-492 in tear trough deformity correction, 433-434, 439, 440 in thread lift, 212-213 in varicose vein photocoagulation, 1120-1121 in Woffles lift, 212-213 Compression therapy, for scars, 40 Conchal defect, in prominent ears, 633 Conchal mastoid sutures, 633 Conchal outline curve, 616 Consultation plastic surgery, 9-10 psychiatric, 27 Contact dermatitis pigmented, 57, 58, 67 with surgical tape, 38 Contouring; see Facial contouring Contraceptives acne and, 73, 76 breast augmentation and, 851 as risk factor, 12 spironolactone and, 73, 82, 83 Controlling patients, 25, 26 Corneal exposure, after blepharoplasty, 369 Corrugator in aging, 263, 264 brow lift nd, 153, 154, 155, 226, 232 in facial anatomy, 102, 227 in forehead lift, 268 forehead rhytids and, 103 hypertrophy, 503 in transblepharoplasty, 267 Corset platysmaplasty, 322-323 Corticosteroids, for scarring, 40 Cosmetic surgery, acceptance of, 18-19 CosmoDerm, 98 CosmoPlast, 98 Costal cartilage, 545, 554 Covering test, 410 Cranial vault, 657, 658 Crosshatching, in filler injection, 108, 1007, 1028 Crow’s feet, 223, 264 Cryotherapy, for scars, 41 Cryptotia, 621, 646-650 Culture beauty and, 15-16, 17, 239 cosmetic surgery and, 18-19

I-7

I-8

Index

Culture—cont’d hymen rupture and, 1077 mental health and, 27 Cupid’s bow, fillers for, 106 Cymetra, 99 Cyproterone acetate, 76 D Dark circles, 446 Deep temporal fascia, 276, 277 Deep vein thrombosis (DVT) body mass index and, 11 risk of, 12 varicose veins and, 1111 Dependent personality disorder, 25, 26 Depressor anguli oris, 102, 704, 705 Depressor labii inferioris, 102, 704, 705 Depressor septi nasi, 705 Depressor supercilii in anatomy, 227, 498 brow lift nd, 154, 498 Dermabrasion, for acne scarring, 79-80 Dermal fat grafting, for sunken eyelids, 492-493 Dermal fillers; see Fillers Dermal graft in gluteal augmentation, 1038 for sunken eyelids, 495 Dermal hyperpigmentation; see Hyperpigmentation Dermatitis allergic, 91 atopic breast augmentation and, 804 MRSA and, 625 rippled hyperpigmentation in, 56, 57, 58 scarring and, 372, 624, 803 hydroquinone, 60 pigmented contact, 57, 58, 67 retinoid, 60, 62, 69, 74, 83 seborrheic, 72, 73, 76 with surgical tape, 38 varicose veins and, 1111 Dermatochalasis, 499 “Diablo” eff ct, 160 Diced cartilage absorption of, 540 complications with, 531 dorsal augmentation with, 526, 528, 530, 591, 602 in secondary cleft rhinoplasty, 602-603, 605 for short nose, 592 for warped cartilage graft, 552 Digastric, 704, 705 Diplopia, 460 Divergence control technique, 715 Diver’s test, 985 Dolichocephaly, 18

Dolphin-shaped infrabrow excision, 252-253, 256-257 Dorsal augmentation, 530-531 in secondary cleft rhinoplasty, 602-603 Dorsal deficiency, 530 Double eyelid folds, 337-338, 339, 340, 342, 347, 360 Dressings, 37, 1073 Dry eye, in blepharoplasty, 340, 369, 460 Drysol, 1126 Duration, of surgery, 12-13 Dysesthesia in brow lift, 228, 292 in gluteal augmentation, 1037 in midface lift, 303 in otoplasty, 638 Dysmorphophobia, 1101 Dyspareunia, 1087 E Ear(s); see also Auricular cartilage; Otoplasty anatomy, 613-618, 627-628, 641, 646, 650 in Chinese patients, 628 cleft, 619, 620 constricted, 622, 641-645 cup, 622, 641-645 expected outcomes with, 623 hidden, 621, 646-650 infection of, after surgery, 625 lobular shape in, 616, 618 location of, 615 lop, 622, 641-645 piercing, 618, 619 prominent, 620, 627-639 proportions of, 614, 628 scarring of, 624-625, 637 shape, 616-618 special considerations with Asian, 613-625 Stahl’s, 621, 650-652 subtle deformities of, 620-622 Early aging, 222; see also Aging Echinacea, 6 Ectropion, 343, 462, 465 in blepharoplasty, 272, 342, 343, 421, 440, 449, 455, 456, 462, 466 in laser skin resurfacing, 89, 91, 93 senile, 342 E-line, 707-708 eMatrix, 192-193, 194; see also Radiofrequency (RF) treatment Endoscopic procedures anatomy in, 275-283 anesthesia for, 285 brow lift, 285-294 forehead contouring, 670-671 instrumentation for, 283-285 midface lift, 295-304

Index

neck lift, 305-314, 328-333 rhinoplasty, 555-566 open versus, 528-529, 590 Endovascular laser photocoagulation (EVLP), for varicose veins, 1111 -1121 EndyMed PRO 3Deep, 191; see also Radiofrequency (RF) treatment Enophthalmos, 264, 265 Entertainment industry, 16-17 Entropion, 479 Ephedra, 6 Ephelides, 56, 58, 59 Epicanthal fold, 339; see also Medial epicanthus Epicanthoplasty, medial, 395-403 Epigastric arteries, 911, 912, 913 Epilepsy, 185 Epiphora, 369, 460 ePrime, 196; see also Radiofrequency (RF) treatment Eruption granuloma, with dermal fillers, 114 Erythromelanosis follicularis faciei et colli, 56 Eumelanin, 53, 55 Eutectic mixture of local anesthetics (EMLA), 88 Evaluation for dermal fillers, 100-101 medical assessment in, 3-7 preoperative assessment in, 7 psychological assessment in, 22-23 psychosocial assessment in, 8 Evolence, 105 Exophthalmos, 472 Expanded polytetrafluoroethylene (ePTFE); see also Gore-Tex hard versus soft, 540 in rhinoplasty, 535, 537 Expectations, patient, 21-23, 675, 785, 980, 1025 Exposure keratopathy, 461 Extraocular muscle disorder, 460 Extremities; see also Arms; Legs fat distribution in, 1000-1001 in physical examination, 7 Eyebrows; see also Brow in aging, 263 reconstruction of, with hair transplantation, 10681069 Eyelash restoration, 1070-1072 Eyelid folds; see also Epicanthal fold dermal fillers and, 101 infold, 349 outfold, 349 Eyelids; see also Blepharoplasty in aging, 263, 444-446, 447 Asian aesthetic preferences with, 18 in Asians, 337-344 bags in, 264, 265, 446, 502 secondary, 462 dermal fillers and, 101

double folds in, 337-338, 339, 340, 342, 347, 349, 360 fillers in, 103 lower, 339, 340, 341 lowering of lower, 467-480 lower margin, 468-469 lower retractors, 470 medial epicanthoplasty in, 395-403 in physical examination, 7 preoperative assessment of, 340-341 sunken, 483-495 in whites versus Asians, 338 Eyelids, in facial rejuvenation, 223 Eye prominence, 472, 473, 662 Eye protection, 85 Eyes; see Periorbital F Face, in physical examination, 7 Face lift in 1970s, 248 in 1980s, 248, 249 in 1990s, 248 in 2000s, 249 in 2010s, 249 auricular boutonnière, 268-270 classic anatomy in, 239 complications with, 246 cultural considerations with, 239 indications for, 240 postoperative care for, 243 preoperative assessment for, 240-241 results with, 244-245 surgical technique for, 241-243 complications with, 247, 250-251 endoscopic midface, 295-304 evolution of, in Japan, 247-249 hematoma in, 244, 246 lower, endoscopic, 305-314 in multimodal approaches, 268-270 neck lift ombined with, 323 problems targeted by, 267 scarring from, 247 short-recovery anesthesia in, 253, 261 blepharoplasty in, 252-253, 256-257 complications with, 261 excess skin in, 255, 261 feathering in, 254 indications for, 251 liposuction in, 254 marking for, 251 preoperative procedure in, 251-253 results with, 258-261

I-9

I-10

Index

Face lift—cont’d short-recovery—cont’d superficial musculoaponeurotic system rhytidectomy in, 254-255 surgical technique for, 254-257 suturing in, 255 undermining in, 251-252, 254 subperiosteal, 682, 687 temporal problems after, 250-251 undermining in, 248, 250-251 Facial asymmetry, orthognathic surgery and, 748 Facial contouring; see also Facial rejuvenation anatomy in, 172 Botox for, 171-182 fat grafting for, 117-126 forehead contouring in, 667-675 hematoma in, 674 indications for, 117, 118 mandibular contouring in, 691-701 masseteric hypertrophy in, 173-182 midface contouring in, 677-689 postoperative care for, 121 preoperative assessment for, 118 surgical technique for, 119-121 Facial feminization surgery (FFS), 671, 675 Facial index, 661 Facial nerve in anatomy, 227, 228, 280-281 in brow lift, open, 231, 236 in face lift, classic, 246 in neck lift, endoscopic, 313 Facial palsy, 501 Facial proportions, 661, 706-707 Facial rejuvenation; see also Facial contouring; Periorbital rejuvenation anatomy in, 172, 217-218 botulinum toxin A for, 129-146 classic face lift or, 239-246 combination approaches for, 222-223 common approaches in, 221-223 in eyelids, 223 fat graft or, 129-146 in forehead and brow complex, 222-223 indications for, 266 in lower face, 223 in midface, 223 in neck, 223 in periorbital region, 223 preoperative assessment for, 221 radiofrequency energy for, 183-201 special considerations in, 217-224 thread lift or, 203-213 Facial skeletal augmentation asymmetry after, 738 chin augmentation in, 732-735 implant materials in, 729-731

orthognathic surgery in, 743-758 temporal augmentation in, 735-737 Facial skeletal patterns, 18-19 Facial skeleton appearance and, 662-664 common procedures for, 665-666 forehead contouring in, 667-675 mandibular contouring in, 691-701 midface contouring in, 677-689 proportions in, 661 in whites versus Asians, 657-664 Facial slimming, with Botox, 151, 156-159 Facial symmetry, 744 Facial vectors, 207 Family, 9 Fanning, in filler injection, 108 Fat distribution tendencies, 999-1001 Fat embolism, in fat grafting, 126 Fat graft; see also Cell-assisted lipotransfer (CAL); Dermal fat grafting; Microautologous fat transplantation (MAFT) in blepharoplasty, upper, 375 in breast augmentation, 837-847 in breast surgery, 765, 769 for facial contouring, 117-126 in gluteal augmentation, 1026-1032, 1037 harvesting, 120, 491, 839 hematoma in, 121 indications for, 118 microautologous fat transplantation versus, 132, 133 postoperative care for, 121 preoperative assessment for, 118 problems targeted by, 267 for sunken eyelids, 488-491 in superficial musculoaponeurotic system later, 118 surgical technique for, 119-121 swelling with, 132, 133 for tear trough deformity, 431, 433 for total facial rejuvenation, 129-146 Fernandez method, 358-359 Fillers for acne scarring, 80 allergic reaction to, 114 anatomical landmarks used with, 101, 102 anatomy with, 101-102 areas targeted with, 103-106 for asymmetry correction, 106 complications with, 114 contraindications for, 100 crosshatching in injection of, 108, 1007, 1028 for Cupid’s bow, 106 demand for, 97 eruption granulomas for, 114 evaluation for, 100-101 eyelids and, 101 fanning in injection of, 108

Index

in forehead, 103 in gluteal augmentation, 1038 injection techniques for, 107-109 for labiomental rhytids, 104 linear threading in injection of, 108 for lip augmentation, 105-106 in lower face, 104 in malar region, 104, 111 microthreading in injection of, 109 in midface, 104 midface flatness and, 101 in nasal tip, 104 in nasolabial folds, 104, 110, 111 naturally derived, 98-99 necrosis with, 114 nerve blocks and, 107 for perioral lines, 105 in periorbital region, 103 for periorbital rejuvenation, 510 permanent, 98 in philtral columns, 106 postoperative care for, 109 for prejowl sulci, 105 preoperative assessment for, 100-101 properties of various, 98-99 pyramidal injection of, 109, 112 semipermanent, 98 serial puncture in injection of, 108 for sunken eyelids, 495 synthetic, 99 for tear trough deformity, 430-433, 441 in temple hollows, 103, 110 temporary, 98 Tyndall eff ct with, 114 in upper face, 103 Financial considerations, of reoperations, 49 Financial responsibility, of patient, 10 Fitzpatrick skin types, 186 Flutamide, 76 Flying-bird incision, 590 Foams, 38 Follicular-unit grafts, 1058-1062 Forehead; see also Brow lift in aging, 264 in Asian face, 225-226 fillers in, 103 high, 229 microbotox in, 161 in white face versus Asian face, 229-230 Forehead and brow complex, 222-223 Forehead contouring anatomy in, 667-668 complications in, 674 endoscopic, 670-671 in gender reassignment, 669, 671, 674 indications for, 668

open, 669-670 patient expectations and, 675 preoperative assessment for, 668-669 results with, 672-674 surgical technique for, 669-671 Forehead lift in multimodal approaches, 267-268 problems targeted by, 267, 272 Foreign bodies, 33 Form, history and physical examination, 4-5 Fractora, 195; see also Radiofrequency (RF) treatment Friction melanosis, 56, 58 Frontal analysis, of chin, 709-710 Frontal bone in brow lift, 233, 236 in facial anatomy, 102 Frontal bossing, 229, 233, 236, 668, 670, 671, 673, 674 Frontal eminence, 668 Frontalis in aging, 264, 499 in anatomy, 227 brow lift nd, 152, 153, 155, 226, 228, 232, 498 Frontalis sling operation, 413 Frontal nerve, 282 G Galactorrhea, 798 Galea, 228 Galeal plane, 279 Garlic, 6 Garments, 38 Gel sheets, 38, 40 Gender reassignment, forehead contouring in, 669, 671, 674 geneO+, 191; see also Radiofrequency (RF) treatment Genioglossus, 704 Geniohyoid, 704 Genioplasty; see also Chin augmentation advancement, 712-714 anatomy in, 703-705 complications in, 724-727 hematoma after, 724 labiomental sulcus deepening after, 724 mentalis overaction after, 724 narrowing, 721-723 neurosensory deficits after, 724 preoperative assessment in, 705-710 reduction, 718-720 setback, 715-717 step deformities after, 724-725 surgical technique for, 711-712 Genitalia, pigmented external, 56; see also Penile enhancement; Vaginal rejuvenation Ginkgo biloba, 6

I-11

I-12

Index

Ginseng, 6 Glabella in brow lift, 232 in facial anatomy, 102 Glogau classification of photoaging, 187 Glucosamine, 6 Glucose transport test (GTET), 837 Gluteal augmentation anatomy in, 1023-1024 complications in, 1032, 1036-1037 dermal grafting in, 1038 fat grafting in, 1026-1032, 1037 fillers in, 1038 hematoma in, 1037 implants in, 1033-1037, 1037-1038 indications for, 1024 preoperative assessment for, 1024-1025 results with, 1030-1032, 1036 sutures in, 1038 Gluteal lift, 1038 Golden point, 557 Goldenseal, 6 Gonial angle, 174 Gore-Tex, 529, 535, 537, 730-731 Graft alar extension, 580-582, 589 alar spreader, 580 bone cartilage versus, 539, 540 in genioplasty, 725 in mandibular contouring, 699, 701 in midface contouring, 679, 681 in orthognathic surgery, 749, 750 in secondary cleft hinoplasty, 602 types of, 539 cartilage in otoplasty, 642-643, 646-649, 651 in rhinoplasty advantages of, 540 auricular, 541-543, 573 costal, 545, 554 implants versus, 539-540 secondary cleft, 601, 602-603 septal, 544-545 warping of, 552-553 caudal rotation, 573-574, 587 dermal in gluteal augmentation, 1038 for sunken eyelids, 495 fat in breast augmentation, 837-847 in breast surgery, 765, 769 in gluteal augmentation, 1026-1032, 1037 hematoma in, 121 for sunken eyelids, 488-491

harvesting of auricular cartilage, 541-543 in cell-assisted lipotransfer, 852, 862 of costal cartilage, 545, 554 in fat grafting, 120, 491, 839, 1027 hematoma in, 543, 545 in microautologous fat transplantation, 135-136 of septal cartilage, 545 septal extension, 575-579, 587-588 Granulomas; see also Infection in blepharoplasty, 360 in breast augmentation, 798 in chin augmentation, 738, 739 with fillers, 114 nontuberculous mycobacterial, 798 in otoplasty, 637 silicone fluid and, 535 with thread lifts, 212, 213 Great auricular nerve, 241 Greater saphenous vein (GSV), 1112, 1116-1117 Gummy smile, 162, 165 H Hair transplantation anatomy in, 1057 for androgenic alopecia, 1063-1066 complications in, 1074 for eyebrow restoration, 1068-1069 for eyelash restoration, 1070-1072 for mustache reconstruction, 1072-1073 postoperative care for, 1073 surgical technique for, 1058-1062 Harvesting of auricular cartilage, 541-543 in cell-assisted lipotransfer, 852, 862 of costal cartilage, 545, 554 in fat grafting, 120, 491, 839, 1027 hematoma in, 543, 545 in microautologous fat transplantation, 135-136 of septal cartilage, 545 Healing; see also Scarring foreign bodies and, 33 in laser resurfacing, 87 mechanical forces and, 31-32 mechanisms of, 31-33 moisture and, 31 techniques for, 37-38 Heart disease, 185 Helix-lobule curve, 616, 622, 623 Hematoma in blepharoplasty, 341, 342, 368-369, 422, 439, 460, 461 in breast augmentation, 775, 777, 778 in breast reconstruction, 957

Index

in breast reduction, 892 in brow lift, 236, 237 in cartilage harvesting, 543, 545 in endoscopic procedures, 313 in face lift classic, 244, 246 short-recovery, 246 in facial contouring, 674 in fat grafting, 121 in flap harvesting, 928 in genioplasty, 724 in gluteal augmentation, 1037 in mandibular contouring, 700 in orthognathic surgery, 755 in osmidrosis surgery, 1134, 1137 in otoplasty, 634, 637, 647, 648, 650 revision surgery and, 47 in rhinoplasty, 605, 608 sequelae of, 48 in varicose vein treatment, 1121 Hemifacial atrophy, 118, 124 Herbal supplements, 6 Herpes, laser resurfacing and, 91 Herring’s law, 406 “High cheekbones,” 218 High-density polyethylene (HDPE); see Medpor History in medical assessment, 3, 4-5 in ptosis evaluation, 408-410 Histrionic patients, 24-25 Huang technique, 457 Human-derived collagen, 98 Hyaluronic acid, as dermal filler, 98 Hydrogel polymers, 99 Hydroquinone for acne scarring, 81 for hyperpigmentation, 59-62, 64, 65, 66, 67 Hydroxyapatite, 731 Hylaform, 98 Hymenorrhaphy anatomy in, 1077-1079 complications in, 1083 culture and, 1077 indications for, 1079 postoperative care for, 1082 preoperative assessment for, 1079 results with, 1082-1083 surgical technique for, 1079-1081 Hyperkeratosis in acne, 72 in laser skin resurfacing, 85 laser therapy for, 64, 69 in senile lentigines, 56, 57, 63

Hyperpigmentation in Asians, 54, 55 categorization of, 55-59 diagnosis of, 55 hydroquinone for, 59-62, 64, 65, 66, 67 laser therapy for, 62-63, 64, 65, 66 mechanism of, 53-54 oral medications for, 63 pathophysiology of, 53-55 retinoids for, 59-62, 64, 65, 66, 67 therapeutic strategy in, 64-65 treatment of, 60-69 Hypesthesia in genioplasty, 703 in otoplasty, 638 I Ice pick acne scar, 78-79 Implant(s) in augmentation rhinoplasty, 555-556 biocompatibility of, 533-534 breast, 771-781, 783-801, 803-822, 830-835 in breast reconstruction, 767-768 breast reconstruction with, 947-959 in chin augmentation, 731, 732-735 expanded polytetrafluoroethylene, 535 in facial skeletal augmentation, 729-740 gluteal, 1033-1037, 1037-1038 Gore-Tex, 730-731 hydroxyapatite, 731 infection and, 534, 535, 536, 537, 539, 540, 777 materials, 529, 555-556, 729-731 Medpor, 529, 535-536, 537, 540, 556, 730 in rhinoplasty, 529-530 autologous grafts versus, 536 contraction of, 539 disadvantages of, 539-540 expanded polytetrafluoroethylene, 535, 537 materials for, 533-538 maxillary spine, 585-586, 589 Medpor, 535-536, 537 silicone, 534-535, 537 shortcomings of, 530 silicone, 730, 771-773, 774, 775-780 in temporal augmentation, 735-737 Inclusion cyst, 342, 343, 369 Infection; see also Granulomas in blepharoplasty, 369, 370 in breast augmentation, 777, 778, 788, 798 in breast reconstruction, 923, 958 capsular contracture and, 821, 824 in facial skeleton augmentation, 738 with fillers, 114

I-13

I-14

Index

Infection—cont’d in gluteal fat grafting, 1032 Gore-Tex implants and, 535, 540 implant size and, 534 in laser skin resurfacing, 91, 93 in mandibular contouring, 700 Medpor implants and, 536 in osmidrosis treatment, 1134 in otoplasty, 625, 637 reoperation and, 48 in rhinoplasty, 532, 539, 540, 591, 593 scarring and, 33 silicone implants and, 537, 539, 777 in thread lift, 213 Inferior alveolar artery, 704 Inferior alveolar nerve, 691-692, 703 Inferior epigastric artery, 911-913, 932 Inferior scleral show, 462 Inferior temporal adhesion, 279 Inferior temporal septum, 227, 276, 277 Infini, 196; see also Radiofrequency (RF) treatment Infracartilaginous incision, 559, 560 Inframammary fold (IMF) in breast augmentation, 783 in breast reconstruction, 917, 928, 948 in breast reduction, 883, 884, 886, 893 in mastopexy, 865 in physical examination, 7 Infratrochlear nerve, 282-283 Intercartilaginous incision, in augmentation rhinoplasty, 558-559 Interfall, 99 Intermediate temporal fascia, 276, 277 Interview, preoperative, 22 INTRAcel, 196; see also Radiofrequency (RF) treatment IntraGen, 194; see also Radiofrequency (RF) treatment Inverted nipple, 900-908 Iontophoresis, for osmidrosis, 1126 I-shaped implant, 556, 558, 561, 562, 563, 590, 591 Isotretinoin, for acne, 73, 74, 75, 81 J Japan, evolution of face-lift urgery in, 247-249 Japanese patients acne in, 75, 81, 82 acquired dermal melanocytosis in, 66 aesthetic preferences of, 18 body mass index in, 976 chin in, 709 Confucian morality and, 337 cryptopia in, 646 epicanthal folds in, 395 face lifts in, 249 ideals of beauty in, 15-16, 18

masseteric hypertrophy in, 156 nipple hyperpigmentation in, 68 osmidrosis in, 1123 pigmented contact dermatitis in, 67 scarring in, 33 solar lentigines in, 66 spironolactone allergy in, 75 testosterone in, 75 Jawline, microbotox in, 161 Jaw surgery bimaxillary protrusion in, 748 facial asymmetry in, 748 hematoma in, 755 indications for, 746-748 mandibular prognathism in, 746-747 postoperative care for, 753-754 preoperative assessment for, 743-745 results with, 754-757 smile arc and, 744-745 surgical planning for, 745-746 surgical technique for, 748-753 Jowls in aging, 212, 218, 220, 222 Botox for, 161 face lift nd, 243 neck lift nd, 305 procedures for, 267 Woffles lift or, 209, 210, 212 Juvéderm, 98 K Kava, 6 Keloid; see also Scarring in acne scarring, 78-79 in Asians versus whites, 868, 1063 in ear surgery, 624-625, 637 skin type and, 186 sutures and, 34 Key line, 616 Korean patients aesthetic preferences of, 16, 18 blepharoplasty skin excision in, 505 body mass index in, 976 breast reduction in, 888 cephalocaudal width in, 580 Confucian morality and, 337 epicanthal folds in, 395 eyelid width in, 350 hymenorrhaphy in, 1077 masseteric hypertrophy in, 156, 157 mean bigonial distance in, 172 nasal inclination in, 101 nasal length in, 576 nasal skin-soft issue envelope in, 568 nostrils in, 568

Index

osmidrosis in, 1123 philtral length in, 576 plastic surgery utilization in, 16 tip projection in, 576, 577 zygoma in, 19 zygomatic reduction in, 666 L Labia, ideal, 1085 Labial hypertrophy, 1086 Labial reduction anatomy in, 1085-1086 central deepithelialized reduction labioplasty in, 1088 indications for, 1086-1087 inferior V-shaped resection in, 1087 ninety-degree Z-plasty in, 1088-1089 postoperative care for, 1089 preoperative assessment for, 1087 results with, 1089-1090 revision surgery in, 1091 Labiomental rhytids, fillers for, 104 Labiomental sulcus, 724 Lactating duct, 907-908 Lamellae, in lower eyelid, 469 Landmarks, anatomical, with dermal fillers, 101, 102 Laser resurfacing ablative, 89-90 for acne scaring, 80, 93 anesthesia for, 88-89 complications with, 91-93 contraindications for, 87 equipment for, 85-87 healing in, 87 histologic changes in, 91-92 indications for, 87-88 nerve block in, 88, 89 postoperative care for, 91 preoperative assessment for, 88 rhytid shoulders in, 90 surgical technique for, 89-90 Laser therapy; see also Endovascular laser photocoagulation (EVLP); Pulsed dye laser ablative for acne scarring, 80 for hyperpigmentation, 63, 64 types of, 86 carbon dioxide, drilling, for acne, 77 Q-switched for hyperpigmentation, 62-63, 64, 65, 66 for scarring, 41 Lateral canthoplasty, 455

Lateral cartilages in rhinoplasty assessment, 557 in secondary cleft hinoplasty, 598, 600, 601, 603 in secondary rhinoplasty, 576 Lateral orbital osteotomy, 679, 680 Lateral pterygoid, in facial contouring, 172 Lateral scleral triangle, 469 LeFort I osteotomy, 750-752 Legal considerations, 13 Legs calf reduction in, 1041-1053 fat distribution in, 1000-1001 ideal, 1042 liposuction in, 1010 varicose veins in, 1108-1121 Lentigo simplex, 56, 58 Levator, in ptosis, 405-407 Levator aponeurosis plication, 411-412, 417, 418 Levator labii superioris, 102, 435, 705 Levator labii superioris alaeque nasi, 102, 705 Levator/Müller’s muscle advancement operation, 412413, 419 Levator palpebrae, in aging, 265 Levator shortening, 375-376 Lichen pilaris, 56 Lid-cheek junction, 426-427; see also Tear trough deformity Lid distraction test, 471 Lifting test, 410 Linear threading, in filler injection, 108 Lip augmentation, 105-106 Liponecrotic cyst, in breast augmentation, 845 Liposuction anesthesia in, 1004 in arms, 1009 cannula in, 1006 contour irregularities after, 1018 fat distribution and, 999-1001 indications for, 1001-1002 in legs, 1010 in neck, 319, 320 postoperative care for, 1011 preoperative assessment for, 1002-1003 results with, 1012-1017 surgical technique for, 1003-1008 treatment modalities, 978 tumescent solution in, 1004-1006 Lip protrusion dermal fillers and, 101 facial skeleton and, 662 Lockwood suspensory ligament, 444, 498 Lower face, in facial rejuvenation, 223 Lowering the lower lid (LLL) complications in, 479 eye prominence in, 472

I-15

I-16

Index

Lowering the lower lid (LLL)—cont’d indications for, 467, 470-471 postoperative care for, 475-476 results with, 476-479 revision surgery in, 479 surgical technique for, 472-476 tone of lower eyelids in, 471 Lower lid retractors, 470 M Macrogenia, 706 Makeup, for scars, 41, 42 Malar bone, 472, 473 Malar eminence, 220, 239 Malar highlights, 221 Malarplasty, 677; see also Midface contouring Malar region, fillers in, 104, 111 Malar retrusion, 446 Male pattern baldness, brow lift nd, 230; see also Alopecia Malpractice claims, 13 Mammaplasty augmentation, 764-766 inframammary approach for, 803-822 transaxillary approach for, 783-801 reduction, 765-766 medial pedicle, 881-893 Mandible, 102, 172 Mandibular angle, 171, 220, 691, 692 Mandibular canal, 703, 704 Mandibular contouring anatomy in, 691-692 anesthesia in, 694 complications in, 700 hematoma in, 700 indications for, 692 inferior alveolar nerve in, 691-692 osteotomy in, 694-697 postoperative care for, 697 preoperative assessment for, 693-694 results with, 698-700 secondary, 701 Mandibular prognathism, 746-747 Mandibular symphysis, 704, 705 Marcus Gunn jaw-winking syndrome, 408 Marginal mandibular branch, of facial nerve, 281, 318, 704 Margin reflex distance (MRD1), 406, 511 Marin-Amat syndrome, 410 Marionette lines after genioplasty, 726 face lift or, 212, 244 hyaluronic acids for, 104

microautologous fat transplantation for, 134, 137, 138, 141, 144 soft issue irregularities and, 726 Masseter, 172, 276, 277 Masseteric atrophy, 181 Masseteric hypertrophy, 105, 156-158, 163, 171-172, 173182 Masseteric ligament, 279 Mastectomy nipple-sparing, 948 skin-sparing, 948 Mastopexy, 765 anatomy in, 865-866 complications in, 879-880 indications for, 866-868 inverted-T, 867, 872-873, 877 no vertical star, 868, 873-874, 878 periareolar, 866, 869-870, 875 preoperative assessment for, 868 recurrent ptosis after, 879 results with, 874-878 scarring in, 879 surgical techniques for, 869-874 vertical, 866, 876 Maxilla, 102, 280 Maxillary alveolar flare, 657, 659 Maxillary bone, 265 Maxillary spine implant, 585-586, 589 McDowell’s goals of otoplasty, 630 Mean bigonial distance, 172, 173 Medial epicanthoplasty complications with, 402-403 contraindications for, 397 indications for, 397 modifi d Park’s technique for, 399-400 postoperative care for, 400 results with, 401-402 revision surgery in, 403 surgical technique for, 397-400 Zhang’s technique for, 397-399 Medial epicanthus anatomy of, 395-396 deformity classification for, 396 deformity severity, 397 Medial pedicle breast reduction, 881-893 Medial pterygoid, in facial contouring, 172 Medial scleral triangle, 469 Medical assessment, 3-7 Medications, in medical assessment, 6 Medicolegal considerations, 13 Medpor, 529, 535-536, 537, 540, 556, 730 Melanin, 53-54 Melanocytosis, 54, 56, 58-59, 66 Melanosis, 56

Index

Melanosomes, 53 Melasma, 56, 58, 59, 66 Men androgenic alopecia in, 1063-1066 baldness in, brow lift nd, 230 blepharoplasty in, 272 brow in, 225 brow lift n, 163 eyebrows in, 152 fat distribution in, 999-1000 masseteric hypertrophy in, 156 mustache reconstruction in, 1072-1073 nasal length in, 576 nasolabial angle in, 576 penile enhancement in, 1101-1108 spironolactone in, 81 tip projection in, 576 upper eyelids in, 507 varicose veins in, 1111 Mental foramen, 703, 704 Mentalis, 102, 704, 705 Mentalis overaction, 724 Mentalis strain, 162 Mental tuberosity, 102 Menton, 739 Mesocephaly, 18-19 Metabolic syndrome, 997 Metabolism, melanin, 54 Methicillin-resistant Staphylococcus aureus (MRSA), in rhinoplasty, 532 Microautologous fat transplantation (MAFT), 130; see also Fat graft contraindications to, 147 equipment, 131-132 fat grafting versus, 132, 133 harvesting in, 135-136 indications for, 134-135 insertion sites for, 137, 138, 146 overview of, 130 parcel size in, 130, 131, 132 perioperative management in, 139-140 postoperative care for, 140 preoperative assessment for, 135 processing and refinement in, 136-137 results with, 140-145 surgical technique for, 135-140 Microbotox, 151, 159-162 Microgenia, 218, 223, 706 Microthermal zones (MTZ), 87 Microthreading, in filler injection, 109 Midface aging of, 278-280, 448-449 in Asian face, 217

in facial rejuvenation, 223 fillers in, 104 retaining ligaments and adhesions of, 278, 279 Midface contouring anatomy in, 678 cheek droop in, 688 complications in, 688 coronal approach in, 679-682, 688 indications for, 678 intraoral approach for, 682-684, 688-689 postoperative care for, 684 preoperative assessment for, 678-679 results with, 684-687 revision surgery in, 688-689 surgical technique for, 679-684 Midface flatness, dermal fillers and, 101 Midface lift, endoscopic, 295-304 Midline highlighting, 267 Milk thistle, 6 Minimal access cranial suspension (MACS) lift, 323324 Minimally invasive procedures; see Endoscopic procedures Minor test, 1125 Modifi d dual-plane face lift; see Face lift, classic Moisture, healing and, 31 Moisturizers, 38 Mongolian spots, 56, 59 Motivations, patient, 21-23, 337 Motor nerves in blepharoplasty, 434 in breast reconstruction, 936 in brow lift, 293 in calf reduction, 1046 in facial rejuvenation, 280-281 in midface lift, 303 in osmidrosis surgery, 1127 MOVAMID kit, 131 Movement sites, 117-118 Müller’s muscle advancement operation, 412-413 Multimodal approaches ancillary procedures in, 270 blepharoplasty in, 267-268 chin augmentation in, 270 combined procedures in, 271-272 complications in, 272 face lift n, 268-270 forehead lift n, 267-268 results with, 270-271 surgical technique in, 267-270 Mustache reconstruction, 1072-1073 Myofibroblasts, 31 Myotonic dystrophy, 406

I-17

I-18

Index

N Narcissistic patients, 25 Nasal aperture, 657 Nasal bone, 102, 526, 659 Nasal bone infracture, 528 Nasal bones, 657, 659, 661 Nasal Botox injections, 162 Nasalis, 102 Nasal length, 524, 576 Nasal spine, 102, 657, 659 Nasal tip broad, 591-592 caudal rotation graft or, 573-574, 587 in cleft hinoplasty, secondary, 601 septal extension graft or, 575-579, 587-588 surgical techniques for, 569-579 suture techniques for, 569-572 Nasal tip, fillers in, 104 Nasion, 657, 658 Nasofrontal angle, 557, 671 Nasojugal groove, 447 Nasolabial angle, 557, 576, 577, 744, 745 Nasolabial folds in aging, 212, 218, 220, 263 Botox in, 162, 165 in face lift classic, 243 short-recovery, 254 Woffles lift, 212 fillers in, 104, 110, 111 rhinoplasty and, 663 Neck aging of, 218, 220 anatomy, 317-318 excess fat in, 319, 320 excess skin in, 318, 320 face lift ombined with, 323 facial rejuvenation in, 223 gland removal in, 324 microbotox in, 161 muscle laxity in, 319, 320 in physical examination, 7 preoperative assessment of, 319-320 in severe aging, 222 Neck lift complications in, 327 endoscopic, 305-314, 328-333 formal, 321-322 in multimodal approaches, 268 open, 321-327 problems targeted by, 267, 272 suture suspension, 328 trampoline platysmaplasty in, 328-330 Needling, of scars, 42

Nerve block in filler placement, 107 in laser resurfacing, 88, 89 Neurectomy, in calf reduction, 1046-1057 Nevus of Ota, 56, 59 Nevus spilus, 56, 58, 59 New-Fill, 99 Nipple hypertrophy classification of, 896 complications in treatment of, 907-908 nipple dome preservation in, 896-897 nipple dome removal in, 898-899 surgical techniques for, 896-899 ideal, 895 inversion complications in treatment of, 907-908 etiologic factors in, 900 grading system for, 901-907 nonsurgical techniques for, 902 suture techniques for, 903-904 reconstruction, 959 retrusion of, 908 Nipple-areola complex (NAC) mastopexy and, 865 pigmented, 56, 68, 769 reconstruction of, 769, 871, 961-971 tattooing, 963, 966, 967 Nipple-sparing mastectomy (NSM), 948 Nipple surgeries, 768, 769 Nontuberculous mycobacterial granuloma (NTG), 798 Nose; see Nasal anatomy, in Asian face, 523-524, 556, 557, 567569 in Korean patients, 16, 568 in physical examination, 7 short, 526, 527, 530, 592 in whites versus Asians, 523, 567 Nostril flare, 524 in Korean patients, 568 in secondary cleft hinoplasty, 603 width, 526 O Obesity; see also Body mass index (BMI) abdominoplasty and, 997 body contouring and, 975 breast reduction and, 886, 914, 916 liposuction and, 1001, 1003 as risk factor, 11 varicose veins and, 1111 Obsessive patients, 25, 26 Obstructive sleep apnea, as risk factor, 11

Index

Occipitofrontalis, 102 Oculomotor nerve, 408 Oculopharyngeal dystrophy, 406 Ophthalmic nerve, 282 Oral contraceptives acne and, 73, 76 breast augmentation and, 851 as risk factor, 12 spironolactone and, 73, 82, 83 Orbicularis oculi in aging, 264, 265 brow lift nd, 154, 155, 228 epicanthal folds and, 395-396 in facial anatomy, 102, 227 hypertrophy of, 472, 473, 498, 499 in lowering of lower lid, 469, 470 in short-recovery face lift, 256-257 Orbicularis oris, 102, 704, 705 Orbicularis retaining ligament, 227, 279, 426, 435 Orbit in Asians versus whites, 661 enlargement of, 265 Orbital bones, 265 Orbital fat, 339, 443, 444, 447, 448 Orbital fat herniation, 499 Orbital fat removal, 452-454, 456 Orbital fat repositioning, 458 Orbital ligament, 228 Orbital septum plication, 456 Orthognathic surgery bimaxillary protrusion in, 748 facial asymmetry in, 748 hematoma in, 755 indications for, 746-748 mandibular prognathism in, 746-747 postoperative care for, 753-754 preoperative assessment for, 743-745 results with, 754-757 smile arc and, 744-745 surgical planning for, 745-746 surgical technique for, 748-753 Osmidrosis acromion in, 1127 assessment and diagnosis of, 1125 deltoid muscle in, 1127 epidemiology of, 1123 latissimus dorsi muscle in, 1127 long thoracic artery and nerve in, 1127 medial antebrachial cutaneous nerve in, 1127 median nerve in, 1127 modifi d W-plasty for, 1131-1133 musculocutaneous nerve in, 1127 nonsurgical treatment of, 1126 pathophysiology of, 1124-1125 pectoralis major muscle in, 1127 phrenic nerve in, 1127

postoperative care for, 1133 radical excision for, 1129-1130 results with, 1134-1137 sternocleidomastoid muscle in, 1127 subclavian artery and vein in, 1127 surgical treatment of, 1127-1133 teres major muscle in, 1127 transverse cervical artery in, 1127 trapezius muscle in, 1127 Osteotomy(ies) in advancement genioplasty, 712 angle-splitting, 692, 693, 696-697, 700 anterior segmental, 752 bilateral sagittal split, 748-750 in cleft hinoplasty, 600, 601, 602 lateral orbital, 679, 680 LeFort I, 750-752 in mandibular contouring, 694-697 in midface contouring, 679-681 in narrowing genioplasty, 721 in orthognathic surgery, 745-746, 748-753 in reduction genioplasty, 718 in setback genioplasty, 715 zygomatic arch, 679, 680, 681, 683 Otoplasty; see also Ear(s) antihelical fold in, 630 cartilage-cutting techniques in, 630 cartilage graft n, 642-643, 646-649, 651 cartilage-sparing techniques in, 630-632 complications in, 637-638, 645, 650, 652 for constricted ear, 641-645 for cryptotia, 646-650 dysesthesia in, 638 granulomas after, 637 hematoma in, 634, 637, 647, 648, 650 hypesthesia in, 638 indications for, 628 infection in, 637 McDowell’s goals of, 630 postoperative care for, 634 preoperative assessment for, 629, 642, 651 for prominent ear, 627-639 results with, 634-636, 644-645, 649, 652 scarring in, 637 skin necrosis after, 637 for Stahl’s ear, 650-652 telephone ear deformity in, 638 Oval face, 226, 239 P Pacemaker, 185 Palpebral aperture aesthetics of, 468-469 ideal, 467 Palpebral bag, 444-445

I-19

I-20

Index

Palpebral fissure, 406 Palpebromalar groove, 426-427, 445 Pannus; see Abdominoplasty Paranoid patients, 24 Paresthesia in brow lift, 292 in forehead contouring, 674 in genioplasty, 724 in midface lift, 303 in varicose vein treatment, 1118 Parotid gland hypertrophy, 158-159, 164, 174 Pars labialis, 704 Pars marginalis, 705 Patient-centered approach, 100 Patients antisocial, 25, 26 controlling, 25, 26 dissatisfaction of, reoperations and, 46-47 expectations of, 21-23, 675, 785, 980, 1025 financial responsibility of, 10 histrionic, 24-25 motivations of, 21-23 narcissistic, 25 obsessive, 25, 26 overly compliant, 25, 26 paranoid, 24, 25 personalities of, 24-26 relationship with, reoperations and, 47 selection of, 8, 9, 22 sociopathic, 25, 26 surgical classification of, 6-7 Peel; see Chemical peel Pellevé, 189; see also Radiofrequency (RF) treatment Pelvic floor, 1095 Penile dysmorphic disorder, 1101 Penile enhancement anatomy in, 1101-1103 complications with, 1108 preoperative assessment for, 1103 results with, 1105-1107 surgical techniques for, 1103-1107 Periareolar mastopexy, 866, 869-870 Perineal body, 1094, 1095 Periocular hollowness, 219 Perioral lines, fillers for, 105 Periorbital aging, 497-499 Periorbital region, in facial rejuvenation, 223 Periorbital rejuvenation; see also Blepharoplasty; Brow lift anatomy in, 497-499 Botox for, 509, 512 combined approach for, 519 filler injection for, 509, 510 indications for, 501-502 preoperative assessment for, 499-500

results with, 510-519 revision surgery in, 520 surgical technique for, 502-510 Periorbital septum, 277, 279 Perlane, 98 Personalities, patient, 24-26 Perthes test, 1112 Pheomelanin, 53, 55 Philtral columns, fillers in, 106 Philtral length, 576 Photoaging, 53, 55; see also Sunlight Glogau classification of, 187 pigmentation and, 239 Physical examination in medical assessment, 3, 4-5 in preoperative assessment, 7 by region, 7 Piercing, of ear, 618, 619 Pigmentation, in aging, 220, 221, 239; see also Hyperpigmentation Pigmentation petaloides actinica, 56 Pigmented contact dermatitis, 57, 58, 67 Pinch test in breast examination, 765, 786, 812, 813 in eyelid examination, 341, 500 in facial examination, 174 in levator aponeurosis plication, 411 Piriform fossa, wide, 527 Pixie ear, 618 Planned stage procedures, reoperations and, 46 Platysma, 102, 218, 254, 705 Platysmal plication, 322-323, 324 Pogonion, 707, 708 Polar bear syndrome, 440 Popply chin, 150, 151, 162, 165 Postinflammatory hyperpigmentation (PIH), 54, 55, 56, 57, 59, 65, 69, 71 Prejowl sulci fillers for, 105 implants for, 223 Preoperative testing, 6 Prezygomatic space, 446 Procerus in aging, 264 in brow lift, 226, 498 brow lift nd, 154, 155, 226, 498 in facial anatomy, 102, 227, 498 in forehead lift, 268 in transblepharoplasty, 267 Profile analysis, 707-709 Projection control sutures, 570 Pruritus in brow lift, 293 in laser skin resurfacing, 91, 93 in midface lift, 303 Pseudomacrogenia, 706

Index

Pseudomicrogenia, 706 Pseudoptosis, 408 Pseudoretrogenia, 706 Psoriasis, 185 Psychiatric consultation, 27 Psychological assessment, 22-23 Psychological postoperative care, 28 Psychosocial assessment, 8 Ptosis; see also Blepharoptosis after brow lift, 293 in aging, 264, 265 brow, 499 cheek, 449 chin, 726 compensated brow, 229 Pulmonary embolism (PE), 12, 1021 Pulsed dye laser, for acne scarring, 81 Punch excision, for acne scarring, 80 Pyramidal injection, of fillers, 109, 112 Q Q-switched laser therapy; see Laser therapy Quadratus labii superioris, 445 R Radiation therapy, for scars, 41 Radiesse, 99 Radiofrequency (RF) treatment anatomy in, 184 bipolar, 184, 189-191 contraindications for, 185 equipment, 188-196 for facial rejuvenation, 183-201 fractional, 192-193 healing in, 184-185 indications for, 185 microneedle fractional, 195-196 monopolar, 184, 188-189 multipolar, 192-196 physics of, 183-184 pretreatment assessment for, 186-187 results with, 196-200 scan fractional, 193 Radix, 524 Ramus, 102 Reality television, 16-17 Recession projection control suture, 570 Rectus abdominis, 911, 912, 917-920 “Recycled” skin, 99 Referrals, to specialists, 6 Relative rest sites, 118 Reoperations; see also Revision surgery altered anatomy and, 48

blood supply alterations and, 49 complications and, 45-46 financial considerations with, 49 for further refinement, 47 goals of, 47 hematomas and, 48 outcomes and, 46-47 patient-physician relationship and, 47 planned stage procedures and, 46 reasons for, 45-47 scarring and, 48 special considerations in, 47-50 timing of, 48, 49 tissue characteristic alterations and, 49 Restylane, 98 Resurfacing; see Laser resurfacing Retinoic acid (RA), for hyperpigmentation, 59-62, 64, 65, 66, 67 Retinoid dermatitis, 62, 69, 74, 83 Retinoids for acne, 74 for acne scarring, 79 Retroauricular incision, 222 Retrobulbar hemorrhage, 368-369, 440 Retrogenia, 706 Retrograde dissection, for zygomatic arch, 278 Reverse Marcus Gunn syndrome, 410 Revision surgery; see also Reoperations; Secondary rhinoplasty in abdominoplasty, 996 in brow lift, 237 in calf reduction, 1052 complications and, 45-46 in ears, 625 in forehead contouring, 674 in labial reduction, 1091 in lowering of lower lid, 479 in mandibular contouring, 701 in medial epicanthoplasty, 403 in midface contouring, 688-689 in periorbital rejuvenation, 520 in sunken eyelid correction, 495 Rhinoplasty alar-columellar discrepancies in, 580-586 alloplasts in, 529-530 anatomy in, 523-524 augmentation, 590-591 anatomy in, 556, 557 common prostheses in, 555-556 complications in, 564-565 postoperative care for, 561 preoperative assessment for, 557, 558 results with, 562-564 surgical technique for, 558-561

I-21

I-22

Index

Rhinoplasty—cont’d bone in, 526 cartilage graft n, autologous, 539-554 cartilage in, 524-525 cleft complications in, 608 indications for, 596 lining deficiency in, 599-600 pathology in, 595 postoperative care for, 605 results with, 606-607 surgical technique for, 597-605 closed versus open, 528-529, 590 primary, 555-566 complications in, 531-532 controversies in, 528-531 dorsal augmentation with autologous tissue in, 530531 expected outcomes in, 531 hematoma in, 605, 608 implants in autologous grafts versus, 536 contraction of, 539 disadvantages of, 539-540 expanded polytetrafluoroethylene, 535, 537 materials for, 533-538 maxillary spine, 585-586, 589 Medpor, 535-536, 537 silicone, 534-535, 537, 555-556 indications for, 524-538 infection in, 532, 539, 540, 591, 593 open, primary and secondary, 567-593 secondary, lateral cartilages in, 576 skin in, 524 in whites, indications for, 525 wide piriform fossa in, 528 Rhytidectomy; see Face lift Rhytid shoulders, 90 Rickett’s line, 707-708 Riedel’s line, 707-708 Riehl’s melanosis; see Pigmented contact dermatitis Risk factors, 11-13, 23 Risorius, 102 Rizaben, 42 Roaccutane; see Isotretinoin Rolling acne scar, 78-79 S Scalp anatomy, 1057 Scalp strip harvesting, 1058 Scar resting therapy, 40 Scarring; see also Acne scarring; Healing; Keloid in abdominoplasty, 979 allergies and, 31, 33, 624

in Asian patients versus whites, 980 in blepharoplasty, 370-371, 387, 463 in body contouring, 980 in breast augmentation, 803-804 compression therapy for, 40 corticosteroids for, 40 cryotherapy for, 41 in ear surgery, 624-625, 637 from face lifts, 247 foreign bodies and, 33 gel sheets for, 40 high-risk regions for, 33 infection and, 33 intraoperative technique and, 34-35 laser therapy for, 41 low-risk regions for, 33, 34 makeup for, 41, 42 in mastopexy, 879 mechanical forces and, 32, 34 mechanisms of, 31-33 in medial epicanthoplasty, 402 needling for, 42 nonsurgical therapy for, 40-42 in penile lengthening, 1103, 1104 postoperative care and, 35-36 prevention of, 33-38 radiation therapy for, 41 reoperations and, 48 in rhinoplasty, in whites versus Asians, 568 scalp alopecia from, 1067-1068 surgical therapy for, 39 sutures and, 34-35 treatment of, 39-42 Scar scale, 187 Schirmer’s test, 341, 500 Scleral triangles, 469 Sculptra, 99 Seborrheic dermatitis, 72, 73, 76 Seborrheic keratosis, 56, 57 Secondary rhinoplasty cleft, 595-608 lateral cartilages in, 576 management of, 593 Secret RF, 196; see also Radiofrequency (RF) treatment Selection, patient, 8, 9, 22 Sensory nerves, 282-283 Sentinel vein, 227, 277 Septal cartilage, 544-545 Septal extension graft, 575-579, 587-588 Septal lengthening, 583-584 Septoorbitoperiostoplasty, 457 Septoperiosteoplasty, 458 Serial puncture, in filler injection, 108 Short nose, 592 Silastic, 529, 1136

Index

Silicone, as dermal filler, 99 Silicone fl id, 535 Silicone implants, 730 breast, 771-773, 774, 775-780 in rhinoplasty, 534-535, 555-556 Silikon 1000, 99 SIMON, 8 Skin closure tape, 37, 38 Skin hyperpigmentation; see Hyperpigmentation Skin-sparing mastectomy (SSM), 948 Sleep apnea, as risk factor, 11 Smile arc, 744-745 Snap-back test, 341, 465, 471, 500 Sociopathic patients, 25, 26 Soft issue fillers; see Fillers Solar lentigines, 56, 57, 66 Spironolactone, for acne, 73, 76, 82 Sponges, 38 Square face, 156, 171, 220, 691 Squinting, 263 Stahl’s ear, 621, 650-652 Sternocleidomastoideus (sternocleidomastoid muscle), 705 Steroid injection, for acne scarring, 81 Strabismus, 477 Stromal vascular fraction (SVF), 849, 854 Stylohyoideus, 705 Subbrow excision, 504 Subcision, for acne scarring, 80-81 Subgaleal plane, 279 Submandibular gland hypertrophy, 158-159, 164 Submandibular gland removal, 324 Submaxillary gland removal, 324 Submental lipectomy, 324 Suborbital malar hypoplasia, 446 Subperiosteal face lift, 682, 687 Sunburn, 56 Sunken eyelids causes of, 342, 483-484 complications in correction of, 491-492 dermal fat grafting for, 492-493 dermal graft xation to periosteum for, 495 fat grafting for, 488-491 fillers for, 495 preoperative assessment for correction of, 484 results in correction of, 494 revision surgery for, 495 surgical technique for correction of, 484-487 tissue filling method for, 485, 487 tissue repositioning method for, 485, 486, 487 Sunlight collagen and, 184, 185 pigmentation and, 239 Superficial cervical fascia, 318

Superficial musculoaponeurotic system (SMAS) in Asian face, 217 asymmetry of face and, 221 in face lift classic, 242, 243 short-recovery, 254-255 fat grafting in, 118 in rhinoplasty, primary closed, 556 Superficial temporal adhesion, 279 Superficial temporal fascia, 276, 277 Superior epigastric artery, 911, 912 Superior temporal fusion line, 226, 232 Superior temporal septum, 227 Supplements, 6 Suprabrow excision, 504 Supraorbital bossing, 669, 673 Supraorbital ligamentous adhesion, 227, 277 Supraorbital nerve, 228, 282, 285 Supraorbital process, 102 Supratarsal depression, 388-389 Supratarsal fold asymmetry, after upper blepharoplasty, 380-382, 387 loosening, after upper blepharoplasty, 379-380, 386 narrowed, after upper blepharoplasty, 382, 387 wide, after upper blepharoplasty, 382-384, 385, 387, 390 Supratrochlear nerve, 228, 232, 282, 285 Surgical adhesive, 37 Surgical patient classification, 6-7 Surgical site infection (SSI); see Granulomas; Infection Surgical tape, 38 Suture(s) advancement projection control suture, 570 in blepharoplasty, 345-347, 352-353, 354-357, 358359, 360, 372-373 columellar-septal suture, 571, 572 conchal mastoid sutures, 633 in face lift, short-recovery, 255 in gluteal augmentation, 1038 in nasal tip surgery, 569-572, 586-587 in neck lift, 328 for nipple inversion, 903-904 in otoplasty, 633, 637 projection control, 570 recession projection control, 570 scarring and, 34-35 tip rotation, 570 Sweat glands, 1124; see also Osmidrosis Sweat test, 1125 SYLVIA, 8 Synkinesia, 406

I-23

I-24

Index

T Taiwanese women, breast reconstruction in, 952 Tape, 37, 38 Tarsoligamentous sling, 469, 470 Tattoos eyebrow, 501 nipple-areola complex, 963, 966, 967 Tear trough deformity, 103, 219, 264, 265, 445-446 Tear trough deformity correction anatomy in, 425-428 Botox for, 430-434 complications with, 433-434, 439 fat graft or, 431, 433 fillers for, 430-433 preoperative assessment for, 428 results with, 431-433, 435-439 surgical, 434-440 Tear trough deformity grading, 428, 429 Tear trough ligament, 427, 428, 431, 435 Teeth in genioplasty, 705 in whites versus Asians, 660 Telephone ear deformity, 638 Television, 16-17 Temple augmentation, 118 Temple hollows, 679 in aging, 264 causes of, 266 fillers in, 103, 110 Temporal augmentation, 735-737 Temporal bone, 102 Temporal branch, of facial nerve, 280-281 Temporal fascia, 276-278 Temporal fossa, 220 Temporalis in anatomy, 102, 276, 277 in facial contouring, 172 in midface contouring, 688 Temporal landmarks, 275-278 Temporal region, after face-lift, complications with, 250-251 Test(s) allergy, 98-99, 100 breast skin elasticity, 808, 809, 810 covering, 410 diver’s, 985 dry eye, 340 eyelid elasticity, 341, 500 eyesight, 340 glucose transport, 837 lid distraction, 471 lifting, 410 Minor, 1125 nasal tip-lobule distraction, 557, 558 Perthes, 1112

pinch in breast examination, 764, 786, 812, 813 in eyelid examination, 341, 500 in facial examination, 174 in levator aponeurosis plication, 411 preoperative, 6 Schirmer’s, 341, 500 snap-back, 341, 465, 471, 500 sweat, 1125 Trendelenburg, 1112 Testosterone, 75 Thermage, 188; see also Radiofrequency (RF) treatment Thighs, liposuction in, 1010 Thread lift advantages of, 204 anesthetic for, 209 complications with, 212-213 evolution of, 205 for facial rejuvenation, 203-213 facial vectors in, 207 indications for, 206 mechanism of, 204 postoperative care for, 210 preoperative assessment for, 206-207 results with, 211-212 surgical technique for, 208-210 Woffles lift n, 203-213 Tip broad, 591-592 caudal rotation graft or, 573-574, 587 in cleft hinoplasty, secondary, 601 septal extension graft or, 575-579, 587-588 surgical techniques for, 569-579 suture techniques for, 569-572 Tip defining points, 576, 577 Tip projection, ideal, 576, 577 Tip rotation sutures, 570 Tornado, 194; see also Radiofrequency (RF) treatment Trampoline platysmaplasty, 328-330 Tranexamic acid, 63 Tranilast, 42 Transconjunctival lower blepharoplasty, 458 Transgender patients; see Gender reassignment Trendelenburg test, 1112 Tretinoin, 61, 74, 81 Triangular muscle defect, 445 Triceps surae, 1042-1043 Trigeminal nerve, 282, 408, 704 Trismus, 688 True vertical line, 709 Trunk fat distribution in, 999-1000 in physical examination, 7 truScript, 189; see also Radiofrequency (RF) treatment Tumescent solution, in liposuction, 1004-1006

Index

Tumor resection, in helix-lobule, 622, 623 Turkish delight method, 602-603 Tyndall eff ct, 114, 434 U Undereye lines, 162 Underlying conditions, 3, 6, 11-13 Undermining, in face-lift urgery, 248, 250-251, 251252 Undesirable facial features, 150 Upper lid crease height, 406 V Vaginal rejuvenation; see also Hymenorrhaphy anatomy in, 1093-1095 indications for, 1095 postoperative care for, 1097 preoperative assessment for, 1095-1096 results with, 1097-1098 surgical technique for, 1096 Vancouver scar scale, 187 Varicose veins, 1108-1121 Vectors, facial, 207 Venous thromboembolism (VTE), 3, 12, 1021 Venus Freeze, 191; see also Radiofrequency (RF) treatment Venus Viva, 193; see also Radiofrequency (RF) treatment Visual acuity, 263, 264 V-touch, 194; see also Radiofrequency (RF) treatment W Warping, of cartilage graft, 552-553 Weir excision, 603, 608 Western beauty, 17, 18 Westerners; see also Blacks; Whites breasts in, 783 eyelash in, 1071 eyelids in, 337, 338, 443 mean bigonial distance in, 172 midface contouring in, 677 osmidrosis in, 1123 “thinness” in, 976

White face, Asian face versus, 151, 217, 220-221 Whites aging in, versus Asians, 220-221, 239 breasts in, 763, 764 eyelids in, 338 facial proportions in, 661 facial skeletal patterns in, 18-19, 657-664 female, Asians versus, 764 forehead in, 229-230 masseteric hypertrophy in, 156 nose in, versus Asians, 523, 567 orbits in, versus Asians, 661 pigmentation in, 54, 55 rhinoplasty in, indications for, 525 scarring in, 980 soft issues in, 664 teeth in, versus Asians, 660 Whitnall’s ligament, 498 Woffles lift, 203-213 Woffles threads, 206, 211 Women, brow in, 225 Wound dressings, 37, 1073 Z Zero meridian, 707 Zone of adhesion, 227 Zone of fixation, 228 Zyderm, 98 Zygoma, in white versus Asian face, 19 Zygomatic angle, 657-658, 660, 664 Zygomatic arch, 276, 277, 278 Zygomatic arch osteotomy, 679, 680, 681, 683 Zygomatic bone, 102 Zygomatic branch, of facial nerve, 281 Zygomatic complex, 678 Zygomatic ligament, 279 Zygomaticocutaneous ligament, 279 Zygomaticomaxillary complex, 682, 683 Zygomaticotemporal nerve, 227 Zygomaticus major, 102, 705 Zygomaticus minor, 102, 705 Zyplast, 98

I-25

K23345_Pu_Index_m3_VOL2_150402.indd 26

4/9/2015 7:57:00 AM