Plastic Surgery: Volume 2: Aesthetic Surgery (Plastic Surgery, 2) [5 ed.] 9780323810395, 9780323873789, 9780323810371, 032381039X

Citation preview

Any screen. Any time. Anywhere.

Activate the eBook version of this title at no additional charge.

Elsevier eBooks+ gives you the power to browse, search, and customize your content, make notes and highlights, and have content read aloud.

Unlock your eBook today. 1. Visit http://ebooks.health.elsevier.com/ 2. Log in or Sign up 3. Scratch box below to reveal your code 

4. Type your access code into the “Redeem Access Code” box 

5. Click “Redeem”

It’s that easy!

Place Peel Off Sticker Here

For technical assistance: email [email protected] call 1-800-545-2522 (inside the US) call +44 1 865 844 640 (outside the US)  

Use of the current edition of the electronic version of this book (eBook) is subject to the terms of the nontransferable, limited license granted on http://ebooks.health.elsevier.com/. Access to the eBook is limited to the first individual who redeems the PIN, located on the inside cover of this book, at http://ebooks.health.elsevier.com/ and may not be transferred to another party by resale, lending, or other means. 2022v1.0

Front matter

Fifth Edition

Plastic Surgery Aesthetic Volume Two

Cover illustration “The Plastic Surgery Huddle” The concept and inspiration for the cover art was derived from a situation that we as plastic surgeons are all familiar with. It is that special time when you know there is a new or interesting case happening down the hall in your hospital. It might be a complex reconstruction, a new flap design or an unusual presentation. There is a buzz and a crowded OR with extra residents, Fellows, students, and colleagues around the table. The “Plastic Surgery huddle” includes additional hands scrubbed-in to assist, wanting to be involved, to learn, and to experience the innovation that is being performed. It is always dynamic, and it is always a learning situation. The color arrangement of the surgical caps/hats around the OR table is intentional. It borrows from the artist’s color wheel, which includes primary colors (red, yellow, and blue) and the secondary colors (orange, purple, and green). All the different colours are meant to represent the dynamic and unique diversity of our discipline as well as the sharing of ideas and collaboration that we all strive to promote in our wonderful specialty of Plastic Surgery. John L. Semple MD, MSc, FRCSC, FACS, LLD Head, Division of Plastic Surgery Women’s College Hospital Professor, Department of Surgery University of Toronto

Content Strategist: Lauren Boyle, Belinda Kuhn Content Development Specialists: Kathryn DeFrancesco, Rebecca Gruliow, Grace Onderlinde, Kevin Travers Project Managers: Anne Collett, Joanna Souch, Julie Taylor Designer: Miles Hitchen Marketing Manager: Mary McCabe-Dunn Video Liaison: Nicholas Henderson

Fifth Edition

Plastic Surgery Aesthetic Volume Two Volume Editors

J. Peter Rubin

Alan Matarasso

MD, FACS

MD, FACS

Professor and Chair, Department of Plastic Surgery Professor of Bioengineering University of Pittsburgh Pittsburgh, PA, United States

Clinical Professor of Surgery Systems Chief of Cosmetic Surgery Hofstra School of Medicine-Northwell Health System New York, NY, United States

Editor-in-Chief

Multimedia Editor

Peter C. Neligan

Daniel Z. Liu

MB, FRCS(I), FRCSC, FACS

MD

Professor Emeritus Surgery, Division of Plastic Surgery University of Washington Seattle, WA, United States

Reconstructive Microsurgeon Oncoplastic and Reconstructive Surgery City of Hope Chicago Zion, IL, United States

For additional online figures, videos, and video lectures visit Elsevier eBooks+

London, New York, Oxford, Philadelphia, St Louis, Sydney 2024

Copyright Elsevier 1600 John F. Kennedy Blvd. Ste 1800 Philadelphia, PA 19103-2899

PLASTIC SURGERY, FIFTH EDITION Copyright © 2024, Elsevier Inc. All rights reserved.

First edition 1990 Second edition 2006 Third edition 2013 Fourth edition 2018 No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www. elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein).

Notice Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds or experiments described herein.  Because of rapid advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors or contributors for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.

Volume 2 ISBN: 978-0-323-81039-5 Volume 2 Ebook ISBN: 978-0-323-87378-9 6 volume set ISBN: 978-0-323-81037-1

Printed in India Last digit is the print number: 9 8 7 6 5 4 3 2 1

Contents Preface to the Fifth Edition xxvii List of Editors xxviii List of Contributors xxix Acknowledgmentsl Dedicationli

17 Skin grafting

206

18 Tissue engineering

220

19 Repair, grafting, and engineering of cartilage

235

20 Repair and grafting of bone

265

21 Repair and grafting of peripheral nerve

295

22 Repair and grafting fat and adipose tissue

309

23 Vascular territories

321

Shawn Loder, Benjamin Levi, and Audra Clark Ramin Shayan and Karl-Anton Harms Wei Liu, Guangdong Zhou, and Yilin Cao

Iris A. Seitz, Chad M. Teven, Bryce Hendren-Santiago, and Russell R. Reid

Volume One: Principles edited by Geoffrey C. Gurtner and Andrea L. Pusic

1 Plastic surgery and innovation in medicine

1

2 History of reconstructive and aesthetic surgery

9

Peter C. Neligan

Riccardo F. Mazzola and Isabella C. Mazzola

3 Applying psychology to routine plastic surgery practice24 Nichola Rumsey and Alex Clarke

4 The role of ethics in plastic surgery and medico-legal issues in plastic surgery

32

5 Business principles for plastic surgeons 6 Value-based healthcare

Hollie A. Power, Kirsty Usher Boyd, Stahs Pripotnev, and Susan E. Mackinnon J. Peter Rubin

Steven F. Morris and G. Ian Taylor

24 Flap physiology, classification, and applications346 Joon Pio Hong and Peter C. Neligan

37

25 Principles and techniques of microvascular surgery

414

60

26 Tissue expansion and implants

442

27 Principles of radiation therapy

452

8 Pre- and intra-operative imaging for plastic surgery83

28 Lymphedema: pathophysiology and basic science

472

9 Patient safety in plastic surgery

29 Benign and malignant nonmelanocytic tumors of the skin and soft tissue

490

Michele A. Manahan and B. Aviva Preminger C. Scott Hultman

Justin M. Broyles, Clifford C. Sheckter, and Anaeze C. Offodile 2nd

7 Digital photography in plastic surgery Daniel Z. Liu

66

Arash Momeni and Lawrence Cai

Jessica Erdmann-Sager and Christopher J. Pannucci

10 Anesthesia and pain management in plastic surgery Paul N. Afrooz and Franklyn P. Cladis

11 Evidence-based medicine and health services research in plastic surgery Sophocles H. Voineskos, Lucas Gallo, Andrea L. Pusic, and Achilleas Thoma

12 Patient-reported outcomes in plastic surgery

Sophocles H. Voineskos, Danny Young-Afat, Madelijn Gregorowitsch, Jonas A. Nelson, Anne F. Klassen, and Andrea L. Pusic

94 101 115 135

146

14 Principles of cancer management

153

15 Wound healing

163

16 Scar prevention, treatment, and revision

186

Stav Brown and Babak J. Mehrara

Kristo Nuutila, David E. Varon, and Indranil Sinha Michelle F. Griffin, Evan Fahy, Michael S. Hu, Elizabeth R. Zielins, Michael T. Longaker, and H. Peter Lorenz

Britta A. Kuehlmann, Eva Brix, and Lukas M. Prantl Stephanie K. Schaub, Joseph Tsai, and Gabrielle M. Kane

Stav Brown, Michelle Coriddi, and Babak J. Mehrara

Rei Ogawa

13 Health services research in plastic surgery Jacqueline N. Byrd and Kevin C. Chung

Fu-Chan Wei, Sherilyn Keng Lin Tay, and Nidal F. Al Deek

30 Melanoma521 Sydney Ch’ng and Alexander H.R. Varey

31 Implants and biomaterials

544

32 Transplantation in plastic surgery

555

33 Technology innovation in plastic surgery: a practical guide for the surgeon innovator

568

34 Robotics in plastic surgery

582

35 Digital technology in plastic surgery

594

Dharshan Sivaraj, Dominic Henn, Timothy W. King, and Kellen Chen Yannick F. Diehm, Valentin Haug, Martin Kauke-Navarro, and Bohdan Pomahac

David Perrault, Leila Jazayeri, and Geoffrey C. Gurtner Karim A. Sarhane and Jesse C. Selber Lynn Jeffers, Hatem Abou-Sayed, and Haley M. Jeffers

36 Aesthetic improvement through noninvasive technologies613 Stelios C. Wilson and Charles H. Thorne

37 Education and teaching in plastic surgery Lydia Helliwell and Johanna N. Riesel

619

vi

Contents

38 Global plastic surgery

625

9.5 Facelift: Platysma-SMAS plication

203

9.6 Facelift: Lateral SMASectomy facelift

212

9.7 Facelift: The extended SMAS technique in facial rejuvenation

219

9.8 High SMAS facelift: combined single flap lifting of the jawline, cheek, and midface

236

9.9 The lift-and-fill facelift

282

9.10 Neck rejuvenation

301

9.11 Male facelift

319

Section I: Aesthetic Anesthesia Techniques 3 Essential elements of patient safety in aesthetic plastic surgery 18

9.12 Secondary facelift irregularities and the secondary facelift

345

4 Pain management in plastic surgery

9.13 Perioral rejuvenation, including chin and genioplasty390

Johanna N. Riesel, Peter Nthumba, George Ho, and Amanda Gosman

39 Gender-affirming surgery

Shane D. Morrison, William M. Kuzon Jr., and Jens U. Berli

Miles G. Berry, James D. Frame III, and Dai M. Davies

634

Index652

Daniel C. Baker and Steven M. Levine

James M. Stuzin

Volume Two: Aesthetic edited by J. Peter Rubin and Alan Matarasso

1 Managing the aesthetic surgery patient Michelle B. Locke and Foad Nahai

2 Principles of practice management and social media for cosmetic surgery Ashley N. Amalfi, Josef G. Hadeed, and Smita R. Ramanadham

1

Stav Brown, Justin L. Bellamy, and Rod J. Rohrich

13

Jeremy T. Joseph, Gabriele C. Miotto, Felmont F. Eaves III, and Galen Perdikis Anna R. Schoenbrunner and Jeffrey E. Janis

5 Anatomic blocks of the face and neck Stelios C. Wilson and Barry Zide

6 Local anesthesia Malcolm D. Paul

Section II: Aesthetic Surgery of the Face 7 Non-surgical skin care and rejuvenation Zoe Diana Draelos

8.1 Editors’ perspective: injectables and non-surgical resurfacing techniques J. Peter Rubin

Timothy Marten and Dino Elyassnia

25

James E. Zins and Jacob Grow Timothy Marten and Dino Elyassnia

Timothy Marten and Dino Elyassnia

Ali Totonchi and Bahman Guyuron

33 42

9.14 Facial feminization

404

10 Editors’ perspective: brow and eye

424

11 Forehead rejuvenation

425

12 Endoscopic brow lift

441

Patrick R. Keller, Matthew Louis, and Devin Coon Alan Matarasso

47 53

Richard Warren

Renato Saltz and Eric W. Anderson

13 Blepharoplasty453 Julius Few Jr., and Marco Ellis

8.2 Injectables and resurfacing techniques: Soft-tissue fillers

54

8.3 Injectables and resurfacing techniques: Botulinum toxin/neurotoxins

73

14 Secondary blepharoplasty

484

15 Asian facial cosmetic surgery

513

16 Facial fat grafting

559

17 Editors’ perspective: nose

567

96

18 Nasal analysis and anatomy

568

8.6 Minimally invasive multimodal facial rejuvenation118

19 Open technique rhinoplasty

581

Kavita Mariwalla

Rawaa Almukhtar and Sabrina G. Fabi

8.4 Injectables and resurfacing techniques: Lasers in aesthetic surgery

Jonathan Cook, David M. Turer, Barry E. DiBernardo, and Jason N. Pozner

8.5 Injectables and resurfacing techniques: Chemical peels Richard H. Bensimon and Peter P. Rullan

84

Seth Z. Aschen and Henry M. Spinelli Jong Woo Choi, Tae Suk Oh, Hong Lim Choi, and Clyde Ishii Francesco M. Egro, Sydney R. Coleman, and J. Peter Rubin Alan Matarasso

Luiz S. Toledo

Rod J. Rohrich and Paul N. Afrooz Rod J. Rohrich and Paul N. Afrooz

20 Closed technique rhinoplasty

607

9.1 Editors’ perspective: surgical facial rejuvenation130

21 Airway issues and the deviated nose

647

9.2 Facial anatomy and aging

22 Secondary rhinoplasty

662

23 Otoplasty and ear reduction

681

24 Hair restoration

690

Alan Matarasso

Bryan Mendelson and Chin-Ho Wong

131

9.3 Principles and surgical approaches of facelift 149 Richard J. Warren

9.4 Facelift: Facial rejuvenation with loop sutures: the MACS lift and its derivatives 180 Patrick Tonnard, Alexis Verpaele, and Rotem Tzur

Mark B. Constantian

Ali Totonchi, Bryan Armijo, and Bahman Guyuron David M. Kahn, Danielle H. Rochlin, and Ronald P. Gruber Charles H. Thorne

Alfonso Barrera and Victor Zhu

Contents

vii

Section III: General Aesthetic Surgery 25.1 Editors’ perspective: liposuction

700

25.2 Liposuction: a comprehensive review of techniques and safety

Volume Three: Craniofacial, Head and Neck Surgery and Pediatric Surgery

701

Part 1: Craniofacial, Head and Neck Surgery: edited by Richard A. Hopper

J. Peter Rubin

Gianfranco Frojo, Jayne Coleman, and Jeffrey Kenkel

1 Management of craniomaxillofacial fractures

25.3 Correction of liposuction deformities with the SAFE liposuction technique

723

26 Editors’ perspective: abdominal contouring

731

Simeon H. Wall Jr. and Paul N. Afrooz Alan Matarasso

27 Abdominoplasty732 Alan Matarasso

28 Lipoabdominoplasty with anatomical definition: a new concept in abdominal aesthetic surgery 775 Osvaldo Ribeiro Saldanha, Andrés F. Cánchica Cano, Taisa Szolomicki, Osvaldo Saldanha Filho, and Cristianna Bonetto Saldanha

2

Srinivas M. Susarla, Russell E. Ettinger, and Paul N. Manson

2 Scalp and forehead reconstruction

39

3 Aesthetic nasal reconstruction

52

Alexander F. Mericli and Jesse C. Selber Frederick J. Menick

4 Auricular construction

Dale J. Podolsky, Leila Kasrai, and David M. Fisher

110

5 Secondary treatment of acquired cranio-orbital deformities138 Allan B. Billig and Oleh M. Antonyshyn

29 Editors’ perspective: truncal contouring

785

6.1 Computerized surgical planning: introduction 155

30 Bra-line back lift

786

6.2 Three-dimensional virtual planning in orthognathic surgery

157

31 Belt lipectomy

792

6.3 Computerized surgical planning in head and neck reconstruction

173

7 Introduction to post-oncologic reconstruction

188

834

8 Overview of head and neck soft-tissue and bony tumors

190

34 Circumferential approaches to truncal contouring: lower bodylift with autologous gluteal flaps for augmentation and preservation of gluteal contour

841

9 Post-oncologic midface reconstruction: the Memorial Sloan-Kettering Cancer Center and MD Anderson Cancer Center approaches

217

35.1 Editors’ perspective: buttock augmentations

854

10 Local flaps for facial coverage

229

35.2 Buttock augmentation with implants

855

11 Lip reconstruction

256

J. Peter Rubin

Joseph Hunstad and Saad A. Alsubaie Amitabh Singh and Al S. Aly

32 Circumferential approaches to truncal contouring in massive weight loss patients: the lower lipo-bodylift Dirk F. Richter and Nina Schwaiger

33 Circumferential approaches to truncal contouring: autologous buttocks augmentation with purse-string gluteoplasty Joseph P. Hunstad and Nicholas A. Flugstad

Robert F. Centeno and Jazmina M. Gonzalez J. Peter Rubin

Jose Abel De la Peña Salcedo, Jocelyn Celeste Ledezma Rodriguez, and David Gonzalez Sosa

819

Constantino G. Mendieta, Thomas L. Roberts III, and Terrence W. Bruner Margaret Luthringer, Nikita O. Shulzhenko, and Joseph F. Capella

37 Medial thigh

Samantha G. Maliha and Jeffrey Gusenoff

878 891

38 Post-bariatric reconstruction

898

39 Energy devices in aesthetic surgery

919

Jonathan W. Toy and J. Peter Rubin David Turer, Jonathan Cook, Jason Pozner, and Barry DiBernardo

40 Aesthetic genital surgery Gary J. Alter

Pradip R. Shetye and Srinivas M. Susarla

Maureen Beederman, Adam S. Jacobson, David L. Hirsch, and Jamie P. Levine Zoe P. Berman and Eduardo D. Rodriguez

35.3 Buttock shaping with fat grafting and liposuction869 36 Upper limb contouring

Richard A. Hopper

926

Index951

Sydney Ch’ng, Edwin Morrison, Pratik Rastogi, and Yu-Ray Chen

Matthew M. Hanasono and Peter G. Cordeiro Nicholas Do and John Brian Boyd Julian J. Pribaz and Mitchell Buller

12 Oral cavity, tongue, and mandibular reconstructions275 Ming-Huei Cheng

13 Hypopharyngeal, esophageal, and neck reconstruction302 Min-Jeong Cho and Peirong Yu

14 Secondary facial reconstruction

336

15 Facial paralysis

359

Afaaf Shakir and Lawrence J. Gottlieb

Simeon C. Daeschler, Ronald M. Zuker, and Gregory H. Borschel

16 Surgical management of facial pain, including migraines390 Anna Schoenbrunner and Jeffrey E. Janis

17 Facial feminization

Luis Capitán, Daniel Simon, and Fermín Capitán-Cañadas

400

viii

Contents

Part 2: Pediatric Surgery: edited by Joseph E. Losee 18 Embryology of the craniofacial complex Jingtao Li and Jill A. Helms

442 451

19.2 Rotation advancement cheiloplasty

456

19.3 Extended Mohler repair

488

Philip Kuo-Ting Chen and Lucia Pannuto

808

25.3 Multisutural syndromic synostosis

827

Sameer Shakir and Jesse A. Taylor

Richard A. Hopper and Benjamin B. Massenburg

Section I: Clefts 19.1 Unilateral cleft lip: introduction

Joseph E. Losee and Michael R. Bykowski

25.2 Nonsyndromic craniosynostosis

25.4 Neurosurgical and developmental issues in craniosynostosis849 Alexandra Junn, John T. Smetona, Michael Alperovich, and John A. Persing

26 Craniofacial microsomia

859

27 Idiopathic progressive hemifacial atrophy

887

28 Robin sequence

902

29 Treacher Collins syndrome

923

21.2 Straight line repair with intravelar veloplasty (IVVP)542

Section III: Pediatrics 30 Congenital melanocytic nevi

935

21.3 Double opposing Z-palatoplasty

549

31 Vascular anomalies

952

21.4 Buccal myomucosal flap palate repair

557

32 Pediatric chest and trunk deformities

974

21.5 The buccal fat pad flap

567

33 Pediatric tumors

988

34 Conjoined twins

1001

Roberto L. Flores

19.4 Anatomic subunit approximation approach to unilateral cleft lip repair

499

20 Repair of bilateral cleft lip

519

21.1 Cleft palate: introduction

538

Raymond W. Tse and David M. Fisher

John B. Mulliken and Daniel M. Balkin Michael R. Bykowski and Joseph E. Losee

Brian Sommerlad

Jordan N. Halsey and Richard E. Kirschner Robert Joseph Mann

James D. Vargo and Steven R. Buchman

21.6 Oral fistula closure

Mirko S. Gilardino, Sabrina Cugno, and Abdulaziz Alabdulkarim

21.7 Alveolar clefts

Katelyn Kondra, Eloise Stanton, Christian Jimenez, Erik M. Wolfswinkel, Stephen Yen, Mark Urata, and Jeffrey Hammoudeh

575 583

21.8 Orthodontics in cleft lip and palate management592 Alvaro A. Figueroa, Alexander L. Figueroa, Gerson R. Chinchilla, and Marta Alvarado

21.9 Velopharyngeal dysfunction

Richard E. Kirschner, Hannah J. Bergman, and Adriane L. Baylis

Craig B. Birgfeld and Scott P. Bartlett Peter J. Taub, Kathryn S. Torok, Daniel H. Glaser, and Lindsay A. Schuster Sofia Aronson, Chad A. Purnell, and Arun K. Gosain Irene Mathijssen

Sara R. Dickie, Neta Adler, and Bruce S. Bauer Arin K. Greene and John B. Mulliken Han Zhuang Beh, Andrew M. Ferry, Rami P. Dibbs, Edward P. Buchanan, and Laura A. Monson Matthew R. Greives, George Washington, Sahil Kapur, and Michael Bentz

Anna R. Carlson, Gregory G. Heuer, and Jesse A. Taylor Index1011

Volume Four: Lower Extremity, Trunk and Burns edited by David H. Song and Joon Pio Hong

618

1 Comprehensive lower extremity anatomy Rajiv P. Parikh and Grant M. Kleiber

2 Management of lower extremity trauma Hyunsuk Peter Suh

1 52

21.10 Secondary deformities of the cleft lip, nose, and palate

636

Section I: Lower Extremity Surgery 3.1 Lymphedema: introduction and editors’ perspective76

21.11 Cleft and craniofacial orthognathic surgery

661

Section II: Craniofacial 22 Pediatric facial fractures

3.2 Imaging modalities for diagnosis and treatment of lymphedema 78

708

3.3 Lymphaticovenular bypass

Han Zhuang Beh, Rami P. Dibbs, Andrew M. Ferry, Robert F. Dempsey, Edward P. Buchanan, and Larry H. Hollier Jr. Stephen B. Baker, Brian L. Chang, and Anusha Singh

John T. Smetona, Jesse A. Goldstein, Michael R. Bykowski, and Joseph E. Losee

102

747

3.5 Debulking strategies and procedures: liposuction of leg lymphedema

111

775

3.6 Debulking strategies and procedures: excision 120

24 Craniofacial clefts

25.1 Craniosynostosis: introduction

Christopher R. Forrest and Johanna N. Riesel

92

3.4 Vascularized lymph node transplant

726

James P. Bradley and Henry K. Kawamoto Jr.

Balazs Mohos and Chieh-Han John Tzou

Wei F. Chen, Lynn M. Orfahli, and Vahe Fahradyan

23 Orbital hypertelorism

Eric Arnaud, Giovanna Paternoster, Roman Khonsari, Samer E. Haber, and Syril James

Joon Pio Hong and David H. Song

Rebecca M. Garza and David W. Chang

Håkan Brorson

Hung-Chi Chen and Yueh-Bih Tang

Contents

4 Lower extremity sarcoma reconstruction Andrés A. Maldonado, Günter K. Germann, and Michael Sauerbier

128

5 Reconstructive surgery: lower extremity coverage154 Joon Pio Hong

6.1 Diagnosis, treatment, and prevention of lower extremity pain 180 Brian L. Chang and Grant M. Kleiber

6.2 Targeted muscle reinnervation in the lower extremity Brian L. Chang and Grant M. Kleiber

6.3 Lower extremity pain: regenerative peripheral nerve interfaces

Nishant Ganesh Kumar, Theodore A. Kung, and Paul S. Cederna

7 Skeletal reconstruction

Marco Innocenti, Stephen Kovach III, Elena Lucattelli, and L. Scott Levin

8 Foot reconstruction

Romina Deldar, Zoe K. Haffner, Adaah A. Sayyed, John S. Steinberg, Karen K. Evans, and Christopher E. Attinger

9.1 Diabetic foot: introduction

Kevin G. Kim, Paige K. Dekker, John D. Miller, Jayson N. Atves, John S. Steinberg, and Karen K. Evans

190 203

Brian L. Chang, Banafsheh Sharif-Askary, and David H. Song

311 327

12 Reconstruction of the posterior trunk

354

13 Abdominal wall reconstruction

388

Reuben A. Falola, Nicholas F. Lombana, Andrew M. Altman, and Michel H. Saint-Cyr Gregory A. Dumanian

14.1 Gender confirmation surgery: diagnosis and management407 Loren Schechter and Rayisa Hontscharuk

14.2 Gender confirmation surgery, male to female: vaginoplasty414 Loren Schechter and Rayisa Hontscharuk

14.3 Gender affirmation surgery, female to male: phalloplasty; and correction of male genital defects421 Alexander Y. Li, Walter C. Lin, and Bauback Safa

14.4 Breast, chest wall, and facial considerations in gender affirmation 439 Kaylee B. Scott, Dana N. Johns, and Cori A. Agarwal

17 Perineal reconstruction

489

Section III: Burn Surgery 18 Burn, chemical, and electrical injuries

501

19 Extremity burn reconstruction

538

20 Management of the burned face and neck

561

21 Pediatric burns

589

Ping Song, Hakim Said, and Otway Louie

Raphael C. Lee and Chad M. Teven

S. Raja Sabapathy, R. Raja Shanmugakrishnan, and Vamseedharan Muthukumar

Sebastian Q. Vrouwe and Lawrence J. Gottlieb

edited by Maurice Y. Nahabedian

265

Paige K. Dekker, Kevin G. Kim, and Karen K. Evans



462

Ibrahim Khansa and Jeffrey E. Janis

Volume Five: Breast

9.3 Diabetic foot: management of vascularity and considerations in soft-tissue reconstruction 296

11 Reconstruction of the chest

16 Pressure sores

228

Jayson N. Atves, John D. Miller, and John S. Steinberg

J. Andres Hernandez, Andrew Nagy Atia, and Scott Thomas Hollenbeck

452

Leila Jazayeri, Andrea L. Pusic, and Peter G. Cordeiro

Index610

9.2 Diabetic foot: management of wounds and considerations in biomechanics and amputations270

Section II: Trunk, Perineum, and Transgender 10 Trunk anatomy

15 Reconstruction of acquired vaginal defects

Vinita Puri and Venkateshwaran Narasiman

210

ix

Section I: Aesthetic Breast Surgery 1 Preoperative assessment and planning of the aesthetic breast patient Kiya Movassaghi and Christopher N. Stewart

1

2 Current status of breast implants

13

3 Primary breast augmentation with implants

28

Patrick Mallucci and Giovanni Bistoni Charles Randquist

4 Autologous fat transfer: fundamental principles and application for breast augmentation 52 Roger Khalil Khouri, Raul A. Cortes, and Daniel Calva-Cerquiera

5 Augmentation mastopexy

69

6 Mastopexy after massive weight loss

83

7 Prevention and management of complications following breast augmentation and mastopexy

92

Justin L. Perez, Daniel J. Gould, Michelle Spring, and W. Grant Stevens Francesco M. Egro and J. Peter Rubin

M. Bradley Calobrace and Chester J. Mays

8 Short scar breast reduction

Elizabeth Hall-Findlay, Elisa Bolletta, and Gustavo Jiménez Muñoz Ledo

102

9 Reduction mammaplasty with inverted-T techniques131 Maurice Y. Nahabedian

10 Breast implant illness: diagnosis and management154 Caroline A. Glicksman and Patricia McGuire

11 Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL): diagnosis and management160 Mark W. Clemens, Eliora A. Tesfaye, and Anand Deva

x

Contents

12 A critical analysis of irrigation solutions in breast surgery Grace Keane, Marissa M. Tenenbaum, and Terence M. Myckatyn

13 Imaging and surveillance in patients with breast implants Bradley Bengtson, Patricia McGuire, Caroline Glicksman, and Pat Pazmiño

174

182

191

15 Management strategies for gynecomastia

200

Michele Ann Manahan

16 Management options for gender affirmation surgery of the breast Ara A. Salibian, Gaines Blasdel, and Rachel Bluebond-Langner

207

Section II: Reconstructive Breast Surgery 17 Preoperative evaluation and planning for breast reconstruction following mastectomy222 Saïd C. Azoury and Liza C. Wu

18 Perfusion assessment techniques following mastectomy and reconstruction Alex Mesbahi, Matthew Cissell, Mark Venturi, and Louisa Yemc

234

19 Introduction to prosthetic breast reconstruction239 Maurice Y. Nahabedian

20 One- and two-stage prepectoral reconstruction with prosthetic devices

Alberto Rancati, Claudio Angrigiani, Maurizio Nava, Dinesh Thekkinkattil, Raghavan Vidya, Marcelo Irigo, Agustin Rancati, Allen Gabriel, and Patrick Maxwell

21 One-stage dual-plane reconstruction with prosthetic devices Brittany L. Vieira and Amy S. Colwell

247

265

293

Kiya Movassaghi and Christopher N. Stewart

25 Management of complications of prosthetic breast reconstruction Nima Khavanin and John Y.S. Kim

Jin Sup Eom and Hyunho Han

32 Autologous breast reconstruction with the superficial inferior epigastric artery (SIEA) flap

413

33 Introduction to autologous reconstruction with alternative free flaps

420

34 Gluteal free flaps for breast reconstruction

424

Pierre Chevray

Maurice Y. Nahabedian

Salih Colakoglu and Gedge D. Rosson

35 Autologous breast reconstruction with medial thigh flaps 433 Venkat V. Ramakrishnan and Nakul Gamanlal Patel

36 Autologous breast reconstruction with the profunda artery perforator (PAP) flap

450

37 Autologous reconstruction with the lumbar artery perforator (LAP) free flap

461

38 Hybrid breast reconstruction: combining flaps and implants

468

39 Innervation of autologous flaps

475

40 Stacked and conjoined flaps

481

41 Management of complications following autologous breast reconstruction

488

Adam T. Hauch, Hugo St. Hilaire, and Robert J. Allen, Sr.

Phillip Blondeel and Dries Opsomer

Aldona J. Spiegel and Janak A. Parikh

Anne C. O’Neill, Vincent J. Choi, and Stefan O.P. Hofer

23 Two-stage prosthetic reconstruction with total muscle coverage Colleen M. McCarthy and Peter G. Cordeiro

371

Adrian McArdle and Joan E. Lipa

Nicholas T. Haddock and Sumeet S. Teotia

280

24 Skin reduction using “smile mastopexy” technique in breast reconstruction

30 Autologous breast reconstruction with the DIEP flap

Arash Momeni, Hani Sbitany, and Suhail K. Kanchwala

22 Two-stage dual-plane reconstruction with prosthetic devices Ara A. Salibian and Nolan S. Karp

355

Dennis C. Hammond

31 Autologous breast reconstruction with the free TRAM flap 396

14 Breast implant explantation: indications and strategies to optimize aesthetic outcomes Connor Crowley, M. Bradley Calobrace, Mark W. Clemens, and Neil Tanna

29 Breast reconstruction with the latissimus dorsi flap

298

42 Enhanced recovery after surgery (ERAS) protocols in breast surgery: techniques and outcomes498 Nicholas F. Lombana, Reuben A. Falola, John C. Cargile, and Michel H. Saint-Cyr

43 Secondary procedures following autologous reconstruction516 Jian Farhadi and Vendela Grufman

44 Introduction to oncoplastic breast surgery

526

45 Partial breast reconstruction using reduction and mastopexy techniques

533

Maurice Y. Nahabedian

304

26 Secondary refinement procedures following prosthetic breast reconstruction

317

27 Introduction to autologous breast reconstruction with abdominal free flaps

46 Oncoplastic breast reconstruction: local flap techniques547

336

47 Surgical and non-surgical management of breast cancer-related lymphedema

Roy de Vita and Veronica Vietti Michelina

Maurice Y. Nahabedian

28 Breast reconstruction with the pedicle TRAM flap Jake C. Laun and Julian J. Pribaz

Albert Losken, Nusaiba F. Baker, and Alexandre Munhoz

Moustapha Hamdi and Claudio Angrigiani

340

Ketan M. Patel, Emma C. Koesters, Rachel Lentz, and Orr Shauly

556

Contents

48 Breast reconstruction and radiotherapy: indications, techniques, and outcomes

Jaume Masià, Cristhian D. Pomata, and Javier Sanz

567

49 Robotic-assisted autologous breast reconstruction581 Karim A. Sarhane and Jesse C. Selber

50 Total breast reconstruction by external vacuum expansion (EVE) and autologous fat transfer (AFT)

590

51 Current options for nipple reconstruction

603

Andrzej Piatkowski and Roger K. Khouri David Chi and Justin M. Sacks

Index610

Introduction:  Plastic surgery contributions to hand surgery James Chang

Section I: Principles of Hand Surgery 1 Anatomy and biomechanics of the hand

James Chang, Anais Legrand, Francisco J. Valero-Cuevas, Vincent R. Hentz, and Robert A. Chase

liii

1

3 Diagnostic imaging of the hand and wrist

70

4 Anesthesia for upper extremity surgery Eugene Park, Jonay Hill, Vanila M. Singh, and Subhro K. Sen

5 Principles of internal fixation

Margaret Fok, Jason R. Kang, Christopher Cox, and Jeffrey Yao

Section II: Trauma Reconstruction 6 Nail and fingertip reconstruction Amanda Brown, Brian A. Mailey, and Michael W. Neumeister

95 109

123

8 Fractures and dislocations of the wrist and distal radius

173

9 Flexor tendon injuries and reconstruction

193

Jin Bo Tang

10 Extensor tendon injuries

Kai Megerle and Karl-Josef Prommersberger

230

11 Replantation250 Dong Chul Lee and Eugene Park

12 Reconstructive surgery of the mutilated hand 272 S. Raja Sabapathy and Hari Venkatraman

13 Thumb reconstruction: Non-­microsurgical techniques305 Jeffrey B. Friedrich, Nicholas B. Vedder, and Elisabeth Haas-Lützenberger

14 Thumb reconstruction: Microsurgical techniques320 Nidal F. Al Deek and Fu-Chan Wei

17 Dupuytren’s disease

384

18 Osteoarthritis in the hand and wrist

411

19 Rheumatologic conditions of the hand and wrist

449

20 Occupational disorders of the hand

491

Section IV: Nerve Disorders 21 Nerve entrapment syndromes

499

22 Peripheral nerve repair and reconstruction

526

23 Brachial plexus injuries: adult and pediatric

552

James K-K. Chan, Paul M.N. Werker, and Jagdeep Nanchahal Paige M. Fox, J. Henk Coert, and Steven L. Moran

Simon Farnebo, Johan Thorfinn, and Lars B. Dahlin Johnny Chuieng-Yi Lu and David Chwei-Chin Chuang

24 Tetraplegia585 Carina Reinholdt and Catherine Curtin

25 Tendon transfers

605

26 Nerve transfers

638

27 Free-functioning muscle transfer

665

Section V: Challenging Disorders 28 The ischemic hand

680

29 The spastic hand

704

30 The stiff hand

716

31 The painful hand

735

Neil F. Jones

Kirsty Usher Boyd, Ida K. Fox, and Susan E. Mackinnon

Hee Chang Ahn, Jung Soo Yoon, and Neil F. Jones

147

Steven C. Haase and Kevin C. Chung

356

Kashyap K. Tadisina, Justin M. Sacks, and Mitchell A. Pet

Simeon C. Daeschler, Kristen M. Davidge, Leila Harhaus, and Gregory H. Borschel

7 Hand fractures and joint injuries

Warren C. Hammert and Randy R. Bindra

16 Tumors of the hand

Elisabet Hagert and Donald Lalonde

49

Alphonsus K.S. Chong, Janice Liao, and David M.K. Tan

337

Andrew O’Brien, Ryan P. Calfee, Jana Dengler, and Amy M. Moore

Celine Yeung and Steven J. McCabe

2 Examination of the upper extremity Ryosuke Kakinoki

Section III: Specific Disorders 15 Infections of the hand

Douglas M. Sammer and Kevin C. Chung

Volume Six: Hand and Upper Extremity

xi

Caroline Leclercq, Nathalie Bini, and Charlotte Jaloux



David T. Netscher, Rita E. Baumgartner, Kimberly Goldie Staines, and Logan W. Carr Hazel Brown, Anna Berridge, Dennis Hazell, Parashar Ramanuj, and Tom J. Quick

Section VI: Congenital Disorders 32 Congenital hand I: Embryology, classification, and principles 746 Michael Tonkin and Kerby C. Oberg

33 Congenital hand II: Malformations – whole limb

770

34 Congenital hand III: Malformations – abnormal axis differentiation – hand plate: proximodistal and radioulnar

790

Aaron Berger, Soumen Das De, Bhaskaranand Kumar, and Pundrique Sharma

Brinkley K. Sandvall and Charles A. Goldfarb

xii

Contents

35 Congenital hand IV: Malformations – abnormal axis differentiation – hand plate: unspecified axis

824

36 Congenital hand V: Deformations and dysplasias – variant growth

842

Christianne A. van Nieuwenhoven

Wee Leon Lam, Xiaofei Tian, Gillian D. Smith, and Shanlin Chen

37 Congenital hand VI: Dysplasias – tumorous conditions868 Amir H. Taghinia and Joseph Upton

38 Congenital hand VII: Dysplasias – congenital contractures898 Ellen Satteson, Paul C. Dell, Xiao Fang Shen, and Harvey Chim

39 Growth considerations in the pediatric upper extremity909 Marco Innocenti and Sara Calabrese

Section VII: New Directions 40 Treatment of the upper extremity amputee Gregory Ara Dumanian, Sumanas W. Jordan, and Jason Hyunsuk Ko

930

41 Upper extremity composite allotransplantation949 Christopher D. Lopez, Joseph Lopez, Jaimie T. Shores, W.P. Andrew Lee, and Gerald Brandacher

42 Aesthetic hand surgery

963

43 Hand therapy

983

David Alan Kulber and Meghan C. McCullough

Wendy Moore, Minnie Mau, and Brittany N. Garcia Index999

Video Contents Volume One Chapter 8: Pre- and intra-operative imaging for plastic surgery 8.1: Injection and monitoring of indocyanine green (ICG) using SPY for real-time lymphatic mapping in patients with lymphedema Arash Momeni and Lawrence Cai

Chapter 15: Wound healing 15.1: Treatment of left ischial pressure ulcer Kristo Nuutila, David E. Varon, and Indranil Sinha

Chapter 17: Skin grafting 17.1: Harvesting a split-thickness skin graft Dennis P. Orgill

Chapter 19: Repair, grafting, and engineering of cartilage 19.1: Surgical procedure of the implantation of in vitro engineered human ear cartilage 19.2: Follow-up analysis of auricular shape and structure, and mechanical property Wei Liu, Guangdong Zhou, and Yilin Cao

Chapter 27: Principles of radiation therapy 27.1: CT simulation and patient setup 27.2: Treatment planning Stephanie K. Schaub, Joseph Tsai, and Gabrielle M. Kane

Chapter 34: Robotics in plastic surgery 34.1: Robotic microsurgery 34.2: Robotic rectus abdominis muscle flap harvest 34.3: Trans-oral robotic surgery 34.4: Robotic latissimus dorsi muscle harvest 34.5: Robotic lymphovenous bypass Jesse C. Selber

Chapter 39: Gender-affirming Surgery 39.1: Pre-operative markings for double incision and free nipple grafting mastectomy. 39.2: Surgical approach to double incision and free nipple grafting mastectomy Edwin Wilkins, Shane D. Morrison, and Martin P. Morris 39.3: Creation of tube-in-tube phalloplasty Jens Urs Berli and Srdjan Kamenko 39.4: Surgical approach to penile inversion vaginoplasty Shane D. Morrison, Martin P. Morris, and William M. Kuzon

Volume Two

Chapter 9.3: Principles and surgical approaches of facelift 9.3.1: Parotid masseteric fascia 9.3.2: Anterior incision 9.3.3: Posterior incision 9.3.4: Facelift skin flap 9.3.5: Buccal fat pad elevation 9.3.6: Facial fat injection Richard J. Warren 9.3.7: Anthropometry, cephalometry, and orthognathic surgery Jonathon S. Jacobs, Jordan M.S. Jacobs, and Daniel I. Taub

Chapter 9.4: Facelift: Facial rejuvenation with loop sutures: the MACS lift and its derivatives 9.4.1: Loop sutures MACS facelift Patrick L. Tonnard

Chapter 9.5: Facelift: Platysma-SMAS plication 9.5.1: Platysma-SMAS plication Dai M. Davies and Miles G. Berry

Chapter 9.9: The lift-and-fill facelift 9.9.1: Adjunctive fat grafting during facelift 9.9.2: Face-lift incision planning Rod J. Rohrich and Erez Dayan

Chapter 9.10: Neck rejuvenation 9.10.1: Intraoperative dissection demonstrating the location of the great auricular nerve during facelift surgery 9.10.2: Intraoperative demonstration of facelift maneuvers in the midface that contribute to neck rejuvenation 9.10.3: Simulated components of neck rejuvenation approached through the submental incision on a fresh cadaver dissection James E. Zins and Jacob Grow 9.10.4: The anterior only approach to the neck James E. Zins, Colin M. Morrison, and C.J. Langevin

Chapter 9.14: Facial feminization 9.14.1: Markings for hairline lowering surgery 9.14.2: Burring of lateral orbital rim 9.14.3: Burring of mandibular body Patrick R. Keller, Matthew Louis, and Devin Coon

Chapter 11: Forehead rejuvenation 11.1: Traditional open brow lift 11.2: Endoscopic brow lift 11.3: Modified lateral brow lift 11.4: Gliding brow lift Richard Warren

Chapter 8.3: Injectables and resurfacing techniques: Botulinum toxin/neurotoxins

Chapter 13: Blepharoplasty

8.3.1: Botulinum toxin injection technique Rawaa Almukhtar and Sabrina G. Fabi

13.1: Perioribital rejuvenation Julius Few Jr. and Marco Ellis

xiv

Video Contents

Chapter 15: Asian facial cosmetic surgery

Chapter 38: Post-bariatric reconstruction

15.1: Nonincisional double eyelidplasty Yeon Jun Kim 15.2: Incisional double eyelidplasty – pretarsal preparation Hong Lim Choi 15.3: Double fold fixation Hong Lim Choi 15.4: Lateral canthal lengthening Yeon Jun Kim 15.5: Medial epicanthoplasty 15.6: Eyelidplasty: Non-incisional method 15.7: Rhinoplasty 15.8: Subclinical ptosis correction (total) 15.9: Secondary rhinoplasty: septal extension graft and costal cartilage strut fixed with K-wire Kyung S. Koh, Jong Woo Choi, and Clyde H. Ishii

38.1: Post-bariatric reconstruction – bodylift procedure J. Peter Rubin and Jonathan W. Toy

Chapter 16: Facial fat grafting 16.1: Structural fat grafting of the face Sydney R. Coleman and Alesia P. Saboeiro

Volume Three Chapter 3: Aesthetic nasal reconstruction 3.1: The three-stage folded forehead flap for cover and lining 3.2: First-stage transfer and intermediate operation Frederick J. Menick

Chapter 4: Auricular construction 4.1: Total auricular construction Akira Yamada

Chapter 5: Secondary treatment of acquired cranio-orbital deformities

Chapter 19: Open technique rhinoplasty

5.1: Temporalis muscle flap 5.2: Orbitozygomatic osteotomy Oleh M. Antonyshyn

19.1: Open technique rhinoplasty Allen L. Van Beek

Chapter 8: Overview of head and neck soft-tissue and bony tumors

Chapter 23: Otoplasty and ear reduction 23.1: Setback otoplasty Leila Kasrai

Chapter 24: Hair restoration 24.1: My preferred hair transplantation technique: A 28 year experience Alfonso Barrera and Victor Zhu

Chapter 27: Abdominoplasty 27.1: Abdominoplasty markings 27.2: Secondary abdominoplasty Alan Matarasso

Chapter 28: Lipoabdominoplasty with anatomical definition: a new concept in abdominal aesthetic surgery 28.1: Lipoabdominoplasty (including secondary lipo) Osvaldo Ribeiro Saldanha, Sérgio Fernando Dantas de Azevedo, Osvaldo Ribeiro Saldanha Filho, Cristianna Bonetto Saldanha, and Luis Humberto Uribe Morelli

Chapter 35.2: Buttock augmentation with implants 35.2.1: Buttock augmentation Terrence W. Bruner, José Abel De la Peña Salcedo, Constantino G. Mendieta, and Thomas L. Roberts

Chapter 36: Upper limb contouring 36.1: Brachioplasty Joseph F. Capella, Margaret Luthringer, and Nikita Shulzhenko 36.2: Upper limb contouring Joseph F. Capella, Matthew J. Travato, and Scott Woehrle

8.1: Surgical approaches to the facial skeleton Yu-Ray Chen, You-Wei Cheong, and Alberto Cordova-Aguilar

Chapter 10: Local flaps for facial coverage 10.1: Facial artery perforator flap 10.2: Local flaps for facial coverage Peter C. Neligan

Chapter 12: Oral cavity, tongue, and mandibular reconstructions 12.1: Profunda artery perforator flap for tongue, inferior maxilla and lower lip defects 12.2: Osteomyocutaneous peroneal artery-based combined flap for reconstruction of type II mandibular defects Ming-Huei Cheng

Chapter 13: Hypopharyngeal, esophageal, and neck reconstruction 13.1: Reconstruction of pharyngoesophageal defects with the anterolateral thigh flap Peirong Yu

Chapter 15: Facial paralysis 15.1: Facial paralysis Eyal Gur 15.2: Facial paralysis 15.3: Cross facial nerve graft 15.4: Gracilis harvest Peter C. Neligan 15.5: Intraoperative gracilis stimulation 15.6: Intraoperative facial nerve stimulation Simeon C. Daeschler, Ronald M. Zuker, and Greogry H. Borschel

Chapter 37: Medial thigh

Chapter 16: Surgical management of facial pain, including migraines

37.1: Thighplasty Samantha G. Maliha and Jeffrey Gusenoff

16.1: Frontal trigger site injection Jeffrey E. Janis and Anna Schoenbrunner

Video Contents

Chapter 17: Facial feminization

Chapter 23: Orbital hypertelorism

17.1: Forehead reconstruction 17.2: Lower jaw and chin contouring Fermin Capitán-Cañadas, Luis Capitán, and Daniel Simon

23.1: Box-shift osteotomy Eric Arnaud

Chapter 19.2: Rotation advancement cheiloplasty 19.2.1: Repair of unilateral cleft lip Philip Kuo-Ting Chen, M. Samuel Noordhoff, Frank Chun-Shin, Chang, and Fuan Chiang Chan 19.2.2: Unilateral cleft lip and palate Philip Kuo-Ting Chen and Lucia Pannuto

Chapter 19.4: Anatomic subunit approximation approach to unilateral cleft lip repair 19.4.1: Medial lip checkpoints David M. Fisher and Raymond W. Tse 19.4.2: Unilateral cleft lip repair – anatomic subunit approximation technique David M. Fisher

Chapter 21.2: Straight line repair with intravelar veloplasty (IVVP) 21.2.1: Straight line repair of the palate with intravelar veloplasty (IVVP) Brian Sommerlad

xv

Chapter 28: Robin sequence 28.1: Tongue lip adhesion technique demonstrated and narrated by the senior author 28.2: Mandibular distraction Arun K. Gosain and Chad A. Purnell

Chapter 29: Treacher Collins syndrome 29.1: Lateral canthotomy 29.2: Ptosis correction 29.3: Dermisfat graft cheek Irene Mathijssen

Chapter 31: Vascular anomalies 31.1: Lip hemangioma Arin K. Greene

Chapter 32: Pediatric chest and trunk deformities 32.1: Cleft sternum 32.2: Thoracic ectopia cordis Han Zhuang Beh, Andrew M. Ferry, Rami P. Dibbs, Edward P. Buchanan, and Laura A. Monson

Chapter 21.3: Double opposing Z-palatoplasty 21.3.1: The Furlow double-opposing Z-palatoplasty Richard E. Kirschner and Jordan N. Halsey

Chapter 21.6: Oral fistula closure 21.6.1: Mobilization of the BFP flap for interposition Mirko S. Gilardino, Sabrina Cugno, and Abdulaziz Alabdulkarim

Volume Four Chapter 3.2: Imaging modalities for diagnosis and treatment of lymphedema

21.7.1: Alveolar bone graft: bone morphogenic protein & demineralized bone matrix Katelyn Kondra, Eloise Stanton, Christian Jimenez, Erik M. Wolfswinkel, Stephen Yen, Mark Urata, and Jeffrey Hammoudeh

3.2.1: ICG lymphangiography for lymphatic mapping before LVA procedure 3.2.2: Microscope-integrated NIRF imaging confirms LVA patency after the anastomosis 3.2.3: UHF-US records the contraction of a functional lymph vessel Balazs Mohos and Chieh-Han John Tzou

Chapter 21.9: Velopharyngeal dysfunction

Chapter 3.3: Lymphaticovenular bypass

21.9.1: Adequate velopharyngeal closer for speech 21.9.2: Velopharyngeal incompetence 21.9.3: Velopharyngeal insufficiency Richard E. Kirschner and Adriane L. Baylis

3.3.1: Supermicrosurgical lymphaticovenicular anastomosis Wei F. Chen, Lynn M. Orfahli, and Vahe Fahradyan

Chapter 21.7: Alveolar clefts

Chapter 21.10: Secondary deformities of the cleft lip, nose, and palate 21.10.1: Abbé flap Larry H. Hollier Jr. and Han Zhuang Beh 21.10.2: Complete takedown 21.10.3: Definitive rhinoplasty Evan M. Feldman, John C. Koshy, Larry H. Hollier Jr., and Samuel Stal 21.10.4: Thick lip and buccal sulcus deformities Evan M. Feldman and John C. Koshy

Chapter 21.11: Cleft and craniofacial orthognathic surgery 21.11.1: Le Fort I BSSO and genioplasty 21.11.2: Genioplasty 21.11.3: Patient recovery from orthognathic surgery Stephen B. Baker

Chapter 3.4: Vascularized lymph node transplant 3.4.1: Supraclavicular lymph node flap harvest Rebecca M. Garza and David W. Chang 3.4.2: Recipient site preparation for vascularized lymph node transfer – axilla David W. Chang

Chapter 3.5: Debulking strategies and procedures: liposuction of leg lymphedema 3.5.1: Liposuction of leg lymphedema: tips and tricks for a successful surgery Håkan Brorson

Chapter 3.6: Debulking strategies and procedures: excision 3.6.1: Charles procedure Peter C. Neligan

xvi

Video Contents

Chapter 4: Lower extremity sarcoma reconstruction 4.1: Case example of a synovial sarcoma in the proximal leg. 4.2: Result 11 years after tumor removal and latissimus dorsi transplantation. Andrés A. Maldonado, Günter K. Germann, and Michael Sauerbier

14.3.6: Radial forearm phalloplasty: venous anastomoses and closure Alexander Y. Li, Walter C. Lin, and Bauback Safa

Chapter 14.4: Breast, chest wall, and facial considerations in gender affirmation

Chapter 5: Reconstructive surgery: lower extremity coverage

14.4.1: Facial feminization: operative technique Kaylee B. Scott, Dana N. Johns, and Cori A. Agarwal

5.1: Anterolateral thigh flap harvest Michel Saint-Cyr

Chapter 17: Perineal reconstruction

Chapter 6.2: Targeted muscle reinnervation in the lower extremity 6.2.1: Targeted muscle reinnervation in the lower extremity Brian L. Chang and Grant M. Kleiber

Chapter 6.3: Lower extremity pain: regenerative peripheral nerve interfaces 6.3.1: Intraoperative demonstration of sciatic nerve neuroma 6.3.2: Demonstration of autologous free skeletal muscle grafts harvested from the lower extremity for RPNIs Nishant Ganesh Kumar, Theodore A. Kung, and Paul S. Cederna

Chapter 7: Skeletal reconstruction 7.1: Harvesting technique of fibular free flap 7.2: Harvesting technique of iliac crest free flap Marco Innocenti, Stephen Kovach III, Elena Lucattelli, and L. Scott Levin 7.3: Medial femoral condyle/medial geniculate artery osseocutaneous free flap dissection Stephen Kovach III and L. Scott Levin

Chapter 9.2: Diabetic foot: management of wounds and considerations in biomechanics and amputations 9.2.1: AT and PT tendon transfers 9.2.2: Cadaver dissection lab: percutaneous tendo-achilles lengthening and vertical contour calcanectomy Jayson N. Atves

Chapter 11: Reconstruction of the chest 11.1: Sternal rigid fixation David H. Song and Michelle C. Roughton

Chapter 12: Reconstruction of the posterior trunk 12.1: Posterior trunk reconstruction with keystone flap Reuben A. Falola, Nicholas F. Lombana, Andrew M. Altman, and Michel H. Saint-Cyr

Chapter 13: Abdominal wall reconstruction 13.1: Ventral hernia repair using narrow well-fixed retrorectus mesh 13.2: “Pumpkin-teeth” flaps for creation of neo-umbilicus Gregory A. Dumanian

Chapter 14.3: Gender affirmation surgery, female to male: phalloplasty; and correction of male genital defects 14.3.1: Right radial forearm phalloplasty: history and markings 14.3.2: Radial forearm phalloplasty: flap donor nerve harvest 14.3.3: Radial forearm phalloplasty: flap shaping 14.3.4: Radial forearm phalloplasty: flap harvest 14.3.5: Radial forearm phalloplasty: vascular anastomoses

17.1: Discovering the role of robotically harvested rectus abdominis muscle flaps in the management of pelvic defects Geraldine T. Klein, Chad M. Bailey, John C. Pederson, Jesse C. Selber, and Louis L. Pisters

Chapter 20: Management of the burned face and neck 20.1: Application of collagen sheet on a partial thickness burn of face 20.2: Resurfacing a post burn scarred face with large full thickness grafts from expanded lower abdominal skin Vinita Puri and Venkateshwaran Narasiman

Chapter 21: Pediatric burns 21.1: Fractional CO2 laser for hypertrophic burn scars Sebastian Q. Vrouwe and Lawrence J. Gottlieb

Volume Five Chapter 3: Primary breast augmentation with implants 3.1: Skin incision and mono-polar needle electrocautery 3.2: Dissection through the deep dermis and subcutaneous fat 3.3: Entrance into the subpectoral space 3.4A: Insertion of the implant – Keller funnel 3.4B: Insertion of the implant – Motiva funnel 3.5: Marking, before performing lucky-8-stitch Charles Randquist

Chapter 5: Augmentation mastopexy 5.1: Preoperative markings for a single-stage augmentation mastopexy 5.2: Augmentation mastopexy W. Grant Stevens

Chapter 8: Short scar breast reduction 8.1: Breast mobility Elizabeth Hall-Findlay, Elisa Bolletta, and Gustavo Jiménez Muñoz Ledo 8.2: SPAIR technique Dennis C. Hammond

Chapter 14: Breast implant explantation: indications and strategies to optimize aesthetic outcomes 14.1: Demonstration of capsulotomy 14.2: Demonstration of a partial capsulectomy 14.3: Demonstration of total capsulectomy showing intact capsule and implant after removal Connor Crowley, M. Bradley Calobrace, Mark W. Clemens, and Neil Tanna

Chapter 15: Management strategies for gynecomastia 15.1: Surgical management of gynecomastia Michele Ann Manahan

Video Contents

15.2: Ultrasound-assisted liposuction Charles M. Malata

Chapter 16: Management options for gender affirmation surgery of the breast 16.1: Preoperative markings and surgical technique for gender affirming double-incision mastectomy Ara A. Salibian, Gaines Blasdel, and Rachel Bluebond-Langner

Chapter 18: Perfusion assessment techniques following mastectomy and reconstruction 18.1: Perfusion imaging as a decision-making tool within the operating room 18.2: ICG fluorescence imaging to determine the extent of perfusion for a perforator flap Alex Mesbahi, Matthew Cissell, Mark Venturi, and Louisa Yemc

Chapter 21: One-stage dual-plane reconstruction with prosthetic devices 21.1: Intraoperative technique: Immediate subpectoral direct-to-implant reconstruction with ADM Brittany L. Vieira and Amy S. Colwell

Chapter 24: Skin reduction using “smile mastopexy” technique in breast reconstruction 24.1: Marking for smile mastopexy 24.2: Operative procedure for smile mastopexy Kiya Movassaghi and Christopher N. Stewart

Chapter 25: Management of complications of prosthetic breast reconstruction

xvii

26.10: Balcony technique for reduction/augmentation mastopexy. Roy de Vita and Veronica Vietti Michelina

Chapter 28: Breast reconstruction with the pedicle TRAM flap 28.1: Unilateral breast reconstruction with a pedicled TRAM flap 28.2: Bilateral breast reconstruction with pedicled TRAM flaps 28.3: Abdominal donor site closure for bilateral TRAM flap Julian Pribaz and Jake Laun 28.4: The bikini inset Jake Laun Paul D. Smith, and Julian Pribaz 28.5: Demonstration of a bipedicled folded TRAM design Julian Pribaz, Jake Laun, Alex Girardot

Chapter 29: Breast reconstruction with the latissimus dorsi flap 29.1: Immediate latis marks 29.2: Delayed latis marks Dennis C. Hammond

Chapter 30: Autologous breast reconstruction with the DIEP flap 30.1: Incision of the anterior rectus fascia 30.2: Incision between the fascial rents 30.3: Intramuscular dissection of the perforator 30.4: Microvascular flap transfer, part 1 30.5: Microvascular flap transfer, part 2 30.6: Drainless progressive tension closure Adrian McArdle and Joan E. Lipa

25.1: Intra-operative video demonstrating poorly incorporated ADM along the inferolateral breast pocket following tissue expander removal 25.2: Patient presents following left sided mastectomy and tissue expander placement with a palpable seroma and fluid wave along the medial breast pocket 25.3: Patient underwent bilateral breast reconstruction following left skin-sparing mastectomy and prophylactic right nipple-sparing mastectomy Nima Khavanin and John Kim

Chapter 31: Autologous breast reconstruction with the free TRAM flap

Chapter 26: Secondary refinement procedures following prosthetic breast reconstruction

34.1: Superior gluteal artery perforator (SGAP) flap 34.2: Inferior gluteal artery perforator (IGAP) flap Peter C. Neligan

26.1: Preoperative 26.2: Postoperative 26.3: Lipoaspiration for lipofilling 26.4: Lipofilling on multiple plane with a fanning technique 26.5: Complete resolution of bilateral animation deformity and capsular contracture in a right breast reconstruction following radiotherapy and left simmetrization 26.6: Complete resolution of bilateral animation deformity and capsular contracture in a right breast reconstruction following radiotherapy and left simmetrization 26.7: Complete resolution of animation deformity after exchange of implant and change of implant placement with prepectoral implant based breast reconstruction. 26.8: Complete resolution of animation deformity after exchange of implant and change of implant placement with prepectoral implant based breast reconstruction. 26.9: Postoperative result in motion after nipple sparing mastectomy with prepectoral implant based breast reconstruction.

Chapter 35: Autologous breast reconstruction with medial thigh flaps

31.1: Elevation of the free TRAM flap Hyunho Han and Jin Sup Eom 31.2: Inset of TRAM flap in delayed breast reconstruction Jin Sup Eom

Chapter 34: Gluteal free flaps for breast reconstruction

35.1: Transverse upper gracilis (TUG) flap 1 Peter C. Neligan 35.2: Transverse upper gracilis (TUG) flap 2 Venkat V. Ramakrishnan

Chapter 36: Autologous breast reconstruction with the profunda artery perforator (PAP) flap 36.1: Profunda artery perforator flap. Adam T. Hauch, Hugo St. Hilaire, and Robert J. Allen Sr.

Chapter 42: Enhanced recovery after surgery (ERAS) protocols in breast surgery: techniques and outcomes 42.1: Traditional transversus abdominis plane block administration by chapter’s senior author

xviii

Video Contents

42.2: Serratus anterior plane and PECS I block administration by chapter’s senior author Nicholas F. Lombana, Reuben A. Falola, John C. Cargile, and Michel H. Saint-Cyr

Chapter 44: Introduction to oncoplastic breast surgery 44.1: Partial breast reconstruction using reduction mammoplasty Maurice Y. Nahabedian

Chapter 47: Surgical and non-surgical management of breast cancer-related lymphedema 47.1: Lymphovenous bypass for BCRL 47.2: Composite SCIP vascularized lymph node transplant Ketan Patel

Volume Six Chapter 1: Anatomy and biomechanics of the hand 1.1: The extensor tendon compartments 1.2: The contribution of the interosseous and lumbrical muscles to the lateral bands 1.3: Extrinsic flexors and surrounding vasculonervous elements, from superficial to deep 1.4: The lumbrical plus deformity 1.5: The sensory and motor branches of the median nerve in the hand James Chang, Vincent R. Hentz, Robert A. Chase, and Anais Legrand

Chapter 2: Examination of the upper extremity 2.1: Flexor profundus test in a normal long finger 2.2: Flexor sublimis test in a normal long finger 2.3: The milking test of the fingers and thumb in a normal hand 2.4: Dynamic tenodesis effect in a normal hand 2.5: Eichhoff test 2.6: Extensor pollicis longus test in a normal person 2.7: Test for the extensor digitorum communis (EDC) muscle in a normal hand 2.8: Test for assessing thenar muscle function 2.9: The “cross fingers” sign 2.10: Scaphoid shift test 2.11: Ulnar fovea sign 2.12: Static two-point discrimination test (s-2PD test) 2.13: Moving 2PD test (m-2PD test) performed on the radial or ulnar aspect of the finger 2.14: Semmes Weinstein monofilament test: The patient should sense the pressure produced by bending the filament 2.15: Allen’s test in a normal person 2.16: Digital Allen’s test 2.17: Adson test 2.18: Roos test Ryosuke Kakinoki

Chapter 3: Diagnostic imaging of the hand and wrist 3.1: Scaphoid lunate dislocation Alphonsus K.S. Chong, David M.K. Tan 3.2: Right wrist positive midcarpal catch up clunk

3.3: Wrist ultrasound Alphonsus K.S. Chong

Chapter 4: Anesthesia for upper extremity surgery 4.1: Supraclavicular block Subhro K. Sen

Chapter 5: Principles of Internal Fixation 5.1: Dynamic compression plating and lag screw technique Christopher Cox 5.2: Headless compression screw 5.3: Locking vs. non-locking plates Jeffrey Yao and Jason R. Kang

Chapter 7: Hand fractures and joint injuries 7.1: PIP volar approach for ORIF Warren C. Hammert and Randy R. Bindra 7.2: Hemi-hamate arthroplasty Warren C. Hammert 7.3: MCP dislocation Warren C. Hammert and Randy R. Bindra 7.4: Metacarpal shaft ORIF narrated 7.5: Bennet reduction Warren C. Hammert

Chapter 9: Flexor tendon injuries and reconstruction 9.1: Zone II flexor tendon repair 9.2: Incision and feed tendon forward 9.3: Distal tendon exposure 9.4: Six-strand M-Tang repair 9.5: Extension-flexion test – wide awake 9.6: How to pass FDP tendon through a palm incision Jin Bo Tang

Chapter 10: Extensor tendon injuries 10.1: Secondary suture of central slip 10.2: Sagittal band reconstruction 10.3: Setting the tension in extensor indicis transfer Kai Megerle

Chapter 11: Replantation 11.1: Replantation Dong Chul Lee 11.2: Hand replantation James Chang

Chapter 12: Reconstructive surgery of the mutilated hand 12.1: Debridement technique James Chang

Chapter 13: Thumb reconstruction: Nonmicrosurgical techniques 13.1: First dorsal metacarpal artery (FDMA) flap 13.2: Osteoplastic thumb reconstruction Jeffrey B. Friedrich

Chapter 14: Thumb reconstruction: Microsurgical techniques 14.1: Trimmed great toe 14.2: Second toe for index finger

Video Contents

14.3: Combined second and third toe for metacarpal hand Nidal F. Al Deek

Chapter 17: Dupuytren’s disease 17.1: Surgical technique of PNF 17.2: Surgical technique of LF James K-K. Chan, Paul M.N. Werker, and Jagdeep Nanchahal

Chapter 18: Osteoarthritis in the hand and wrist 18.1: Ligament reconstruction tendon interposition arthroplasty of the thumb carpometacarpal joint James W. Fletcher

Chapter 19: Rheumatologic conditions of the hand and wrist 19.1: Silicone metacarpophalangeal arthroplasty Kevin C. Chung and Evan Kowalski 19.2: Extensor tendon rupture and end-side tendon transfer James Chang

Chapter 21: Nerve entrapment syndromes 21.1: The manual muscle testing algorithm 21.2: Scratch collapse test – carpal tunnel Elisabet Hagert 21.3: Injection technique for carpal tunnel surgery Donald Lalonde 21.4: Carpal tunnel and cubital tunnel releases in the same patient in one procedure with field sterility: Part 1 – local anesthetic injection for carpal tunnel Donald Lalonde and Michael Bezuhly 21.5: Wide awake carpal tunnel surgery Donald Lalonde 21.6: Endoscopic carpal tunnel release 21.7: Clinical exam and surgical technique – Lacertus syndrome Elisabet Hagert 21.8.1: Triple nerve release 1 21.8.2: Triple nerve release 2 21.8.3: Triple nerve release 3 Donald Lalonde 21.9: Carpal tunnel and cubital tunnel releases in the same patient in one procedure with field sterility: Part 2 – local anesthetic injection for cubital tunnel Donald Lalonde and Michael Bezuhly 21.10: Injection technique for cubital tunnel surgery 21.11: Wide awake cubital tunnel surgery Donald Lalonde 21.12: Clinical exam and surgical technique – Radial tunnel syndrome 21.13: Clinical exam and surgical technique – Lateral intermuscular syndrome 21.14: Clinical exam and surgical technique – Axillary nerve entrapment Elisabet Hagert

Chapter 22: Peripheral nerve repair and reconstruction 22.1: Suture repair of the cut digital nerve 22.2: Suture repair of the median nerve Simon Farnebo, Johan Thorfinn, and Lars B. Dahlin

xix

Chapter 23: Brachial plexus injuries: adult and pediatric 23.1: Supraclavicular brachial plexus dissection Johnny Chuieng-Yi Lu and David Chwei-Chin Chuang 23.2: Nerve transfer results 1 23.3: Nerve transfer results 2 23.4: Operative demonstration of 1) Contralateral C7 to innervate injured median nerve via free vascularized ulnar nerve graft, 2) 3rd to 5th intercostal nerve transfer to musculocutaneous nerve for a patient with right total root avulsion 23.5: Nerve transfer results 3 23.6: Nerve transfer results 4 David Chwei-Chin Chuang 23.7: Long-term result after total left brachial plexus palsy reconstruction Johnny Chuieng-Yi Lu and David Chwei-Chin Chuang 23.8: Nerve transfer results 5 David Chwei-Chin Chuang

Chapter 24: Tetraplegia 24.1: The single-stage grip and release procedure 24.2: Postoperative results after single-stage grip release procedure in OCu3-5 patients 24.3: Postoperative function after grip release procedure Carina Reinholdt and Catherine Curtin

Chapter 26: Nerve transfers 26.1: Guyon’s canal release and carpal tunnel release – extended Susan E. Mackinnon and Andrew Yee

Chapter 27: Free-functioning muscle transfer 27.1: Gracilis functional muscle harvest Gregory H. Borschel

Chapter 28: The ischemic hand 28.1: Extended sympathectomy of the radial, ulnar and common digital arteries for Raynaud’s phenomenon Neil F. Jones 28.2: Radial artery reconstruction with cephalic vein graft 28.3: Ulnar artery reconstruction with DIEA graft Hee Chang Ahn and Jung Soo Yoon

Chapter 29: The spastic hand 29.1: Hyperselective neuroectomy musculo-cutaneous Caroline Leclercq, Nathalie Bini, and Charlotte Jaloux

Chapter 30: The stiff hand 30.1: Volkmann angle allowing finger extension 30.2: Post-Operative demonstration 30.3: Joint demonstration after three days in a resting splint 30.4: Full function of joints during hockey practice 30.5: Weak grip strength, enough to impact work efficiency 30.6: Improved grip after elevating the original flap David T. Netscher, Rita E. Baumgartner, Kimberly Goldie Staines, and Logan W. Carr

Chapter 31: The painful hand 31.1: Surgical intervention: nerve root avulsion injuries 31.2: Surgical intervention: decompression and neurolysis Hazel Brown, Anna Berridge, Dennis Hazell, Parashar Ramanuj, and Tom J. Quick

xx

Video Contents

Chapter 32: Congenital hand I: Embryology, classification, and principles

Chapter 39: Growth considerations in the pediatric upper extremity

32.1: Pediatric trigger thumb release James Chang

39.1: Epiphyseal transplant harvesting technique Marco Innocenti and Sara Calabrese

Chapter 33: Congenital hand II: Malformations – whole limb

Chapter 41: Upper extremity composite allotransplantation

33.1: Function of left hand of patient in Figure 33-4 33.2: Congenital radioulnar synostosis of the right forearm and narrowing of the proximal radioulnar joint on the left forearm Aaron Berger, Soumen Das De, Bhaskaranand Kumar, and Pundrique Sharma

41.1: Upper extremity composite tissue allotransplantation W.P. Andrew Lee and Vijay S. Gorantla

Chapter 36: Congenital hand V: Deformations and dysplasia – variant growth 36.1: Surgical release of trigger thumb 36.2: Surgical release of trigger finger Wee Leon Lam, Xiaofei Tian, Gillian D. Smith, and Shanlin Chen 36.3: Thumb hypoplasia Amir H. Taghinia and Joseph Upton III

Chapter 37: Congenital hand VI: Dysplasia – tumorous conditions 37.1: Excision of venous malformation Joseph Upton III and Amir H. Taghinia

Chapter 42: Aesthetic hand surgery 42.1: Injection of radiesse using a bolus technique 42.2: Post-injection massage 42.3: Markings for autologous fat grafting 42.4: A fanning technique is used to maximize surface area contact between the fat and recipient tissues David Alan Kulber and Meghan C. McCullough

Chapter 43: Hand therapy 43.1: Fabrication of the RMA orthosis Wendy Moore, Minnie Mau, and Brittany N. Garcia

Lecture Video Contents Volume One Chapter 1: Plastic surgery and innovation in medicine Plastic surgery and innovation in medicine Peter C. Neligan

Chapter 25: Principles and techniques of microvascular surgery Principles and techniques of microvascular surgery Fu-Chan Wei, Sherilyn Keng Lin Tay, and Nidal F. Al Deek

Chapter 26: Tissue expansion and implants

Chapter 7: Digital photography in plastic surgery

Tissue expansion and implants Britta A. Kuehlmann, Eva Brix, and Lukas M. Prantl

Digital photography in plastic surgery

Chapter 27: Principles of radiation therapy

Daniel Z. Liu Chapter 8: Pre-and intra-operative imaging for plastic surgery Pre- and intra-operative imaging in plastic surgery Arash Momeni and Lawrence Cai

Chapter 16: Scar prevention, treatment, and revision Scar prevention, treatment, and revision Michelle F. Griffin, Evan Fahy, Michael S. Hu, Elizabeth R. Zielins, Michael T. Longaker, and H. Peter Lorenz

Principles of radiation therapy Stephanie K. Schaub, Joseph Tsai, and Gabrielle M. Kane

Chapter 29: Benign and malignant nonmelanocytic tumors of the skin and soft tissue Benign and malignant nonmelanocytic tumors of the skin and soft tissue Rei Ogawa

Chapter 39: Gender-affirming surgery Gender-affirming surgery Shane D. Morrison, William M. Kuzon Jr., and Jens U. Berli

Chapter 17: Skin grafting Skin grafting Shawn Loder, Benjamin Levi, and Audra Clark

Chapter 19: Repair, grafting, and engineering of cartilage Repair, grafting, and engineering of cartilage Wei Liu, Guangdong Zhou, and Yilin Cao

Chapter 20: Repair and grafting of bone Repair and grafting of bone Iris A. Seitz, Chad M. Teven, Bryce Hendren-Santiago, and Russell R. Reid

Chapter 21: Repair and grafting of peripheral nerve Repair and grafting of peripheral nerve Hollie A. Power, Kirsty Usher Boyd, Stahs Pripotnev, and Susan E. Mackinnon

Chapter 22: Repair and grafting fat and adipose tissue Repair and grafting fat and adipose tissue J. Peter Rubin

Chapter 23: Vascular territories Vascular territories Steven F. Morris and G. Ian Taylor

Chapter 24: Flap physiology, classification, and applications Flap physiology, classification, and applications Joon Pio Hong and Peter C. Neligan Flap pathophysiology and pharmacology Cho Y. Pang and Peter C. Neligan

Volume Two Chapter 5: Anatomic blocks of the face and neck Anatomic blocks of the face and neck Stelios C. Wilson and Barry Zide

Chapter 7: Non-surgical skin care and rejuvenation Non-surgical skin care and rejuvenation Zoe Diana Draelos

Chapter 8.2: Injectables and resurfacing techniques: Soft-tissue fillers Injectables and resurfacing techniques: soft-tissue fillers Kavita Mariwalla

Chapter 8.3: Injectables and resurfacing techniques: Botulinum toxin/neurotoxins Injectables and resurfacing techniques: botulinum toxin/neurotoxins Rawaa Almukhtar and Sabrina G. Fabi

Chapter 8.4: Injectables and resurfacing techniques: Lasers in aesthetic surgery Injectables and resurfacing techniques: Lasers in aesthetic surgery Jonathan Cook, David M. Turer, Barry E. DiBernardo, and Jason N. Pozner

Chapter 8.5: Injectables and resurfacing techniques: Chemical peels Injectables and resurfacing techniques: Chemical peels Richard H. Bensimon and Peter P. Rullan

xxii

Lecture Video Contents

Chapter 9.2: Facial anatomy and aging

Chapter 11: Forehead rejuvenation

Facial anatomy and aging Bryan Mendelson and Chin-Ho Wong

Forehead rejuvenation Richard Warren

Chapter 9.3: Principles and surgical approaches of facelift

Chapter 12: Endoscopic brow lift

Principles and surgical approaches of facelift Richard J. Warren

Endoscopic brow lifting Renato Saltz and Eric W. Anderson

Chapter 13: Blepharoplasty

Chapter 9.4: Facelift: Facial rejuvenation with loop sutures: the MACS lift and its derivatives

Blepharoplasty Julius Few Jr. and Marco Ellis

Facelift: Facial rejuvenation with loop sutures: the MACS lift and its derivatives Patrick Tonnard, Alexis Verpaele, and Rotem Tzur

Chapter 14: Secondary blepharoplasty Secondary blepharoplasty Seth Z. Aschen and Henry M. Spinelli

Chapter 9.5: Facelift: Platysma-SMAS plication

Chapter 15: Asian facial cosmetic surgery

Facelift: Platysma-SMAS plication Miles G. Berry, James D. Frame III, and Dai M. Davies

Asian facial cosmetic surgery Jong Woo Choi, Tae Suk Oh, Hong Lim Choi, and Clyde Ishii

Chapter 9.6: Facelift: Lateral SMASectomy facelift

Chapter 16: Facial fat grafting

Facelift: Lateral SMASectomy facelift Daniel C. Baker and Steven M. Levine

Facial fat grafting Francesco M. Egro, Sydney R. Colman, and J. Peter Rubin

Chapter 18: Nasal analysis and anatomy

Chapter 9.7: Facelift: The extended SMAS technique in facial rejuvenation

Nasal analysis and anatomy Rod J. Rohrich and Paul N. Afrooz

Facelift: The extended SMAS technique in facial rejuvenation James M. Stuzin

Chapter 19: Open technique rhinoplasty

Chapter 9.8: High SMAS facelift: Combined single flap lifting of the jawline, cheek and midface High SMAS facelift: combined single flap lifting of the jawline, cheek and midface Timothy Marten and Dino Elyassnia

Chapter 9.9: The lift-and-fill facelift The lift-and-fill facelift Stav Brown, Justin L. Bellamy, and Rod J. Rohrich

Chapter 9.10: Neck rejuvenation Neck rejuvenation James E. Zins and Jacob Grow

Chapter 9.11: Male facelift Male facelift Timothy Marten and Dino Elyassnia

Open technique rhinoplasty Rod J. Rohrich and Paul N. Afrooz

Chapter 20: Closed technique rhinoplasty Closed technique rhinoplasty Mark B. Constantian

Chapter 21: Airway issues and the deviated nose Airway issues and the deviated nose Ali Totonchi, Bryan Armijo, and Bahman Guyuron

Chapter 22: Secondary rhinoplasty Secondary rhinoplasty David M. Kahn, Danielle H. Rochlin, and Ronald P. Gruber

Chapter 23: Otoplasty and ear reduction Otoplasty and ear reduction Charles H. Thorne

Chapter 24: Hair restoration

Chapter 9.12: Secondary facelift irregularities and the secondary facelift

Hair restoration Alfonso Barrera and Victor Zhu

Secondary facelift irregularities and the secondary facelift Timothy Marten and Dino Elyassnia

Chapter 25.2: Liposuction: a comprehensive review of techniques and safety

Chapter 9.13: Perioral rejuvenation, including chin and genioplasty

Liposuction: A comprehensive review of techniques and safety Gianfranco Frojo, Jayne Coleman, and Jeffrey Kenkel

Perioral rejuvenation, including chin and genioplasty Ali Totonchi and Bahman Guyuron

Chapter 25.3: Correction of liposuction deformities with the SAFE liposuction technique

Chapter 9.14: Facial femininization Facial feminization Patrick R. Keller, Matthew Louis, and Devin Coon

Correction of liposuction deformities with the SAFE liposuction technique Simeon H. Wall Jr. and Paul N. Afrooz

Lecture Video Contents

Chapter 27: Abdominoplasty Abdominoplasty Alan Matarasso

Volume Three

Chapter 30: Bra-line back lift

Chapter 1: Management of craniomaxillofacial fractures

Bra-line back lift Joseph Hunstad and Saad A. Alsubaie

Management of craniomaxillofacial fractures Srinivas M. Susarla, Russell E. Ettinger, and Paul N. Manson

Chapter 31: Belt Lipectomy

Chapter 2: Scalp and forehead reconstruction

Belt lipectomy Amitabh Singh and Al S. Aly

Scalp and forehead reconstruction Alexander F. Mericli and Jesse C. Selber

Chapter 32: Circumferential approaches to truncal contouring in massive weight loss patients: the lower lipo-bodylift

Chapter 3: Aesthetic nasal reconstruction

Circumferential approaches to truncal contouring in massive weight loss patients: the lower lipo-bodylift Dirk F. Richter and Nina Schwaiger

Chapter 33: Circumferential approaches to truncal contouring: autologous buttocks augmentation with purse-string gluteoplasty Circumferential approaches to truncal contouring: autologous buttocks augmentation with purse-string gluteoplasty Joseph P. Hunstad and Nicholas A. Flugstad

Chapter 34: Circumferential approaches to truncal contouring: Lower bodylift with autologous gluteal flaps for augmentation and preservation of gluteal contour Circumferential approaches to truncal contouring: Lower bodylift with autologous gluteal flaps for augmentation and preservation of gluteal contour Robert F. Centeno and Jazmina M. Gonzalez

Chapter 35.2: Buttock augmentation with implants Buttock augmentation with implants Jose Abel De la Peña Salcedo, Jocelyn Celeste Ledezma Rodriguez, and David Gonzalez Sosa

Chapter 35.3: Buttock shaping with fat grafting and liposuction

Aesthetic nasal reconstruction Frederick J. Menick

Chapter 4: Auricular construction Auricular construction Dale J. Podolsky, Leila Kasrai, and David M. Fisher

Chapter 8: Overview of head and neck soft-tissue and bony tumors Overview of head and neck soft-tissue and bony tumors Sydney Ch'ng and Edwin Morrison

Chapter 9: Post-oncologic midface reconstruction: the Memorial Sloan-Kettering Cancer Center and MD Anderson Cancer Center Approaches Post-oncologic midface reconstruction: the MSKCC and MDACC approaches Matthew M. Hanasono and Peter G. Cordeiro

Chapter 10: Local flaps for facial coverage Local flaps for facial coverage Nicholas Do and John Brian Boyd

Chapter 11: Lip reconstruction Lip reconstruction Julian J. Pribaz and Mitchell Buller Complex lip reconstruction: local flaps Julian J. Pribaz Total lip reconstruction Julian J. Pribaz

Buttock shaping with fat grafting and liposuction Constantino G. Mendieta, Thomas L. Roberts III, and Terrence W. Bruner

Chapter 12: Oral cavity, tongue, and mandibular reconstructions

Chapter 36: Upper limb contouring

Oral cavity, tongue, and mandibular reconstructions Ming-Huei Cheng

Upper limb contouring Margaret Luthringer, Nikita O. Shulzhenko, and Joseph F. Capella

Chapter 38: Post-bariatric reconstruction Post-bariatric reconstruction Jonathan W. Toy and J. Peter Rubin

Chapter 40: Aesthetic genital surgery Aesthetic genital surgery Gary J. Alter

xxiii

Chapter 13: Hypopharyngeal, esophageal, and neck reconstruction Hypopharyngeal, esophageal, and neck reconstruction Min-Jeong Cho and Peirong Yu

Chapter 15: Facial paralysis Facial paralysis Simeon C. Daeschler, Ronald M. Zuker, and Gregory H. Borschel

xxiv

Lecture Video Contents

Chapter 19.1: Unilateral cleft lip: introduction

Chapter 12: Reconstruction of the posterior trunk

Unilateral cleft lip Joseph E. Losee and Michael R. Bykowski

Reconstruction of the posterior trunk Reuben A. Falola, Nicholas F. Lombana, Andrew M. Altman, and Michel H. Saint-Cyr

Chapter 20: Repair of bilateral cleft lip Repair of bilateral cleft lip John B. Mulliken and Daniel M. Balkin

Chapter 21.1: Cleft palate: introduction Cleft palate Michael R. Bykowski and Joseph E. Losee

Chapter 21.4: Buccal myomucosal flap palate repair Buccal myomucosal flap palate repair Robert Joseph Mann

Chapter 25.2: Nonsyndromic craniosynostosis Nonsyndromic craniosynostosis Sameer Shakir and Jesse A. Taylor

Chapter 28: Robin sequence Robin sequence Sofia Aronson, Chad A. Purnell, and Arun K. Gosain

Chapter 31: Vascular anomalies Vascular anomalies Arin K. Greene and John B. Mulliken

Volume Four Chapter 2: Management of lower extremity trauma Management of lower extremity trauma Hyunsuk Peter Suh

Chapter 3.3: Lymphaticovenular bypass Lymphaticovenular bypass Wei F. Chen, Lynn M. Orfahli, and Vahe Fahradyan

Chapter 3.4: Vascularized lymph node transplant Vascularized lymph node transplant Rebecca M. Garza and David W. Chang

Chapter 3.6: Debulking strategies and procedures: excision Debulking strategies and procedures: excision Hung-Chi Chen and Yueh-Bih Tang

Chapter 5: Reconstructive surgery: lower extremity coverage Reconstructive surgery: lower extremity coverage Joon Pio Hong

Chapter 11: Reconstruction of the chest Reconstruction of the chest Brian L. Chang, Banafsheh Sharif-Askary, and David H. Song

Chapter 13: Abdominal wall reconstruction Abdominal wall reconstruction Gregory A. Dumanian

Chapter 14.1: Gender confirmation surgery: diagnosis and management Gender confirmation surgery: diagnosis and treatment Loren Schechter and Rayisa Hontscharuk

Chapter 15: Reconstruction of acquired vaginal defects Reconstruction of acquired vaginal defects Leila Jazayeri, Andrea L. Pusic, and Peter G. Cordeiro

Chapter 16: Pressure sores Pressure sores Ibrahim Khansa and Jeffrey E. Janis

Chapter 17: Perineal reconstruction Perineal reconstruction Ping Song, Hakim Said, and Otway Louie

Volume Five Chapter 3: Primary breast augmentation with implants Primary breast augmentation with implants Charles Randquist

Chapter 4: Autologous fat transfer: Fundamental principles and application for breast augmentation Autologous fat transfer: fundamental principles and application for breast augmentation Roger Khalil Khouri, Raul A. Cortes, and Daniel Calva-Cerquiera

Chapter 5: Augmentation mastopexy Augmentation mastopexy Justin L. Perez, Daniel J. Gould, Michelle Spring, and W. Grant Stevens

Chapter 9: Reduction mammaplasty with inverted-T techniques Reduction mammaplasty with inverted-T techniques Maurice Y. Nahabedian

Chapter 20: One- and two-stage prepectoral reconstruction with prosthetic devices One- and two-stage prepectoral reconstruction with prosthetic devices Alberto Rancati, Claudio Angrigiani, Maurizio Nava, Dinesh Thekkinkattil, Raghavan Vidya, Marcelo Irigo, Agustin Rancati, Allen Gabriel, and Patrick Maxwell

Lecture Video Contents

xxv

Chapter 21: One-stage dual-plane reconstruction with prosthetic devices

Chapter 48: Breast reconstruction and radiotherapy: indications, techniques, and outcomes

One-stage dual-plane reconstruction with prosthetic devices Brittany L. Vieira and Amy S. Colwell

Breast reconstruction and radiotherapy: indications, techniques, and outcomes Jaume Masià, Cristhian D. Pomata, and Javier Sanz

Chapter 27: Introduction to autologous breast reconstruction with abdominal free flaps Introduction to autologous breast reconstruction with abdominal free flaps Maurice Y. Nahabedian

Volume Six Chapter 1: Anatomy and biomechanics of the hand

Chapter 29: Breast reconstruction with the latissimus dorsi flap

Anatomy and biomechanics of the hand James Chang, Anais Legrand, Francisco J. Valero-Cuevas, Vincent R. Hentz, and Robert A Chase

Breast reconstruction with the latissimus flap Dennis C. Hammond

Chapter 7: Hand fractures and joint injuries

Chapter 30: Autologous breast reconstruction with the DIEP flap Autologous breast reconstruction with the DIEP flap Adrian McArdle and Joan E. Lipa

Chapter 34: Gluteal free flaps for breast reconstruction Gluteal free flaps for breast reconstruction Salih Colakoglu and Gedge D. Rosson

Chapter 35: Autologous breast reconstruction with medial thigh flaps Autologous breast reconstruction with medial thigh flaps Venkat V. Ramakrishnan and Nakul Gamanlal Patel

Chapter 36: Autologous breast reconstruction with the profunda artery perforator (PAP) flap Autologous breast reconstruction with the profunda artery perforator (PAP) flap Adam T. Hauch, Hugo St. Hilaire, and Robert J. Allen Sr.

Chapter 37: Autologous reconstruction with the lumbar artery perforator (LAP) free flap Autologous reconstruction with the lumbar artery perforator (LAP) free flap Phillip Blondeel and Dries Opsomer

Chapter 40: Stacked and conjoined flaps

Hand fractures and joint injuries Warren C. Hammert and Randy R. Bindra

Chapter 8: Fractures and dislocations of the wrist and distal radius Fractures and dislocations of the wrist and distal radius Steven C. Haase and Kevin C. Chung

Chapter 11: Replantation Replantation Dong Chul Lee and Eugene Park

Chapter 13: Thumb reconstruction: Nonmicrosurgical techniques Thumb reconstruction: Non-microsurgical techniques Jeffrey B. Friedrich, Nicholas B. Vedder, and Elisabeth Haas-Lützenberger

Chapter 14: Thumb reconstruction: Microsurgical techniques Thumb reconstruction: Microsurgical techniques Nidal F. Al Deek and Fu-Chan Wei

Chapter 21: Nerve entrapment syndromes Nerve entrapment syndromes Elisabet Hagert and Donald Lalonde

Chapter 22: Peripheral nerve repair and reconstruction Peripheral nerve repair and reconstruction Simon Farnebo, Johan Thorfinn, and Lars B. Dahlin

Stacked and conjoined flaps Nicholas T. Haddock and Sumeet S. Teotia

Chapter 24: Tetraplegia

Chapter 43: Secondary procedures following autologous reconstruction

Tetraplegia Carina Reinholdt and Catherine Curtin

Secondary procedures following autologous reconstruction Jian Farhadi and Vendela Grufman

Chapter 25: Tendon transfers Tendon transfers Neil F. Jones

Chapter 44: Introduction to oncoplastic breast surgery

Chapter 26: Nerve transfers

Introduction to oncoplastic breast surgery Maurice Y. Nahabedian

Nerve transfers Kirsty Usher Boyd, Ida K. Fox, and Susan E. Mackinnon

xxvi

Lecture Video Contents

Chapter 30: The stiff hand The stiff hand David T. Netscher, Rita E. Baumgartner, Kimberly Goldie Staines, and Logan W. Carr

Chapter 31: The painful hand Clinical assessment of the function of the sympathetic nervous system Clinical assessment of the function of the nervous system: Hoffman-Tinel Test Hazel Brown, Anna Berridge, Dennis Hazell, Parashar Ramanuj, and Tom J. Quick

Chapter 39: Growth considerations in the pediatric upper extremity Growth considerations in the Pediatric upper extremity Marco Innocenti and Sara Calabrese

Chapter 40: Treatment of the upper extremity amputee Treatment of the upper extremity amputee Gregory Ara Dumanian, Sumanas W. Jordan, and Jason Hyunsuk Ko

Preface to the Fifth Edition This is the 5th edition of Plastic Surgery but the third and last edition for which I have been lucky enough to be Editor-in Chief. Looking back on the almost 15 years I have been involved in this series, I marvel at how many advances have been made in the specialty in that relatively short time. My predecessors, Drs. McCarthy and Mathes, who edited the 1st and 2nd editions, did so by themselves. When I took over the 3rd edition I realized that the specialty had become so complex that one person could not possibly have the bandwidth to do justice to all the information that an encyclopedic series such as this demands. I therefore introduced separate editors for each volume, bringing their subspecialty expertise to each volume, helping to highlight advances in their areas of subspecialty as well as identifying leaders in the field and up-and-coming authorities to author the various chapters. In this edition we have increased the number of volume editors. This reflects the ever-increasing complexity as well as the most recent advances in each area. In this 5th edition, Andrea Pusic joins Geoff Gurtner in Volume 1; Alan Matarasso teams up with Peter Rubin in Volume 2; Richard Hopper has replaced Ed Rodriguez (who did an outstanding job but, because of increased work demands, had to step down) and edited Volume 3 with Joe Losee; JP Hong joined David Song in Volume 4. Mo Nahabedian in Volume 5 and Jim Chang in Volume 6 updated both of those volumes. Developments continue within the specialty and we have endeavored to capture them in this edition. Dr. Daniel Liu, the multimedia editor has, once again, done an amazing job in compiling and editing the media content. In the 3rd edition we compiled multiple movies to complement the text. In the 4th edition we considerably expanded the list of videos and added lectures to accompany selected chapters. Many of these presentations were done by the chapter authors; the rest were compiled by Dr. Liu and myself from the content of the individual chapters. We have kept many of the movies and lectures from the previous editions and added to them yet again. A significant feature in this edition is the artwork on the cover. I am truly indebted to John Semple, a friend and former colleague of mine in Toronto, for providing this original piece of art. As well as being a talented and widely published plastic surgeon, John is an artist and a musician as well as being Fellow of the Canadian National Geographic Society, well known for his research on climate change in the Himalayas. I asked John if he would consider doing a painting for the cover of this edition and was delighted when he accepted.

In both the 3rd and 4th editions, we started the process of organizing the content with face-to-face meetings with the volume editors as well as the Elsevier team. Because of COVID, this was not possible for this edition so it was all planned via video conferencing. We held regular online meetings between Elsevier and the volume editors during the whole production process. This proved not only to be convenient, but extremely efficient. We went through the 4th edition volume by volume, chapter by chapter, decided what needed to stay, what needed to be added, what needed to be revised, and what needed to be changed. We also decided who should write the various chapters, keeping many existing authors, replacing others, and adding some new ones; we did this in order to really reflect the changes occurring within the specialty. Apart from the updated content, there is a lot that is new in each volume of this edition. We have new chapters on patient-reported outcome measures (PROMs), on education and teaching in Plastic Surgery, on gender-affirmation surgery, lymphedema, local anesthetic blocks in aesthetic surgery, facial feminization, diabetic foot management, to name but some. We have also added multiple algorithms for various conditions, all in an effort to make the text easier to use and more approachable. In my travels around the world since the 3rd edition was published, I’ve been struck by the impact this publication has had on the specialty and, more particularly, on training. Everywhere I go, I’m told how the text is an important part of didactic teaching and a font of knowledge. It was gratifying to see the 3rd edition translated into Portuguese, Spanish, and Chinese. The 4th edition has been equally successful. When I first took over as Editor-in-Chief of this series, Elsevier wanted a new edition to be produced every 5 years. At first I thought that was too ambitious, but as this 5th edition is published I am struck, once again, by the extent of what has changed and how the specialty has continually developed, as evidenced by the number of completely new chapters (34), not to mention all the updated ones. I hope this 5th edition continues to contribute to the specialty, remains a resource for practicing surgeons, and continues to prepare our trainees for their future careers in Plastic Surgery. Peter C. Neligan Phoenix, AZ March, 2023

List of Editors Editor-in-Chief Peter C. Neligan, MB, FRCS(I), FRCSC, FACS Professor Emeritus Surgery, Division of Plastic Surgery University of Washington Seattle, WA, United States

Volume 3: Pediatric Surgery Joseph E. Losee, MD Ross H. Musgrave Professor of Pediatric Plastic Surgery Department of Plastic Surgery University of Pittsburgh Medical Center Chief, Division of Pediatric Plastic Surgery UPMC Children’s Hospital of Pittsburgh Pittsburgh, PA, United States

Volume 1: Principles Geoffrey C. Gurtner, MD, FACS Professor and Chair, Department of Surgery Professor of Biomedical Engineering College of Medicine University of Arizona Tucson, AZ, United States

Volume 4: Lower Extremity, Trunk and Burns David H. Song, MD, MBA, FACS Physician Executive Director and Chairman Plastic Surgery Georgetown University Washington, DC, United States

Andrea L. Pusic, MD Chief, Division of Plastic and Reconstructive Surgery Brigham and Women’s Hospital Boston, MA, United States

Joon Pio Hong, MD, PhD, MMM Professor, Plastic Surgery Asan Medical Center University of Ulsan Seoul, Republic of Korea Adjunct Professor Plastic and Reconstructive Surgery Georgetown University Washington, DC, United States

Volume 2: Aesthetic J. Peter Rubin, MD, FACS Professor and Chair, Department of Plastic Surgery Professor of Bioengineering University of Pittsburgh Pittsburgh, PA, United States

Volume 5: Breast Maurice Y. Nahabedian, MD, FACS Former Professor of Plastic Surgery Johns Hopkins University, Georgetown University, and the Virginia Commonwealth University Private practice – National Center for Plastic Surgery McLean, VA, United States

Alan Matarasso, MD, FACS Clinical Professor of Surgery Systems Chief of Cosmetic Surgery Hofstra School of Medicine-Northwell Health System New York, NY, United States

Volume 6: Hand and Upper Extremity James Chang, MD Johnson & Johnson Distinguished Professor and Chief Division of Plastic Surgery Stanford University Medical Center Palo Alto, CA, United States

Volume 3: Craniofacial, Head and Neck Surgery Richard A. Hopper, MD, MS Chief, Division of Craniofacial and Plastic Surgery Surgical Director, Craniofacial Center Seattle Children’s Hospital Marlys C. Larson Professor Department of Surgery University of Washington Seattle, WA, United States

Multimedia editor

Daniel Z. Liu, MD Reconstructive Microsurgeon Oncoplastic and Reconstructive Surgery City of Hope Chicago Zion, IL, United States

List of Contributors The editors would like to acknowledge and offer grateful thanks for the input of all previous editions’ contributors, without whom this new edition would not have been possible. VOLUME ONE Hatem Abou-Sayed, MD, MBA, FACS Private Practice Plastic Surgeon Tim Sayed MD, P.C. La Jolla and Newport Beach, CA; Co-Founder and Chief Medical Officer YesDoctor Irvine, CA; Co-Founder and Chief Medical Officer Elevai Labs Newport Beach, CA, United States Paul N. Afrooz, MD Resident Plastic and Reconstructive Surgery University of Pittsburgh Medical Center Pittsburgh, PA, United States Nidal F. Al Deek, MD, MSc Associate Professor of Surgery Division of Plastic and Reconstructive Microsurgery Cleveland Medical Center, University Hospitals Case Western Reserve School of Medicine Cleveland, OH, United States; Chang Gung Memorial Hospital, and Chang Gung School of Medicine Taipei, Taiwan Jens U. Berli, MD Associate Professor Division Chief Plastic Surgery Department of Surgery Oregon Health and Science University Portland, OR, United States Kirsty Usher Boyd, MD, FRCSC Associate Professor Division of Plastic Surgery The Ottawa Hospital University of Ottawa Ottawa, ON, Canada Eva Brix, MD Consultant Plastic Surgeon Department of Plastic, Hand, and Reconstructive Surgery University Hospital Regensburg Regensburg, Germany Stav Brown, MD Research Fellow Plastic and Reconstructive Surgery Memorial Sloan Kettering Cancer Center New York, NY, United States Justin M. Broyles, MD Assistant Professor of Surgery Plastic and Reconstructive Surgery Harvard Medical School, Brigham and Women’s Hospital Boston, MA, United States

Jacqueline N. Byrd, MD, MPH, MS Research Fellow Surgery, Center for Health Outcomes and Policy University of Michigan Ann Arbor, MI; Resident Surgery University of Texas Southwestern Dallas, TX, United States Lawrence Cai, MD Division of Plastic and Reconstructive Surgery Stanford University Medical Center Palo Alto, CA, United States Yilin Cao, MD, PhD Professor Shanghai 9th People’s Hospital Shanghai Jiao Tong University School of Medicine Shanghai, China Kellen Chen, PhD Assistant Research Professor Department of Surgery Department of Biomedical Engineering College of Medicine University of Arizona – Tucson Tucson, AZ, United States Sydney Ch’ng, MBBS, PhD, FRACS Associate Professor Faculty of Medicine and Health The University of Sydney Sydney, NSW, Australia Kevin C. Chung, MD, MS Professor of Surgery Section of Plastic Surgery University of Michigan; Chief of Hand Surgery University of Michigan; Assistant Dean for Faculty Affairs University of Michigan Ann Arbor, MI, United States Franklyn P. Cladis, MD, FAAP Associate Professor of Anesthesiology Department of Anesthesiology The Children’s Hospital of Pittsburgh of UPMC; Program Director, Pediatric Anesthesiology Fellowship The Children’s Hospital of Pittsburgh of UPMC Pittsburgh, PA, United States Audra Clark, MD Assistant Professor General Surgery University of Texas Southwestern Dallas, TX, United States

Alex Clarke, DSc honoris causa, DClinPsych, MSc, BSc (Hons), AFBPS Visiting Professor, Chartered Clinical and Health Psychologist Centre for Appearance Research UWE Bristol Bristol, United Kingdom Michelle Coriddi, MD Attending Plastic Surgery Memorial Sloan Kettering Cancer Center New York, NY, United States Yannick F. Diehm, MD, MSc Resident Doctor Department of Hand, Plastic and Reconstructive Surgery BG Trauma Center Ludwigshafen Ludwigshafen, Germany Jessica Erdmann-Sager, MD, FACS Assistant Professor Harvard Medical School Division of Plastic Surgery Brigham and Women’s Hospital Newton, MA, United States Evan Fahy, MD Clinical Research Fellow Stanford University School of Medicine Division of Plastic and Reconstructive Surgery Stanford, CA, United States Lucas Gallo, MD, MSc, PhD(c) Resident Physician Clinician Investigator Program; Division of Plastic Surgery, Department of Surgery McMaster University Hamilton, ON, Canada Amanda Gosman, MD Professor and Chief of Plastic Surgery Director of Craniofacial and Pediatric Plastic Surgery UC San Diego School of Medicine San Diego, CA, United States Madelijn Gregorowitsch, MD, PhD, MHSc General Practitioner in Training and Clinical Epidemiologist The Julius Center, University Medical Center Utrecht Utrecht, The Netherlands Michelle F. Griffin, MBChB, PhD Clinical Research Fellow Stanford University School of Medicine Division of Plastic and Reconstructive Surgery Stanford, CA, United States

xxx

List of Contributors

Geoffrey C. Gurtner, MD Professor and Chair Department of Surgery Professor of Biomedical Engineering College of Medicine University of Arizona Tucson, AZ, United States Karl-Anton Harms, MBBS O’Brien Institute Department St Vincent’s Institute for Medical Research Melbourne, VIC, Australia Valentin Haug, MD Resident Doctor Department of Hand, Plastic and Reconstructive Surgery BG Trauma Center Ludwigshafen Ludwigshafen, Germany Lydia Helliwell, MD Plastic, Hand and Reconstructive Surgeon Brigham and Women’s Hospital Harvard Medical School Boston, MA, United States Bryce Hendren-Santiago, BS Medical Student Pritzker School of Medicine University of Chicago Chicago, IL, United States Dominic Henn, MD Department of Plastic Surgery University of Texas Southwestern Medical Center Dallas, TX, United States George Ho, MD Division of Plastic, Reconstructive and Aesthetic Surgery Department of Surgery University of Toronto Toronto, ON, Canada Joon Pio Hong, MD, PhD, MMM Professor Plastic Surgery Asan Medical Center, University of Ulsan Seoul, Republic of Korea; Adjunct Professor Plastic and Reconstructive Surgery Georgetown University Washington, DC, United States Michael S. Hu, MD Clinical Research Fellow Stanford University School of Medicine Division of Plastic and Reconstructive Surgery Stanford, CA, United States C. Scott Hultman, MD, MBA Professor and Vice Chair Department of Plastic Surgery Johns Hopkins University School of Medicine; Director Burn Center Johns Hopkins Bayview; Fellowship Director Burn Surgical Critical Care Johns Hopkins Bayview Baltimore, MD, United States

Leila Jazayeri, MD Microsurgery Fellow Plastic and Reconstructive Surgery Memorial Sloan Kettering New York, NY, United States

Daniel Z. Liu, MD Reconstructive Microsurgeon Oncoplastic and Reconstructive Surgery City of Hope Chicago Zion, IL, United States

Haley M. Jeffers Student Harvard University Boston, MA, United States

Wei Liu, MD, PhD Professor Plastic and Reconstructive Surgery Shanghai 9th People’s Hospital Shanghai Jiao Tong University School of Medicine Shanghai, China

Lynn Jeffers, MD, MBA, FACS Chief Medical Officer CommonSpirit/Dignity Health St. John’s Regional Medical Center and St. John’s Hospital Camarillo, CA Plastic Surgery Private Practice Oxnard and Camarillo, CA, United States Gabrielle M. Kane, MB, BCh, EdD, FRCPC Professor Emeritus Radiation Oncology University of Washington Seattle, WA, United States Martin Kauke-Navarro, MD Resident Physician Department of Surgery, Division of Plastic Surgery Yale School of Medicine New Haven, CT, United States Timothy W. King, MD, PhD, MSBE, FAAP, FACS Stuteville Division Chief of Plastic and Reconstructive Surgery Professor, Department of Surgery Loyola Stritch School of Medicine Maywood, IL; Plastic Surgery Site Director Department of Surgery Hines VA Hospital Hines, IL, United States Anne F. Klassen, BA(Hons), DPhil Professor Department of Pediatrics McMaster University Hamilton, ON, Canada Britta A. Kuehlmann, Dr. med. Postdoctoral Research Fellow Plastic Surgery Stanford University Palo Alto, CA, United States; Plastic Aesthetic Surgeon, Scientist and Founder, CEO and MD of CINEOLUX Düsseldorf, North Rhine-Westphalia, Germany WiIliam M. Kuzon Jr., MD, PhD Reed O. Dingman Professor of Surgery Department of Surgery University of Michigan Ann Arbor, MI, United States Benjamin Levi, MD Dr. Lee Hudson-Robert R. Penn Chair in Surgery Associate Professor in the Department of Surgery University of Texas Southwestern Medical Center, Dallas, TX, United States

Shawn Loder, MD Resident Department of Plastic Surgery University of Pittsburgh Pittsburgh, PA, United States Michael T. Longaker, MD, MBA, FACS Deane P. and Louise Mitchell Professor of Plastic Surgery Stanford University School of Medicine Division of Plastic and Reconstructive Surgery Stanford, CA, United States H. Peter Lorenz, MD Pediatric Plastic Surgery Service Chief and Professor Stanford University School of Medicine Division of Plastic and Reconstructive Surgery Stanford, CA, United States Susan E. Mackinnon, MD, FRCSC, FACS Minot Packer Fryer Professor of Surgery Director of the Center for Nerve Injury and Paralysis Professor of Plastic and Reconstructive Surgery Division of Plastic and Reconstructive Surgery Washington University School of Medicine St. Louis, MO, United States Michele A. Manahan, MD, MBA, FACS Professor of Clinical Plastic and Reconstructive Surgery Department of Plastic and Reconstructive Surgery Johns Hopkins University School of Medicine Baltimore, MD, United States Isabella C. Mazzola, MD Attending Plastic Surgeon Klinki für Plastiche und Ästhetische Chirurgie Klinikum Landkreis Erding Erding, Germany Riccardo F. Mazzola, MD Plastic Surgeon Department of Specialistic Surgical Sciences Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico Milan, Italy Babak J. Mehrara, MD Chief Plastic and Reconstructive Surgery Memorial Sloan Kettering Cancer Center; Member Plastic and Reconstructive Surgery Memorial Sloan Kettering Cancer Center New York, NY; Professor Plastic and Reconstructive Surgery Weill Cornell Hospital New York, NY, United States

List of Contributors

Arash Momeni, MD Director, Clinical Outcomes Research Division of Plastic and Reconstructive Surgery Stanford University Medical Center Palo Alto, CA, United States

David Perrault, MD Division of Plastic and Reconstructive Surgery Stanford University Stanford, CA, United States

Steven F. Morris, MD, MSc, FRCS(C) Professor Department of Surgery Dalhousie University Halifax, NS, Canada

Bohdan Pomahac, MD Professor of Surgery Chief, Division of Plastic and Reconstructive Surgery Frank F. Kanthak Professor of Surgery Department of Surgery Yale School of Medicine New Haven, CT, United States

Shane D. Morrison, MD, MS Assistant Professor Division of Plastic Surgery, Department of Surgery Seattle Children’s Hospital; Division of Plastic Surgery, Department of Surgery University of Washington Medical Center Seattle, WA, United States

Hollie A. Power, MD, FRCSC Assistant Professor Division of Plastic Surgery, Department of Surgery University of Alberta Edmonton, AB, Canada

Peter C. Neligan, MB, FRCS(I), FRCSC, FACS Professor Emeritus Surgery, Division of Plastic Surgery University of Washington Seattle, WA, United States

Lukas M. Prantl, MD, PhD University Center for Plastic, Reconstructive, and Hand Surgery University Hospital Regensburg Regensburg, Germany

Jonas A. Nelson, MD, MPH Assistant Professor Department of Surgery Memorial Sloan Kettering New York, NY, United States

B. Aviva Preminger, MD, MPH, FACS Preminger Plastic Surgery New York, NY, United States

Peter Nthumba, MD, MSc AIC Kijabe Hospital Department of Plastic Surgery Vanderbilt University Medical Center Nashville, TN, United States Kristo Nuutila, MSc, PhD Principal Research Scientist US Army Institute of Surgical Research San Antonio, TX; Associate Professor of Surgery Uniformed Services University of the Health Sciences Bethesda, MD, United States Anaeze C. Offodile 2nd, MD, MPH Assistant Professor Department of Plastic and Reconstructive Surgery University of Texas MD Anderson Cancer Center; Assistant Professor Department of Health Services Research University of Texas MD Anderson Cancer Center Houston, TX, United States Rei Ogawa, MD, PhD, FACS Professor Department of Plastic, Reconstructive and Aesthetic Surgery Nippon Medical School Tokyo, Japan Christopher J. Pannucci, MD, MS Plastic and Microvascular Surgeon Private Practice Plastic Surgery Northwest Spokane, WA, United States

Karim A. Sarhane, MD, MSc General, Laparoscopic, and Peripheral Nerve Surgeon Burjeel Royal Hospital, Al Ain Abu Dhabi United ArabEmirates Stephanie K. Schaub, MD Assistant Professor Department of Radiation Oncology University of Washington School of Medicine Seattle, WA, United States Iris A. Seitz, MD, PhD Edward-Elmhurst Healthcare Naperville, IL, United States Jesse C. Selber, MD, MPH, FACS Professor, Vice Chair, Director of Clinical Research Department of Plastic Surgery MD Anderson Cancer Center Houston, TX, United States Ramin Shayan, MBBS, PhD, FRACS(Plast) Associate Professor O’Brien Institute Department St. Vincent’s Institute for Medical Research Melbourne, VA, Australia

Stahs Pripotnev, MD, FRCSC Assistant Professor Division of Plastic Surgery Roth | McFarlane Hand and Upper Limb Centre Western University London, ON, Canada

Clifford C. Sheckter, MD Assistant Professor Plastic and Reconstructive Surgery Stanford University Stanford, CA; Associate Director Regional Burn Center Santa Clara Valley Medical Center San Jose, CA, United States

Andrea L. Pusic, MD Professor Chief, Division of Plastic and Reconstructive Surgery Brigham and Women’s Hospital Boston, MA, United States

Indranil Sinha, MD Plastic and Reconstructive Surgery Brigham and Women’s Hospital; Associate Professor Harvard Medical School Boston, MA, United States

Russell R. Reid, MD, PhD Professor Surgery/Section of Plastic and Reconstructive Surgery University of Chicago Medicine Chicago, IL, United States

Dharshan Sivaraj, BS Research Fellow Division of Plastic Surgery, Department of Surgery Stanford University University of Arizona – Tucson Tucson, AZ, United States

Johanna N. Riesel, MD Pediatric Craniofacial and Plastic Surgery The Hospital for Sick Children Toronto, ON, Canada J. Peter Rubin, MD Professor and Chair Department of Plastic Surgery University of Pittsburgh; Professor Bioengineering University of Pittsburgh Pittsburgh, PA, United States Nichola Rumsey, BSC, MSc, PhD Professor Emerita Centre for Appearance Research UWE Bristol Bristol, United Kingdom

xxxi

Sherilyn Keng Lin Tay, MRCS, MSc, FRCS(Plast) Consultant Plastic Surgeon Plastic Surgery Glasgow Royal Infirmary Glasgow, United Kingdom G. Ian Taylor, AO, FRACS Professor Department of Anatomy and Physiology University of Melbourne; Department of Plastic Surgery Royal Melbourne Hospital Melbourne, VIC, Australia Chad M. Teven, MD, MBA, FACS, HEC-C Assistant Professor of Surgery (Clinical) Northwestern University Feinberg School of Medicine Chicago, IL, United States

xxxii

List of Contributors

Achilleas Thoma, MD, MSc, FRCS(C), FACS Clinical Professor, Department of Surgery Associate Member, Department of Health Research Methods, Evidence and Impact (HEI) McMaster University Hamilton, ON, Canada Charles H. Thorne, MD Chairman Department of Plastic Surgery Lenox Hill Hospital New York, NY, United States Joseph Tsai, MD, PhD Department of Radiation Oncology University of Washington School of Medicine Seattle, WA, United States Alexander H.R. Varey, MBChB, MRCS, FRACS, FRCS(Plast), PhD Clinical Associate Professor Faculty of Health and Medicine University of Sydney; Faculty Member Melanoma Institute Australia Sydney; Staff Specialist Plastic and Reconstructive Surgery Westmead Hospital Sydney, NSW, Australia David E. Varon, BS University of Michigan Medical School Ann Arbor, MI, United States Sophocles H. Voineskos, MD, MSc Assistant Professor Division of Plastic Surgery, Department of Surgery University of Toronto Toronto, ON, Canada Fu-Chan Wei, MD, FACS Professor Plastic and Reconstructive Surgery Chang Gung Memorial Hospital Kweishan, Taoyuan, Taiwan Stelios C. Wilson, MD Private Practice Charles H. Thorne MD Plastic Surgery New York, NY, United States Danny Young-Afat, MD, PhD, MHSc Plastic Surgeon and Clinical Epidemiologist Department of Plastic and Reconstructive Surgery Amsterdam University Medical Center Amsterdam, The Netherlands Guangdong Zhou, MD, PhD Professor Plastic and Reconstructive Surgery, Shanghai Key Laboratory of Tissue Engineering Research Shanghai 9th People’s Hospital Shanghai Jiao Tong University School of Medicine Shanghai, China Elizabeth R. Zielins, MD Clinical Research Fellow Stanford University School of Medicine Division of Plastic and Reconstructive Surgery Stanford, CA, United States

VOLUME TWO Paul N. Afrooz, MD Private Practice Miami, FL, United States Rawaa Almukhtar, MD, MPH Scripps Medical Group Dermatology San Diego, CA, United States Saad A. Alsubaie, MD, FACS, FRCSC Asthetic Plastic Surgeon North Texas Plastic Surgery Dallas, TX, United States Gary J. Alter, MD Assistant Clinical Professor Division of Plastic Surgery University of California Los Angeles, CA, United States Al S. Aly, MD Professor of Plastic Surgery Department of Plastic Surgery University of Texas Southwestern Medical Center Dallas, TX, United States Ashley N. Amalfi, MD Board Certified Plastic Surgeon Quatela Center for Plastic Surgery Rochester, NY; Clinical Assistant Professor of Surgery Division of Plastic Surgery University of Rochester School of Medicine Rochester, NY, United States Eric W. Anderson, MD Resident Plastic Surgery University of Utah Salt Lake City, UT, United States Bryan Armijo, MD Plastic Surgery Dallas Plastic Surgery Institute Dallas, TX, United States Seth Z. Aschen, MD Weill Cornell Medical College Division of Plastic and Reconstructive Surgery Weill Cornell Medicine New York, NY, United States Daniel C. Baker, MD Professor of Surgery Institute of Reconstructive Plastic Surgery New York University Medical Center Department of Plastic Surgery New York, NY, United States Alfonso Barrera, MD, FACS Clinical Assistant Professor Plastic Surgery Baylor College of Medicine Houston, TX, United States Justin Bellamy, MD Board Certified Plastic Surgeon West Palm Beach, FL, United States Richard Hector Bensimon, MD Medical Director Plastic Surgery Bensimon Center Portland, OR, United States

Miles G. Berry, MS, FRCS (Plast) Aestheticus Plastic and Aesthetic Surgery London Welbeck Hospital London, UK Stav Brown, MD Research Fellow Plastic and Reconstructive Surgery Memorial Sloan Kettering Cancer Center New York, NY, United States Terrence W. Bruner, MD, MBA AnMed Health Cosmetic and Plastic Surgery Anderson, SC, United States Andrés F. Cánchica Cano, MD Plastic and Reconstructive Surgeon Private Practice Medellín, Colombia Joseph Francis Capella, MD Chief, Post-bariatric Body Contouring Division of Plastic Surgery Hackensack University Medical Center Hackensack, NJ, United States Robert F. Centeno, MD, MBA Medical Director St. Croix Plastic Surgery & MediSpa; Chief Medical Quality Officer Governor Juan F. Luis Hospital & Medical Center Christiansted, US Virgin Islands Sydney R. Coleman, MD Assistant Clinical Professor Plastic Surgery University of Pittsburgh Medical Center Pittsburgh, PA, United States Mark B. Constantian, MD Adjunct Clinical Professor Surgery (Plastic Surgery) University of Wisconsin School of Medicine Madison, WI; Visiting Professor Department of Plastic Surgery University of Virginia Health System Charlottesville, VA, United States Jonathan Cook, MD Plastic Surgeon Private Practice Sanctuary Plastic Surgery Boca Raton, FL, United States Hong Lim Choi JW Plastic Surgery Clinic Seoul, Republic of Korea Jong Woo Choi, MD, PhD, MMM Professor Department of Plastic and Reconstructive Surgery University of Ulsan College of Medicine Asan Medical Center Seoul, Republic of Korea Jayne Coleman Professor Department of Anesthesiology and Pain Medicine University of Texas Southwestern Medical Center Dallas, TX, United States

List of Contributors

Devin Coon, MD, MSE Associate Professor of Plastic Surgery and Biomedical Engineering Department of Plastic and Reconstructive Surgery Johns Hopkins University Baltimore, MD, United States Dai M. Davies, FRCS Consultant and Institute Director Institute of Cosmetic and Reconstructive Surgery London, UK Jose Abel De la Pena Salcedo, MD, FACS Plastic Surgeon Director Instituto de Cirugia Plastica SC Huixquilucan, State of Mexico, Mexico Daniel A. Del Vecchio, MD, MBA Instructor in Surgery Massachusetts General Hospital Boston, MA, United States Zoe Diana Draelos, MD Consulting Professor Department of Dermatology Duke University School of Medicine Durham, NC, United States Barry DiBernardo, MD, FACS Clinical Associate Professor, Plastic Surgery Rutgers, New Jersey Medical School Newark, NJ; Director, New Jersey Plastic Surgery Montclair, NJ, United States Felmont F. Eaves, III, MD, FACS Adjunct Professor of Surgery (Plastic), Emory University ME Plastic Surgery Founder, Executive Chair, and Chief Medical/ Technical Officer, Brijjit Medical, Inc. Atlanta, GA, United States Francseco M. Egro, MD, MSc, MRCS Associate Professor Department of Plastic Surgery University of Pittsburgh Medical Center Pittsburgh, PA, United States Dino Elyassnia, MD, FACS Plastic Surgeon Private Practice Marten Clinic of Plastic Surgery San Francisco, CA, United States Marco Ellis, MD Assistant Professor Plastic Surgery Northwestern Medicine, Feinberg School of Medicine Chicago, IL, United States Sabrina G. Fabi, MD Volunteer Assistant Clinical Professor Department of Dermatology University of California San Diego, San Diego, CA; Associate Dermatology Cosmetic Laser Dermatology San Diego, CA, United States

Julius Few Jr., MD Director Plastic Surgery The Few Institute for Aesthetic Plastic Surgery Chicago, IL Clinical Professor Plastic Surgery University of Chicago Pritzker School of Medicine Chicago, IL Health Science Clinician Northwestern University Plastic Surgery Chicago, IL, United States Nicholas A. Flugstad, MD Plastic Surgeon Denton Plastic Surgery Denton, TX, United States James D. Frame III, MBBS, FRCS, FRCSEd, FRCS(Plast) Professor of Aesthetic Plastic Surgery Anglia Ruskin University Chelmsford, Essex, UK Gianfranco Frojo, MD Plastic Surgeon Private Practice Virginia Beach, VA, United States Jazmina M. Gonzalez, MD Plastic and Cosmetic Surgery Younger Image Plastic Surgery Center Vienna, VA, United States David Gonzalez Sosa, MD Plastic and Reconstructive Surgery Hospital Quirónsalud Torrevieja Alicante, Spain Jacob Grow, MD Plastic Surgery Associate Plastic Surgery Southern Indiana Aesthetic & Plastic Surgery Columbus, IN, United States Ronald P. Gruber, MD Adjunct Clinical Professor Division of Plastic and Reconstructive Surgery Stanford University Stanford, CA; Clinical Professor Division of Plastic and Reconstructive Surgery University of California San Francisco San Francisco, CA, United States Jeffrey Gusenoff, MD Professor of Plastic Surgery Department of Plastic Surgery University of Pittsburgh Pittsburgh, PA, United States Bahman Guyuron, MD Emeritus Professor Plastic Surgery Case Western Reserve University Cleveland, OH, United States Josef G. Hadeed, MD, FACS Plastic Surgeon Hadeed Plastic Surgery Beverly Hills, CA, United States

xxxiii

Joseph Hunstad, MD Plastic Surgeon Plastic Surgery Hunstad-Kortesis-Bharti Center for Cosmetic Plastic Surgery and Medical Spa Huntersville, NC, United States Clyde Ishii, MD John A. Burns School of Medicine Department of Surgery University of Hawaii Honolulu, HI; Assistant Clinical Professor of Surgery University of Hawaii Honolulu, HI; Chief, Plastic Surgery Department of Surgery Shriners Hospital Honolulu, HI, United States Jeffrey E. Janis, MD Professor of Plastic Surgery, Neurosurgery, Neurology, and Surgery Department of Plastic and Reconstructive Surgery Chief of Plastic Surgery, University Hospital Department of Plastic and Reconstructive Surgery Ohio State University Wexner Medical Center Columbus, OH; Past President, American Society of Plastic Surgeons, American Council of Academic Plastic Surgeons, American Hernia Society, and Migraine Surgery Society United States Jeremy T. Joseph, MD Plastic and Reconstructive Surgery Resident Department of Surgery Eastern Virginia Medical School Norfolk, VA, United States David M. Kahn, MD Associate Professor of Plastic Surgery Division of Plastic Surgery Stanford University, Palo Alto, CA, United States Patrick R. Keller, MD Resident Physician Department of Plastic and Reconstructive Surgery Johns Hopkins University Baltimore, MD, United States Jeff Kenkel, MD Professor and Chair Department of Plastic Surgery University of Texas Southwestern Medical Center Dallas, TX, United States Jocelyn Celeste Ledezma Rodriguez, MD Private Practice Guadalajara, Jalisco, Mexico Steven Levine, MD Assistant Professor of Surgery Department of Surgery Hofstra Medical School – Northwell Health System, New York, NY, United States

xxxiv

List of Contributors

Michelle Locke, MBChB, MD, FRACS (Plastics) Plastic and Reconstructive Surgeon Department of Plastic Surgery Middlemore Hospital Auckland; Associate Professor Department of Surgery University of Auckland Auckland, New Zealand Matthew Louis, MD Resident Physician Department of Plastic and Reconstructive Surgery Johns Hopkins University Baltimore, MD, United States Margaret Luthringer, MD Resident Division of Plastic and Reconstructive Surgery Rutgers New Jersey Medical School Newark, NJ, United States Samantha G. Maliha, MD,MS Resident Physician Plastic Surgery University of Pittsburgh Pittsburgh, PA, United States Kavita Mariwalla Director Dermatology Mariwalla Dermatology West Islip, NY, United States Timothy Marten, MD, FACS Private Practice Founder and Director Marten Clinic of Plastic Surgery San Francisco, CA, United States Alan Matarasso, MD, FACS Clinical Professor of Surgery Systems Chief of Cosmetic Surgery Hofstra School of Medicine-Northwell Health System New York, NY, United States Bryan Christopher Mendelson, AM, FRCSE, FRACS, FACS, Diplomate American Board of Plastic Surgery Plastic Surgeon Aesthetic Plastic Surgery The Centre for Facial Plastic Surgery Melbourne, VIC, Australia Constantino G. Mendieta, MD Board Certified Plastic and Reconstructive Surgeon Miami, FL, United States Gabriele C. Miotto, MD Private Practice Adjunct Associate Professor, Division of Plastic Surgery Emory School of Medicine Atlanta, GA, United States Foad Nahai, MD Professor of Surgery Emory University Atlanta, GA, United States

Tae Suk Oh, MD, PhD Professor Department of Plastic and Reconstructive Surgery University of Ulsan College of Medicine Asan Medical Center Seoul, Republic of Korea Sabina Paiva, MD Serviço de Cirurgia Plástica Dr. Osvaldo Saldanha Santos, São Paulo, Brazil Malcolm Paul, MD Clinical Professor of Surgery Department of Plastic Surgery University of California, Irvine, CA, United States Galen Perdikis, MD Chair, Professor Department of Plastic Surgery Vanderbilt University Medical Center Nashville, TN, United States Jason Pozner, MD Adjunct Clinical Faculty Plastic Surgery Cleveland Clinic Florida, Weston, FL; Sanctuary Plastic Surgery Boca Raton, FL, United States Smita R. Ramanadham, MD, FACS Board-certified Plastic Surgeon SR Plastic Surgery P.C Montclair and East Brunswick, NJ, United States Dirk F. Richter, MD Institut ID Aesthetic Surgery and Regenerative Medicine Cologne, Germany Danielle H. Rochlin, MD Plastic Surgery Resident Division of Plastic and Reconstructive Surgery Stanford University Palo Alto, CA, United States Thomas L. Roberts, III Plastic Surgery Center of the Carolinas Spartanburg, SC, United States Rod J. Rohrich, MD Clinical Professor of Plastic Surgery Baylor College of Medicine Past Chair/Distinguished Professor of Plastic Surgery University of Texas Southwestern Medical Center Founding Partner Dallas Plastic Surgery Institute Dallas, TX, United States Peter J. Rubin, MD Professor and Chair Plastic Surgery University of Pittsburgh Pittsburgh, PA; Professor Bioengineering University of Pittsburgh Pittsburgh, PA, United States

Peter P. Rullan, MD Medical Director, Dermatology Institute Chula Vista, CA; Volunteer Clinical Faculty Department of Dermatology University of California San Diego, CA, United States Cristianna Bonetto Saldanha, MD Plastic and Reconstructive Surgeon Santos, São Paulo, Brazil Osvaldo Ribeiro Saldanha, MD, PhD Plastic Surgery Service Osvaldo Saldanha Santos, São Paulo, Brazil; Director of Plastic Surgery Services Department Metropolitan University of Santos – UNIMES São Paulo, Brazil Osvaldo Saldanha Filho, MD Plastic and Reconstructive Surgeon Santos, São Paulo, Brazil Renato Saltz, MD, FACS Adjunct Professor University of Utah Saltz Plastic Surgery and Spa Vitoria Salt Lake City and Park City, UT, United States Anna Schoenbrunner, MD, MAS Department of Plastic and Reconstructive Surgery Ohio State University Columbus, OH, United States Nina Schwaiger, Dr. Plastic and Aesthetic Surgery Clinic Dr. Reba Hanover, Germany Nikita O. Shulzhenko, MD Resident Division of Plastic and Reconstructive Surgery Rutgers New Jersey Medical School Newark, NJ, United States Amitabh Singh, MBBS, MS, DNB, MCh Plastic Surgery Fortis Memorial Research Institute Gurgaon, India Henry M. Spinelli, MD Clinical Professor Surgery and Neurological Surgery Plastic Surgery and Neurological Surgery New York Presbyterian Weill Cornell Medicine New York, NY, United States James M. Stuzin, MD Clinical Professor (Voluntary) Plastic Surgery University of Miami School of Medicine Miami, FL, United States Taisa Szolomicki, MD Plastic and Reconstructive Surgeon Balneário Camboriú, Santa Catarina, Brazil Charles H. Thorne, MD Chairman Department of Plastic Surgery Lenox Hill Hospital New York, NY, United States

List of Contributors

Luiz Toledo, Prof., Dr. Private Practice Plastic Surgery MMC Polyclinic Dubai, United Arab Emirates; Private Practice Plastic Surgery Hospital Saint Louis Lisbon, Portugal Patrick Tonnard, MD, PhD Plastic Surgeon Coupure Centre for Plastic Surgery Ghent, Belgium Ali Totonchi Professor Case Western Reserve University Plastic Surgery MetroHealth Medical Center Cleveland, OH, United States Jonthan W. Toy, MD, FRCSC Associate Clinical Professor Plastic Surgery University of Alberta Edmonton, AB, Canada Rotem Tzur, MD Private Practice Tel Aviv, Israel David Turer, MD, MS Assistant Professor Plastic Surgery University of Pittsburgh Pittsburgh, PA, United States Alexis Verpaele, MD, PhD Plastic Surgeon Coupure Centre for Plastic Surgery Ghent, Belgium Simeon Wall Jr., MD, FACS Director The Wall Center for Plastic Surgery Shreveport, LA; Assistant Clinical Professor Department of Plastic Surgery UT Southwestern Medical Center Dallas, TX; Assistant Clinical Professor Department of Surgery LSU Health Sciences Center at Shreveport Shreveport, LA, United States Richard J. Warren, MD, FRCSC Clinical Professor Division of Plastic Surgery University of British Columbia Vancouver, BC, Canada Stelios C. Wilson, MD Plastic Surgeon Charles H. Thorne MD Plastic Surgery New York, NY, United States Chin-Ho Wong, MBBS, MRCSE, MMed (Surg), FAMS (Plast Surg) Plastic Surgeon Plastic Surgery W Aesthetic Plastic Surgery Singapore

Victor Zhu, MD, MHS Department of Plastic Surgery Kaiser Permanente San Francisco San Francisco, CA, United States Barry M. Zide, MD, DMD Professor Plastic Surgery NYU Langone Health New York, NY, United States James E. Zins, MD Chair, Department of Plastic Surgery Cleveland Clinic Cleveland, OH, United States

VOLUME THREE Neta Adler, MD Plastic Surgeon Ann & Robert H. Lurie Children’s Hospital of Chicago Chicago, IL, United States Abdulaziz Alabdulkarim, MD, FRCSC Craniofacial Surgery Fellow Division of Plastic, Reconstructive and Aesthetic Surgery McGill University Health Center Montreal, QC, Canada; Department of Plastic Surgery Prince Sattam Bin Abdulaziz University Kharj, Riyadh, Saudi Arabia Michael Alperovich, MD, MSc Division of Plastic Surgery Yale School of Medicine New Haven, CT, United States Marta Alvarado, DDS, MS Orthodontist Department of Orthodontics Facultad de Odontología Universidad de San Carlos de Guatemala Guatemala City, Guatemala Oleh M. Antonyshyn, MD Professor Plastic Surgery University of Toronto Toronto, ON, Canada Eric Arnaud, MD Unité fonctionnelle de chirurgie craniofaciale, Service de Neurochirurgie Pédiatrique, Hôpital Necker – Enfants Malades, Assistance Publique – Hôpitaux de Paris, Centre de Référence Maladies Rares CRANIOST, Filière Maladies Rares TeteCou, ERN Cranio Paris, France; Clinique Marcel Sembat, Ramsay Générale de Santé Boulogne-Billancourt, France Sofia Aronson, MD Resident Physician Division of Plastic Surgery Northwestern University Feinberg School of Medicine Chicago, IL, United States

xxxv

Stephen B. Baker, MD, DDS Professor and Program Director Plastic Surgery Medstar Georgetown University Hospital Washington, DC; Medical Director Craniofacial Program Inova Children’s Hospital Falls Church, VA; Attending Physician Plastic Surgery Children’s National Medical Center Washington, DC, United States Daniel M. Balkin, MD, PhD Instructor in Surgery Harvard Medical School Department of Plastic and Oral Surgery Boston Children’s Hospital Boston, MA, United States Scott P. Bartlett, MD Professor of Surgery Department of Surgery University of Pennsylvania Philadelphia, PA; Mary Downs Endowed Chair in Craniofacial Treatment and Research Division of Plastic Surgery Children’s Hospital of Philadelphia Philadelphia, PA, United States Bruce S. Bauer, MD Chief Division of Plastic Surgery NorthShore University HealthSystem Highland Park, IL; Clinical Professor of Surgery Department of Surgery University of Chicago Pritzker School of Medicine Chicago, IL, United States Adriane L. Baylis, PhD, CCC-SLP Speech Scientist Department of Plastic and Reconstructive Surgery Nationwide Children’s Hospital Columbus, OH; Director, VPD Program and Co-Director, 22q Center Department of Plastic and Reconstructive Surgery Nationwide Children’s Hospital Columbus, OH; Associate Professor-Clinical Department of Plastic Surgery Ohio State University College of Medicine Columbus, OH, United States Maureen Beederman, MD Assistant Professor Department of Surgery, Section of Plastic and Reconstructive Surgery University of Chicago Chicago, IL, United States Han Zhuang Beh, MD Cleft, Craniofacial and Pediatric Plastic Surgeon Plastic Surgery Cook Children’s Hospital Fort Worth, TX, United States

xxxvi

List of Contributors

Michael Bentz, MD, FAAP, FACS Chairman, Division of Plastic Surgery Department of Surgery University of Wisconsin Madison, WI; Vice Chair of Clinical Affairs Department of Surgery University of Wisconsin Madison, WI, United States Hannah J. Bergman, MD Plastic and Reconstructive Surgery The Center for Plastic Surgery at CoxHealth Springfield, MO; Clinical Instructor of Surgery University of Missouri School of Medicine Columbia, MO, United States Zoe P. Berman, MD Postdoctoral Research Fellow Hansjörg Wyss Department of Plastic Surgery NYU Langone Health New York, NY; Resident Physician Department of General Surgery Maimonides Medical Center Brooklyn, NY, United States Allan B. Billig, MD Department of Plastic, Reconstructive, and Hand Surgery Hadassah University Medical Center Jerusalem, Israel Craig B. Birgfeld, MD Associate Professor Department of Surgery Division of Plastic and Reconstructive Surgery University of Washington Craniofacial Fellowship Director Seattle Children’s Hospital Seattle, WA, United States Gregory H. Borschel, MD, FACS, FAAP James Joseph Harbaugh, Jr. Professor of Plastic Surgery Department of Plastic Surgery Riley Hospital for Children Indianapolis, IN, United States John Brian Boyd, MB, ChB, MD, FRCS, FECSC, FACS Chief of Plastic Surgery Department of Surgery Harbor-UCLA Torrance, CA; Professor of Surgery Department of Surgery University of California, Los Angeles Los Angeles, CA, United States James P. Bradley, MD Professor and Vice Chairman Plastic and Reconstructive Surgery Northwell Health New York, NY, United States Edward P. Buchanan, MD, FACS Professor, Director of Cleft Care, Program Director Craniofacial Fellowship Department of Surgery Baylor College of Medicine Houston, TX, United States

Steven R. Buchman, MD M. Haskell Newman Professor in Plastic Surgery Department of Surgery University of Michigan Medical School Ann Arbor, MI; Professor of Neurosurgery (Joint Appointment) Department of Neurosurgery University of Michigan Medical School Ann Arbor, MI; Director, Craniofacial Anomalies Program Department of Surgery University of Michigan Medical Center Ann Arbor, MI; Chief, Pediatric Plastic Surgery CS Mott Children’s Hospital Ann Arbor, MI, United States Mitchell Buller, MEng, MD Resident Physician Plastic Surgery University of South Florida Tampa, FL, United States Michael R. Bykowski, MD Assistant Professor, Department of Plastic Surgery Surgical Director, Vascular Anomalies Center Surgical Director, Craniofacial Scleroderma Center Division of Pediatric Plastic Surgery UPMC Children’s Hospital of Pittsburgh Pittsburgh, PA, United States Luis Capitán, MD, PhD Director and Head Surgeon Surgical Department The Facialteam Group Marbella, Málaga, Spain Fermín Capitán-Cañadas, PhD R&D Director Department of Research and Development The Facialteam Group Marbella, Málaga, Spain Anna R. Carlson, MD Fellow in Craniofacial Surgery Plastic Surgery Children’s Hospital of Philadelphia Philadelphia, PA, United States Sydney Ch’ng, MBBS, PhD, FRACS Associate Professor Faculty of Medicine and Health University of Sydney Sydney, NSW, Australia Brian L. Chang, MD Resident Department of Plastic and Reconstructive Surgery MedStar Georgetown University Hospital Washington, DC, United States Philip Kuo-Ting Chen, MD Director Craniofacial Center Taipei Medical University Hospital Taipei; Professor of Surgery Taipei Medical University Taipei, Taiwan

Yu-Ray Chen, MD Professor of Surgery Gung University Chang Gung Memorial Hospital Taipei, Taiwan Ming-Huei Cheng, MD, MBA Professor A+ Surgery Clinic Taoyuan, Taiwan Gerson R. Chinchilla, DDS, MS Director Department of Orthodontics Facultad de Odontología Universidad de San Carlos de Guatemala Guatemala City, Guatemala Min-Jeong Cho, MD Assistant Professor Department of Plastic and Reconstructive Surgery The Ohio State University Columbus, OH, United States Peter G. Cordeiro, MD The William G Cahan Chair in Surgery Plastic and Reconstructive Surgery Service Memorial Sloan Kettering Cancer Center Professor of Surgery Weil Medical College of Cornell University New York, NY, United States Sabrina Cugno, MD, MSc, FRCSC, FACS, FAAP Division of Plastic, Reconstructive and Aesthetic Surgery Montreal Children’s Hospital McGill University Health Center Montreal, QC, Canada Simeon C. Daeschler, MD, Dr. med Postdoctoral Fellow Neuroscience and Mental Health Program SickKids Research Institute The Hospital for Sick Children (SickKids) Toronto, ON, Canada Robert F. Dempsey, MD, FACS, FAAP Assistant Professor Division of Plastic Surgery Department of Surgery Texas Children’s Hospital Baylor College of Medicine Houston, TX, United States Rami P. Dibbs, MD Plastic Surgery University of Texas Medical Branch Galveston, TX, United States Sara R. Dickie, MD Clinician Educator Surgery University of Chicago Hospital, Pritzker School of Medicine Chicago, IL; Attending Surgeon Section of Plastic and Reconstructive Surgery NorthShore University HealthSystem Northbrook, IL, United States Nicholas Do, MD Assistant Professor Plastic Surgery Harbor-UCLA Medical Center Torrance, CA, United States

List of Contributors

Russell E. Ettinger, MD Assistant Professor Craniofacial & Plastic Surgery Seattle Children’s Hospital Seattle, WA; Assistant Professor Plastic Surgery University of Washington Seattle, WA, United States Andrew M. Ferry, MD Clinical Research Fellow Division of Plastic Surgery, Michael E. DeBakey Department of Surgery Baylor College of Medicine Houston, TX; Clinical Research Fellow Division of Plastic Surgery, Department of Surgery Texas Children’s Hospital Houston, TX, United States

Mirko S. Gilardino, MD, MSc, FRCSC, FACS Chief Division of Plastic, Reconstructive and Aesthetic Surgery McGill University Health Center Montreal, QC; Director, H.B. Williams Craniofacial and Cleft Surgery Unit Montreal Children’s Hospital Montreal, QC, United States Daniel H. Glaser, MD, MPH Clinical Fellow Division of Pediatric Rheumatology UPMC Children’s Hospital of Pittsburgh Pittsburgh, PA; Assistant Professor of Clinical Pediatrics (Rheumatology) Department of Pediatrics Yale University School of Medicine New Haven, CT, United States

Alexander L. Figueroa, DMD Adjunct Attending Orthodontist Rush Craniofacial Center Division of Plastic Surgery, Department of Surgery Rush University Medical Center Chicago, IL, United States

Jesse A. Goldstein, MD Associate Professor, Department of Plastic Surgery Craniofacial Surgery Fellowship Director Division of Pediatric Plastic Surgery UPMC Children’s Hospital of Pittsburgh Pittsburgh, PA, United States

Alvaro A. Figueroa, DDS, MS Adjunct Associate Professor Rush Craniofacial Center Division of Plastic Surgery, Department of Surgery Rush University Medical Center Chicago, IL, United States

Arun K. Gosain, MD Children’s Service Board Professor and Chief Stanley Manne Children’s Research Institute Ann & Robert H. Lurie Children’s Hospital of Chicago Chicago, IL, United States

David M. Fisher, MB, BCh, FRCSC, FACS, MFA Medical Director, Cleft Lip and Palate Program Plastic Surgery The Hospital for Sick Children (SickKids) Toronto, ON; Professor Department of Surgery University of Toronto Toronto, ON, Canada Roberto L. Flores, MD Joseph G. McCarthy Associate Professor of Reconstructive Plastic Surgery Hansjörg Wyss Department of Plastic Surgery NYU Langone Health New York, NY, United States Christopher R. Forrest, MD, MSc, FRCSC, FACS Chief, Division of Plastic and Reconstructive Surgery The Hospital for Sick Children (SickKIds) Professor and Chair, Division of Plastic, Reconstructive and Aesthetic Surgery Department of Surgery, Temerty Faculty of Medicine University of Toronto Toronto, ON, Canada

Lawrence J. Gottlieb, MD Professor of Surgery Section of Plastic and Reconstructive Surgery, Department of Surgery University of Chicago Chicago, IL, United States Arin K. Greene, MD, MMSc Vascular Anomalies and Pediatric Plastic Surgery Endowed Chair Department of Plastic and Oral Surgery Boston Children’s Hospital Boston, MA; Professor of Surgery Harvard Medical School Boston, MA, United States Matthew R. Greives, MD, MS Thomas D. Cronin Chair of Plastic Surgery Division of Plastic Surgery, Department of Surgery McGovern Medical School at the University of Texas Health Sciences Center at Houston Houston, TX, United States Samer E. Haber, MD Unité fonctionnelle de chirurgie craniofaciale, Service de Neurochirurgie Pédiatrique, Hôpital Necker – Enfants Malades, Assistance Publique – Hôpitaux de Paris; Centre de Référence Maladies Rares CRANIOST, Filière Maladies Rares TeteCou, ERN Cranio Paris, France

xxxvii

Jordan N. Halsey, MD Assistant Professor Plastic Surgery Johns Hopkins All Children’s Hospital Saint Petersburg, FL, United States Jeffrey Hammoudeh, DDS, MD, FACS Associate Chief Plastic and Maxillofacial Surgery University of Southern California Children’s Hospital Los Angeles Los Angeles, CA, United States Matthew M. Hanasono, MD Professor, Deputy Chair, and Fellowship Program Director Department of Plastic Surgery University of Texas MD Anderson Cancer Center Houston, TX, United States Jill A. Helms, DDS, PhD Professor Department of Surgery Stanford University Stanford, CA, United States Gregory G. Heuer, MD, PhD Associate Professor of Neurosurgery Perelman School of Medicine at the University of Pennsylvania Children’s Hospital of Philadelphia Philadelphia, PA, United States David L. Hirsch, MD, DDS, FACS Professor of OMFS/dental Medicine Zucker School of Medicine at Hofstra-Northwell SVP, Dental Medicine Service Line, Northwell Health System Chair of Dental Medicine/OMFS at Long Island Jewish, North Shore, Lenox Hill Hospital New York, NY, United States Larry H. Hollier Jr., MD Surgeon in Chief Texas Children’s Hospital Professor Department of Surgery Baylor College of Medicine Houston, TX, United States Richard A. Hopper, MD, MS Chief Division of Craniofacial and Plastic Surgery Seattle Children’s Hospital Seattle, WA; Surgical Director Craniofacial Center Seattle Children’s Hospital Seattle, WA; Marlys C. Larson Professor Department of Surgery University of Washington Seattle, WA, United States Adam S. Jacobson, MD, FACS Chief, Division of Head and Neck Surgery Co-Director, Head and Neck Center Director, Fellowship in Head and Neck Oncologic and Reconstructive Surgery Department of Otolaryngology – Head and Neck Surgery New York University – Langone Health New York, NY, United States

xxxviii

List of Contributors

Syril James, MD Unité fonctionnelle de chirurgie craniofaciale, Service de Neurochirurgie Pédiatrique, Hôpital Necker – Enfants Malades, Assistance Publique – Hôpitaux de Paris; Centre de Référence Maladies Rares CRANIOST, Filière Maladies Rares TeteCou, ERN Cranio Paris, France; Clinique Marcel Sembat, Ramsay Générale de Santé Boulogne-Billancourt, France Jeffrey E. Janis, MD Department of Plastic and Reconstructive Surgery Ohio State University Wexner Medical Center Columbus, OH; Past President, American Society of Plastic Surgeons, American Council of Academic Plastic Surgeons, American Hernia Society, and Migraine Surgery Society, United States Christian Jimenez, BS Medical Student Plastic and Reconstructive Surgery Keck School of Medicine of USC Los Angeles, CA, United States

Jamie P. Levine, MD Associate Professor Plastic Surgery NYU Langone Medical Center New York, NY; Chief of Microsurgery New York, NY, United States Jingtao Li, DDS, PhD Associate Professor Oral & Maxillofacial Surgery West China Hospital of Stomatology Sichuan University Chengdu, Sichuan, China Joseph E. Losee, MD Vice Dean for Faculty Affairs, University of Pittsburgh School of Medicine Dr. Ross H. Musgrave Endowed Chair in Pediatric Plastic Surgery Professor and Executive Vice Chair, Department of Plastic Surgery Division Chief, Pediatric Plastic Surgery, UPMC Children’s Hospital of Pittsburgh Pittsburgh, PA, United States

Alexandra Junn, MD Department of Plastic and Reconstructive Surgery MedStar Georgetown University Hospital Washington, DC, United States

Robert Joseph Mann, MD, FACS Senior Surgeon & Surgical Committee Member, Global Smile Foundation Executive Director of the Michigan / Ohio Chapter of Healing the Children Grand Rapids, MI, United States

Sahil Kapur, MD Resident Physician Division of Plastic Surgery University of Wisconsin Madison, WI, United States

Paul N. Manson, MD Distinguished Service Professor Plastic Surgery Johns Hopkins University Baltimore, MD, United States

Leila Kasrai, MD, MPH, FRCSC Division of Plastic Surgery St Joseph’s Health Centre Toronto, ON, Canada

Benjamin B. Massenburg, MD Resident in Plastic and Reconstructive Surgery Department of Surgery Division of Plastic and Reconstructive Surgery University of Washington Seattle, WA, United States

Henry K. Kawamoto Jr., MD, DDS Clinical Professor, Emeritus Surgery, Division of Plastic Surgery University of California, Los Angeles Los Angeles, CA, United States Roman Khonsari, MD, PhD Unité fonctionnelle de chirurgie craniofaciale Service de chirurgie maxillofaciale et chirurgie plastique, Hôpital Necker – Enfants Malades, Assistance Publique – Hôpitaux de Paris; Centre de Référence Maladies Rares CRANIOST, Filière Maladies Rares TeteCou, ERN Cranio; Faculté de Médecine, Université Paris Cité Paris, France Richard E. Kirschner, MD Chair Department of Plastic and Reconstructive Surgery Nationwide Children’s Hospital Columbus, OH; Professor Pediatrics and Plastic Surgery Ohio State University College of Medicine Columbus, OH, United States Katelyn Kondra, MD Department of Plastic and Maxillofacial Surgery Children’s Hospital Los Angeles Los Angeles, CA, United States

Irene Mathijssen, MD, PhD, MBA-H Professor and Head of Department Plastic and Reconstructive Surgery and Hand Surgery Erasmus Medical Center Rotterdam, The Netherlands Frederick J. Menick, MD Medical Director, Cleft Lip and Palate Program Plastic Surgery The Hospital for Sick Children (SickKids) Toronto, ON; Professor Department of Surgery University of Toronto Toronto, ON, Canada Alexander F. Mericli, MD, FACS Associate Professor Plastic Surgery University of Texas MD Anderson Cancer Center Houston, TX, United States Laura A. Monson, MD Assistant Professor Department of Surgery Division of Plastic Surgery Houston, TX, United States

Edwin Morrison, LLB, BComm (Hons Eco), MBBS, FRACS Plastic and Reconstructive Surgery St Vincent’s Hospital Melbourne, VIC; Plastic and Reconstructive Surgery Peter Mac Hospital Melbourne, VIC, Australia John B. Mulliken, MD Professor of Surgery Harvard Medical School Department of Plastic and Oral Surgery Boston Children’s Hospital Boston, MA, United States Lucia Pannuto, MD Fellow Craniofacial surgery Taipei Medical University Hospital Taipei, Taiwan Giovanna Paternoster, MD Unité fonctionnelle de chirurgie craniofaciale, Service de Neurochirurgie Pédiatrique, Hôpital Necker – Enfants Malades, Assistance Publique – Hôpitaux de Paris; Centre de Référence Maladies Rares CRANIOST, Filière Maladies Rares TeteCou, ERN Cranio Paris, France John A. Persing, MD Emeritus Professor of Surgery Division of Plastic Surgery Yale School of Medicine New Haven, CT, United States Dale J. Podolsky, BSc, BESc, MD, PhD, FRCSC Surgeon Craniofacial Surgery The Hospital for Sick Children (SickKids) Toronto, ON, Canada Julian J. Pribaz, MD Professor of Surgery Department of Plastic Surgery University of South Florida Tampa, FL, United States Chad A. Purnell, MD Assistant Professor Division of Plastic, Reconstructive, and Cosmetic Surgery University of Illinois-Chicago Chicago, IL; Craniofacial Surgeon Department of Plastic Surgery Shriners Hospitals for Children – Chicago Chicago, IL, United States Pratik Rastogi, MBBS (Hons), GDAAD, MS, FRACS (PRS) Consultant Plastic and Reconstructive Surgeon St George Hospital Sydney, Australia Johanna N. Riesel, MD Assistant Professor, Division of Plastic and Reconstructive Surgery The Hospital for Sick Children (SickKIds) Division of Plastic, Reconstructive and Aesthetic Surgery Department of Surgery, Temerty Faculty of Medicine University of Toronto Toronto, ON, Canada

List of Contributors

Eduardo D. Rodriguez, MD, DDS Professor and Chair Hansjörg Wyss Department of Plastic Surgery NYU Langone Health New York, NY, United States

Eloise Stanton, BA Medical Student Plastic and Reconstructive Surgery Keck School of Medicine of USC Los Angeles, CA, United States

Anna Schoenbrunner, MD, MAS Department of Plastic and Reconstructive Surgery The Ohio State University Columbus, OH, United States

Srinivas M. Susarla, DMD, MD, FACS, FAAP Associate Professor Oral and Maxillofacial Surgery University of Washington School of Dentistry Seattle, WA; Associate Professor Surgery (Plastic) University of Washington School of Medicine Seattle, WA, United States

Lindsay A. Schuster, DMS, MS Director, Cleft-Craniofacial Orthodontics Pediatric Plastic Surgery UPMC Children’s Hospital of Pittsburgh Pittsburgh, PA; Associate Professor of Plastic Surgery Department of Plastic Surgery University of Pittsburgh School of Medicine Pittsburgh, PA, United States Jesse C. Selber, MD, MPH, FACS Associate Professor Plastic Surgery University of Texas MD Anderson Cancer Center Houston, TX, United States Afaaf Shakir, MD Resident Section of Plastic and Reconstructive Surgery Department of Surgery University of Chicago Chicago, IL, United States Sameer Shakir, MD Assistant Professor Division of Pediatric Plastic Surgery, Children’s Wisconsin Department of Plastic Surgery, Medical College of Wisconsin Milwaukee, WI, United States Pradip R. Shetye, DDS, BDS, MDS Associate Professor (Orthodontics), Director of Craniofacial Orthodontics, and Director of Craniofacial Orthodontic Fellowship Hansjörg Wyss Department of Plastic Surgery NYU Langone Health New York, NY, United States Daniel Simon, DMD Director and Head Surgeon Surgical Department The Facialteam Group Marbella, Málaga, Spain Anusha Singh, MD, MSc Resident Physician Department of Plastic Surgery MedStar Georgetown University Hospital Washington, DC, United States John T. Smetona, MD Craniofacial and Pediatric Plastic Surgery Director of Orthognathic Surgery Advocate Health Oak Lawn, IL, United States Brian Sommerlad, MBBS, DSc(Med) UCL(Hon), FRCS, FRCSE(Hon), FRCPCH, FRCSLT(Hon) Honorary Consultant Plastic Surgeon Department of Plastic Surgery Great Ormond Street Hospital for Children London, United Kingdom

Peter J. Taub, MD, MS Professor and System Chief Division of Plastic and Reconstructive Surgery Icahn School of Medicine at Mount Sinai New York, NY; Director, Cleft and Craniofacial Center Division of Plastic and Reconstructive Surgery Icahn School of Medicine at Mount Sinai New York, NY, United States Jesse A. Taylor, MD Chief, Division of Plastic, Reconstructive, and Oral Surgery Department of Surgery Children’s Hospital of Philadelphia Philadelphia, PA, United States Kathryn S. Torok, MD Co-Director, Pediatric Craniofacial Scleroderma Center UPMC Children’s Hospital of Pittsburgh Pittsburgh, PA; Associate Professor of Pediatrics Pediatric Rheumatology University of Pittsburgh School of Medicine Pittsburgh, PA, United States Raymond W. Tse, MD, FRCSC Associate Professor Craniofacial and Plastic Surgery Seattle Children’s Hospital Seattle, WA, United States Mark Urata, MD, DDS Chief Division of Plastic and Reconstructive Surgery Keck School of Medicine of USC Los Angeles, CA; Chair Division of Oral and Maxillofacial Surgery Ostrow School of Dentistry of USC Los Angeles, CA; Associate Dean of Surgery and Hospital Affairs Ostrow School of Dentistry of USC Los Angeles, CA; Division Head Division of Plastic and Maxillofacial Surgery Children’s Hospital Los Angeles Los Angeles, CA, United States James D. Vargo, MD Craniofacial and Pediatric Plastic Surgeon Plastic Surgery Children’s Hospital and Medical Center Omaha, NE; Assistant Professor of Plastic Surgery Department of Surgery University of Nebraska Medical Center Omaha, NE, United States

xxxix

George Washington, MD Resident Plastic and Reconstructive Surgery University of Texas Health Science Center at Houston Houston, TX, United States Erik Wolkswinkel, MD Assistant Professor Division of Plastic and Reconstructive Surgery Oregon Health & Science University Portland, OR, United States Stephen Yen, DMD, PhD Division of Dentistry and Orthodontics Children’s Hospital Los Angeles Los Angeles, CA, United States Peirong Yu, MD Professor Plastic Surgery University of Texas MD Anderson Cancer Center Houston, TX, United States Ronald M. Zuker, MD, FRCSC, FACS, FRCSEd(Hon) Professor of Surgery Department of Surgery University of Toronto Toronto, ON; Staff Plastic and Reconstructive Surgeon Department of Surgery The Hospital for Sick Children (SickKids) Toronto, ON, Canada

VOLUME FOUR Cori A. Agarwal, MD Associate Professor Plastic Surgery University of Utah Salt Lake City, UT, United States Andrew M. Altman, MD Associate Professor Department of Surgery Baylor Scott & White/Texas A&M Temple, TX, United States Andrew Nagy Atia, MD Department of Surgery Division of Plastic, Maxillofacial, and Oral Surgery Duke University Hospital Durham, NC, United States Christopher E. Attinger, MD Chief, Division of Wound Healing Department of Plastic Surgery Georgetown University Hospital Washington, DC, United States Jayson N. Atves, DPM, AACFAS Assistant Professor Plastic Surgery Georgetown University Washington, DC; Program Director MedStar Georgetown University Hospital Foot and Ankle Research Fellowship Washington, DC, United States

xl

List of Contributors

Håkan Brorson, MD, PhD Professor, Senior Consultant Plastic Surgeon Department of Clinical Sciences Lund University Plastic and Reconstructive Surgery Skåne University Malmö, Sweden; Professor Faculty of Medicine Esculera de Graduados, Asociación Médica Buenos Aires, Argentina; Professor Lund University Cancer Centre Lund, Sweden Paul S. Cederna, MD Chief of Plastic Surgery Robert Oneal Professor of Plastic Surgery Professor of Biomedical Engineering Section of Plastic Surgery, Department of Surgery University of Michigan Ann Arbor, MI, United States Brian L. Chang, MD Resident Department of Plastic and Reconstructive Surgery MedStar Georgetown University Hospital Washington, DC, United States David W. Chang, MD Professor Department of Surgery University of Chicago Chicago, IL, United States Hung-Chi Chen, MD, PhD, FACS Professor Department of Plastic Surgery China Medical University Hospital Taichung, Taiwan Wei F. Chen, MD, FACS Professor of Plastic Surgery Head, Regional Microsurgery and Supermicrosurgery Co-director, Center for Lymphedema Research and Reconstruction Department of Plastic Surgery Cleveland Clinic Cleveland, OH, Unites States Peter G. Cordeiro, MD, FACS Professor of Surgery Weil Medical College of Cornell University New York, NY; William G. Cahan Chair in Surgery Plastic and Reconstructive Surgery Service Memorial Sloan Kettering Cancer Center Westfield, NJ, United States Paige K. Dekker, MD Plastic and Reconstructive Surgery MedStar Georgetown University Hospital Washington, DC, United States Romina Deldar, MD PGY-4, General Surgery MedStar Georgetown University Hospital Washington, DC, United States

Gregory A. Dumanian, MD Stuteville Professor of Surgery Division of Plastic Surgery Northwestern Feinberg School of Medicine Chicago, IL, United States Karen K. Evans, MD Plastic and Reconstructive Surgery MedStar Georgetown University Hospital Washington, DC, United States Vahe Fahradyan, MD Assistant Professor Division of Plastic and Reconstructive Surgery Mayo Clinic Rochester, MN, United States Reuben A. Falola, MD, MPH Postdoctoral Research Fellow Plastic & Reconstructive Surgery Baylor Scott & White Temple, TX, United States Rebecca M. Garza, MD Rebecca Garza Plastic Surgery Schererville, IN, United States Günter K. Germann, MD, PhD Professor of Plastic Surgery Department of Plastic, Reconstructive, Hand and Aesthetic Surgery ETHIANUM Clinic Heidelberg Heidelberg, Germany Lawrence J. Gottlieb, MD, FACS Professor of Surgery Section of Plastic & Reconstructive Surgery University of Chicago Chicago, IL, United States Zoe K. Haffner, BS Medical Student Georgetown University School of Medicine Washington, DC, United States J. Andres Hernandez, MD, MBA Resident Physician Division of Plastic, Maxillofacial and Oral Surgery Duke University Hospital Medical Center Durham, NC, United States Scott Thomas Hollenbeck, MD, FACS Plastic and Reconstructive Surgery Duke University Durham, NC, United States Joon Pio Hong, MD, PhD, MMM Professor Plastic Surgery Asan Medical Center University of Ulsan Seoul, Republic of Korea; Adjunct Professor Plastic and Reconstructive Surgery Georgetown University Washington, DC, United States Rayisa Hontscharuk, MD, MSc, FRCSC Plastic, Reconstructive and Aesthetic Surgeon Private Practice Toronto Plastic Surgery Toronto, ON, Canada

Marco Innocenti, MD Chairman and Professor of Plastic Surgery University of Bologna Director of Orthoplastic Surgery Department Rizzoli Institute Bologna, Italy Jeffrey E. Janis, MD Professor of Plastic Surgery, Neurosurgery, Neurology, and Surgery Department of Plastic and Reconstructive Surgery Ohio State University Wexner Medical Center Columbus, OH; Chief of Plastic Surgery, University Hospital Department of Plastic and Reconstructive Surgery Ohio State University Wexner Medical Center Columbus, OH, United States Leila Jazayeri, MD Microsurgery Fellow Plastic and Reconstructive Surgery Memorial Sloan Kettering Cancer Center New York, NY, United States Dana N. Johns, MD Assistant Professor Plastic Surgery University of Utah Salt Lake City, UT, United States Ibrahim Khansa, MD, FAAP, FACS Assistant Professor of Plastic and Reconstructive Surgery Department of Plastic and Reconstructive Surgery Nationwide Children’s Hospital Columbus, OH, United States Kevin G. Kim, MD Plastic and Reconstructive Surgery MedStar Georgetown University Hospital Washington, DC, United States Grant M. Kleiber, MD Attending Surgeon, Assistant Professor Plastic and Reconstructive Surgery MedStar Georgetown University Hospital MedStar Washington Hospital Center Washington, DC, United States Stephen Kovach III, MD Herndon B. Lehr Endowed Associate Professor Division of Plastic Surgery, Department of Orthopaedic Surgery University of Pennsylvania Philadelphia, PA; Assistant Professor Department of Orthopaedic Surgery University of Pennsylvania Philadelphia, PA, United States Nishant Ganesh Kumar, MD House-Officer Section of Plastic Surgery, Department of Surgery University of Michigan Ann Arbor, MI, United States Theodore A. Kung, MD Associate Professor Section of Plastic Surgery Department of Surgery University of Michigan Ann Arbor, MI, United States

List of Contributors

Raphael C. Lee, MS (BmE), MD, ScD, FACS, FIAMBE Paul and Allene Russell Distinguished Service Professor Emeritus Departments of Surgery, Medicine, Molecular Engineering and Molecular Biosciences University of Chicago Chicago Electrical Trauma Rehabilitation Institute Chicago, IL, United States L. Scott Levin, MD, FACS Chair Orthopaedic Surgery Perelman School of Medicine at the University of Pennsylvania Philadelphia, PA, United States Alexander Y. Li, MD, MS Surgeon Plastic and Reconstructive Surgery Stanford Hospital and Clinics Palo Alto, CA, United States Walter C. Lin, MD, FACS Attending Surgeon Reconstructive Microsurgery The Buncke Clinic San Francisco, CA, United States Nicholas F. Lombana, MD, BS Associate Professor Department of Surgery Baylor Scott & White/Texas A&M Temple, TX, United States Otway Louie, MD Associate Professor Surgery University of Washington Medical Center Seattle, WA, United States Elena Lucattelli, MD Breast Unit A. Franchini Hospital Santarcangelo di Romagna, Italy Andrés A. Maldonado, MD, PhD Plastic Surgery University of Getafe Madrid, Spain; Department of Plastic, Hand and Reconstructive Surgery BG Unfallklinik Frankfurt Frankfurt, Germany John D. Miller, DPM Plastic and Reconstructive Surgery MedStar Georgetown University Hospital Washington, DC, United States Balazs Mohos, MD Microsurgery Fellow Plastic and Reconstructive Surgery, Department of Surgery Hospital of Divine Savior (Göttlicher Heiland Krankenhaus) Vienna, Austria; Heart and Vascular Center, Semmelweis University Budapest, Hungary; Plastic and Reconstructive Surgery, Department of Surgery County Hospital Veszprem Veszprem, Hungary

Vamseedharan Muthukumar, DNB, M Ch, DrNB, MRCS Junior Consultant, Department of Plastic Surgery Ganga Hospital Coimbatore, Tamil Nadu, India Venkateshwaran Narasiman, MS, MCh. Plastic Surgery Consultant Plastic Surgeon Director- Wound Clinic Jupiter Hospital, Thane, Maharashtra, India; Hon. Visiting Consultant Seth G S Medical College and KEM Hospital Mumbai, India Lynn M. Orfahli, MD Resident Division of Plastic and Reconstructive Surgery University of Colorado Aurora, CO, United States Rajiv P. Parikh, MD, MPHS Attending Surgeon, Assistant Professor Plastic and Reconstructive Surgery MedStar Georgetown University Hospital MedStar Washington Hospital Center Washington, DC, United States Vinita Puri, MS (General Surgery), MCh (Plastic Surgery) Professor and Head Department of Plastic Surgery Seth G S Medical College and KEM Hospital Mumbai, Maharashtra, India Andrea L. Pusic, MD Chief Plastic and Reconstructive Surgery Brigham and Women’s Hospital Boston, MA, United States S. Raja Sabapathy, MS, MCh, DNB, FRCSE, FAMS, Hon FRCSG, Hon FRCS (Eng), Hon FACS, DSc (Hon) Chairman Department of Plastic Surgery, Hand Surgery, Reconstructive Microsurgery, and Burns Ganga Hospital Coimbatore, Tamil Nadu, India Hakim Said, MD, FACS Clinical Associate Professor Division of Plastic Surgery University of Washington Seattle, WA, United States Bauback Safa, MD, MBA, FACS Attending Surgeon Reconstructive Microsurgery The Buncke Clinic San Francisco, CA; Adjunct Clinical Faculty Division of Plastic and Reconstructive Surgery Stanford University Palo Alto, CA, United States Michel H. Saint-Cyr, MD, FRCSC Professor Plastic Surgery Banner MD Anderson Cancer Center Phoenix, AZ, United States

xli

Michael Sauerbier, MD, PhD PROFESSOR SAUERBIER Private Practice for Hand and Plastic Surgery Bad Homburg v.d. Höhe, Germany Adaah A. Sayyed, BS Medical Student Georgetown University School of Medicine Washington, DC, United States Loren Schechter, MD Professor of Surgery Division of Plastic Surgery Rush University Medical Center Chicago, IL, United States Kaylee B. Scott, MD Resident Physician Division of Plastic Surgery University of Utah Salt Lake City, UT, United States R. Raja Shanmugakrishnan, MS, DNB, MRCS Consultant, Department of Plastic and Burns Surgery Ganga Hospital Coimbatore, Tamil Nadu, India Banafsheh Sharif-Askary, MD Resident Department of Plastic and Reconstructive Surgery MedStar Georgetown University Hospital Washington, DC, United States David H. Song, MD, MBA Physician Executive Director and Chairman Plastic Surgery Georgetown University Washington, DC, United States Ping Song, MD Virginia Hospital Center Department of Plastic and Reconstructive Surgery Arlington, VA, United States John S. Steinberg, DPM Professor Plastic Surgery Georgetown University School of Medicine Washington, DC, United States Hyunsuk Peter Suh, MD, PhD Associate Professor Plastic Surgery Asan Medical Center Seoul, Republic of Korea Yueh-Bih Tang, MD, PhD Professor in Plastic Surgery National Taiwan University Hospital Taipei; Attending Plastic Surgeon Far Eastern Memorial Hospital New Taipei City, Taiwan Chad M. Teven, MD, MBA, FACS, HEC-C Assistant Professor of Surgery (Clinical) Division of Plastic Surgery Northwestern University Feinberg School of Medicine Chicago, IL, United States

xlii

List of Contributors

Chieh-Han John Tzou, MD, PhD, MBA Director of Plastic and Reconstructive Surgery Hospital of Divine Savior (Göttlicher Heiland Krankenhaus) Vienna; Associate Professor of Plastic and Reconstructive Surgery Faculty of Medicine Sigmund Freud University Vienna; Director Lymphedema and Facial Palsy Center TZOU MEDICAL Vienna, Austria Sebastian Q. Vrouwe, MD, FRCSC Assistant Professor of Surgery Section of Plastic & Reconstructive Surgery University of Chicago Chicago, IL, United States

VOLUME FIVE Allen Gabriel, MD, FACS Plastic Surgeon Vancouver, WA; Clinical Professor Plastic Surgery Loma Linda University Medical Center Loma Linda, CA, United States Robert J. Allen Sr., MD Director Microsurgical Breast Reconstruction Department Ochsner Baptist Hospital New Orleans, LA; Clinical Professor of Plastic Surgery Department of Plastic and Reconstructive Surgery Louisiana State University New Orleans, LA, United States Claudio Angrigiani, MD Director Oncoplastic Surgery Hospital de Clínicas José de San Martín University of Buenos Aires Buenos Aires, Argentina Eric Michel Auclair, MD Plastic Surgeon Clinique Nescens Paris, France Saïd C. Azoury, MD Assistant Professor of Surgery (Plastic Surgery) Division of Plastic Surgery University of Pennsylvania Philadelphia, PA; Assistant Professor of Orthopaedic Surgery Orthopedic Surgery University of Pennsylvania Philadelphia, PA, United States Nusaiba F. Baker, PhD MD PhD Student Medicine Emory University Atlanta, GA, United States

Bradley P. Bengtson, MD, FACS Founder and CEO Bengtson Center for Aesthetics and Plastic Surgery Grand Rapids, MI; Associate Professor Department of Surgery Michigan State University Grand Rapids, MI, United States Giovanni Bistoni, MD Department of Surgery “Pietro Valdoni” Plastic Surgery Unit Policilinico Umberto I, University of Rome “Sapienza” Rome, Italy Gaines Blasdel, BS Research Associate Department of Urology NYU Langone Health New York City, NY; University of Michigan Medical School Ann Arbor, MI, United States Phillip Blondeel, MD, PhD, FCCP Professor Plastic and Reconstructive Surgery Ghent University Ghent, Belgium Rachel Bluebond-Langner, MD Associate Professor of Plastic Surgery Hansjörg Wyss Department of Plastic Surgery NYU Grossman School of Medicine New York, NY, United States Elisa Bolletta, MD, MRBS (Master’s Degree in Surgical Oncology, Reconstructive and Aesthetic Breast Surgery) Department of Plastic and Reconstructive Surgery Policlinico Sant’Orsola-Malpighi IRCCS Bologna, Italy M. Bradley Calobrace, MD Gratis Clinical Faculty Department of Plastic Surgery University of Louisville; CaloAesthetics Plastic Surgery Center Louisville, KY, United States Daniel Calva-Cerquiera, MD Miami Breast Center Miami, FL, United States John C. Cargile, MD Department of Anesthesiology Baylor Scott & White Memorial Hospital Temple, TX, United States Pierre Chevray, MD, PhD Plastic Surgeon Institute for Reconstructive Surgery Houston Methodist Hospital Houston, TX; Associate Professor Surgery Weill Cornell Medical College New York, NY; Adjunct Associate Professor Surgery Baylor College of Medicine Houston, TX, United States

David Chi, MD, PhD Resident Physician Division of Plastic and Reconstructive Surgery Washington University in St. Louis St. Louis, MO, United States Vincent J. Choi, BSc (Med), MBBS, MS, FRACS (Plast) Plastic Surgery University Health Network, University of Toronto Toronto, ON, Canada Matthew Cissell, DHSc, PA-C Surgical Physician Assistant National Center for Plastic Surgery McLean, VA, United States Salih Colakoglu, MD Assistant Professor Department of Plastic and Reconstructive Surgery Johns Hopkins University School of Medicine Baltimore, MD, United States Amy S. Colwell, MD Professor Division of Plastic Surgery Massachusetts General Hospital, Harvard Medical School Boston, MA, United States Raul A. Cortes, MD Miami Breast Center Miami, FL, United States Mark W. Clemens II, MD, MBA, FACS Professor Plastic Surgery MD Anderson Cancer Center; Associate Vice President Perioperative Services MD Anderson Cancer Center Houston, TX, United States Peter G. Cordeiro, MD Attending Surgeon Department of Surgery Memorial Sloan Kettering Cancer Center; Professor of Surgery Weil Medical College of Cornell University New York, NY, United States Connor Crowley, MD Resident Doctor Department of Surgery Northwell New Hyde Park, NY, United States Anand Deva, MBBS(Hons), MS, FRACS Professor Plastic and Reconstructive Surgery Integrated Specialist Healthcare Miranda, NSW, Australia Roy de Vita Chief Plastic and Reconstructive Surgery Department Regina Elena National Cancer Institute Rome, Italy Francesco M. Egro, MD, MSc, MRCS Associate Professor, Department of Plastic Surgery Associate Professor, Department of Surgery University of Pittsburgh Pittsburgh, PA, United States

List of Contributors

Jin Sup Eom, MD, PhD Professor Plastic Surgery Asan Medical Center University of Ulsan, College of Medicine Seoul, Republic of Korea Reuben A. Falola, MD, MPH Postdoctoral Research Fellow Division of Plastic and Reconstructive Surgery Baylor Scott & White Medical Center Temple, TX, United States Jian Farhadi, MD, PD Professor Plastic Surgery Group Zurich; Professor University of Basel Basel, Switzerland Caroline A. Glicksman, MD, MSJ Assistant Clinical Professor Department of Surgery Hackensack Meridian School of Medicine Nutley, NJ, United States Daniel J. Gould, MD, PhD Surgeon, Private Practice Gould Plastic Surgery Beverly Hills, CA, United States Vendela Grufman, MD Consultant Plastic Surgery Plastic Surgery Group Zurich, Switzerland Nicholas T. Haddock VC Business Affairs, Associate Professor Department of Plastic Surgery University of Texas Southwestern Dallas, TX, United States Elizabeth J. Hall-Findlay, MD, FRCSC Private Practice Banff Plastic Surgery Banff, AB, Canada Moustapha Hamdi, MD, PhD Professor Plastic and Reconstructive Surgery Brussels University Hospital Brussels, Belgium Dennis C. Hammond, MD Assistant Program Director Grand Rapids Plastic Surgery Residency Spectrum Health Grand Rapids, MI, United States Hyunho Han, MD, PhD Associate Professor Asan Medical Center University of Ulsan, College of Medicine Seoul, Republic of Korea Adam T. Hauch, MD, MBA Assistant Professor of Clinical Surgery Department of Surgery Louisiana State University New Orleans, LA, United States Stefan O.P. Hofer, MD, PhD, FRCSC Professor of Plastic Surgery University Health Network, University of Toronto Toronto, ON, Canada

Marcelo Irigo, MD Chief Plastic Surgery Hospital Italiano La Plata La Plata, Argentina Suhail K. Kanchwala, MD Associate Professor of Surgery Division of Plastic Surgery University of Pennsylvania Philadelphia, PA, United States Nolan S. Karp, MD Professor of Plastic Surgery Hansjörg Wyss Department of Plastic Surgery NYU Grossman School of Medicine, New York, NY, United States Grace Keane, MD Resident Physician Plastic and Reconstructive Surgery Washington University School of Medicine Saint Louis, MO, United States Nima Khavanin, MD Resident Physician Plastic and Reconstructive Surgery Johns Hopkins University School of Medicine Baltimore, MD, United States Roger Khalil Khouri, MD, FACS Medical Director Miami Breast Center Miami, FL; Professor Department of Surgery Florida International University School of Medicine Miami, FL, United States John Y.S. Kim, MD, MA Professor Department of Surgery Northwestern University Chicago, IL, United States Emma C. Koesters, MD Assistant Professor Plastic and Reconstructive Surgery University of Southern California Los Angeles, CA, United States Jake C. Laun, MD Assistant Professor Department of Plastic Surgery University of South Florida Tampa, FL, United States Patricia McGuire, MD, FACS Clinical Instructor of Surgery Washington University St Louis, MO, United States Gustavo Jiménez Muñoz Ledo, MD Private Practice Phi Aesthetics León Guanajuato, México Anne C. O’Neill, MBBCh, MMedSci, FRCS(Plast), MSc, PhD Associate Professor of Plastic Surgery University Health Network, University of Toronto Toronto, ON, Canada

xliii

Andrzej Piatkowski, MD, PhD Associate Professor Department of Plastic and Reconstructive Surgery Maastricht University Medical Centre, MUMC+ Maastricht, The Netherlands Rachel Lentz, MD Assistant Professor Plastic and Reconstructive Surgery University of Washington Seattle, WA, United States Joan E. Lipa, MD, MSc, FRCSC, FACS Associate Professor Department of Surgery, Division of Plastic, Reconstructive & Aesthetic Surgery University of Toronto; Active Staff Sunnybrook Health Sciences Centre Toronto, ON, Canada Nicholas F. Lombana, MD Plastic Surgery Resident Division of Plastic and Reconstructive Surgery Baylor Scott & White Medical Center Temple, TX, United States Albert Losken, MD, FACS Emory University Division of Plastic and Reconstructive Surgery Emory University Hospital Atlanta, GA, United States Patrick Mallucci, MD Director of Plastic Surgery Mallucci London London, United Kingdom Michele Ann Manahan, MD, MBA, FACS Professor of Clinical Plastic and Reconstructive Surgery Vice Chair of Faculty and Staff Development and Well-Being Department of Plastic and Reconstructive Surgery Johns Hopkins Hospital Baltimore, MD, United States Past President, MedChi, The Maryland State Medical Society Jaume Masià, MD, PhD Chief and Professor Plastic Surgery Sant Pau University Hospital (Universitat Autonoma de Barcelona) Barcelona, Spain Chester J. Mays, MD Plastic Surgeon CaloAaesthetics Plastic Surgery Center CaloAesthetics Plastic Surgery Louisville, KY, United States Patrick Maxwell, MD Plastic Surgeon Assistant Professor of Surgery Vanderbilt University Nashville, TN, United States

xliv

List of Contributors

Adrian McArdle, MBBCh, MD, FRCSI, FEBOPRAS Assistant Professor Department of Surgery, Division of Plastic, Reconstructive and Aesthetic Surgery University of Toronto; Division of Plastic and Reconstructive Surgery Trillium Health Partners Toronto, ON, Canada Colleen M. McCarthy, MD, MHS Attending Surgeon Department of Surgery Memorial Sloan Kettering Cancer Center New York, NY, United States Alexandre Munhoz, MD, PhD Plastic Surgery Hospital Sírio-Libanês São Paulo; Professor Plastic Surgery Instituto do Câncer do Estado de São Paulo São Paulo, SP, Brazil Alex Mesbahi, MD, FACS Founding Partner National Center for Plastic Surgery McLean, VA, United States Arash Momeni, MD, FACS Director, Clinical Outcomes Research Division of Plastic & Reconstructive Surgery Stanford University Medical Center Palo Alto, CA, United States Kiya Movassaghi, MD, DMD, FACS Assistant Clinical Professor; Director, Aesthetic Surgery Fellowship at Movassaghi Plastic Surgery Division of Plastic Surgery Oregon Health & Science and University Portland, OR, United States Terence M. Myckatyn, MD, FACS, FRCSC Professor, Plastic and Reconstructive Surgery Washington University School of Medicine Saint Louis, MO, United States Maurizio Nava, MD Breast & Plastic Surgeon Assistant Professor of Surgery University of Milan Milan, Italy Maurice Y. Nahabedian, MD, FACS Former Professor of Plastic Surgery Johns Hopkins University, Georgetown University and the Virginia Commonwealth University Private practice- National Center for Plastic Surgery Mclean, VA, United States Dries Opsomer, MD Plastic Surgery OLV Aalst Aalst, Belgium Janak A. Parikh, MD, MSHS Resident Plastic Surgery Houston Methodist Houston, TX, United States

Ketan M. Patel, MD Assistant Professor Plastic and Reconstructive Surgery University of Southern California Los Angeles, CA, United States Nakul Gamanlal Patel, BSc(Hons), MBBS(Lond), FRCS(Plast) Consultant Plastic Surgeon Department for Plastic Surgery and Burns University Hospitals of Leicester Leicester, United Kingdom Pat Pazmiño Associate Professor Division of Plastic Surgery University of Miami Miller School of Medicine Miami, FL, United States Justin L. Perez, MD Plastic Surgeon Medical Director, Marina Plastic Surgery MarinaRox Aesthetic Fellowship Marina del Rey, CA, United States Cristhian D. Pomata, MD, MSc Associate Plastic Surgery Clinica Planas Barcelona, Spain Julian J. Pribaz, MD Professor of Surgery Department of Plastic Surgery University of South Florida Tampa, FL, United States

Justin M. Sacks, MD, MBA, FACS Chief Division of Plastic and Reconstructive Surgery Sidney M. Jr. and Robert H. Shoenberg Professor of Surgery Washington University in St. Louis School of Medicine St. Louis, MO, United States Michel H. Saint-Cyr, MD, MBA, FRCSC Professor Department of Plastic and Reconstructive Surgery Banner M.D. Anderson Cancer Center Phoenix, AZ, United States Javier Sanz, MD, PhD Associate Professor Pompeu Fabra University Barcelona Radiation Oncologist Radiation Oncology Department Hospital del Mar Barcelona, Spain Hugo St. Hilaire, MD, DDS, FACS Clinical Professor of Surgery Division Chief Plastic and Reconstructive Surgery Louisiana State University Baton Rouge, LA, United States Ara A. Salibian, MD Assistant Professor Plastic & Reconstructive Surgery University of California, Davis School of Medicine Sacramento, California, United States

Venkat V. Ramakrishnan, MS, FRCS, FRACS (Plastic Surgery) Consultant Plastic Surgeon St. Andrews Centre for Plastic Surgery Broomfield Hospital UK Chelmsford, Essex, United Kingdom

Karim A. Sarhane, MD, MSc General, Laparoscopic and Peripheral Nerve Surgeon Burjeel Royal Hospital, Al Ain Abu Dhabi, UAE

Agustin Rancati, MD Department of Surgery Hospital Británico Buenos Aires Buenos Aires, Argentina

Hani Sbitany, MD Professor of Surgery Division of Plastic Surgery Mount Sinai Medical Center New York, NY, United States

Alberto Rancati, MD, PhD Breast & Plastic Surgery Assistant Professor Surgery Florida International University – FIU Miami, FL, United States Charles Randquist, MD Plastic Surgeon Victoriakliniken Saltsjöbaden, Sweden Gedge D. Rosson, MD Associate Professor Department of Plastic and Reconstructive Surgery Johns Hopkins University School of Medicine Baltimore, MD, United States J. Peter Rubin, MD, MBA, FACS Chair, Department of Plastic Surgery at UPMC and the University of Pittsburgh UPMC Endowed Professor of Plastic Surgery Professor of Bioengineering University of Pittsburgh Pittsburgh, PA, United States

Jesse C. Selber, MD, MPH, FACS Professor, Vice Chair, Director of Clinical Research Department of Plastic Surgery MD Anderson Cancer Center Houston, TX, United States Orr Shauly Resident Physician Plastic and Reconstructive Surgery Emory University School of Medicine Atlanta, GA, United States Aldona J. Spiegel, MD Houston Methodist Institute for Reconstructive Surgery Houston Methodist Hospital Houston, TX, United States Michelle Spring, MD, FACS Mountain West Plastic Surgery  Kalispell, MT, United States Sandpoint, ID, United States

List of Contributors

Grant Stevens, MD Professor Emeritus of Surgery Founder, Marina Plastic Surgery Associates Keck School of Medicine of USC Los Angeles, CA, United States Christopher N. Stewart, MD Plastic Surgeon Private Practice New Beautiful You Casper, WY, United States Neil Tanna, MD, MBA Professor Plastic Surgery Zucker School of Medicine at Hofstra/Northwell Hempstead, NY; Associate Program Director Plastic Surgery Northwell Health; Vice President, Women’s Surgical Services Northwell Health Great Neck, NY, United States Marissa Tenenbaum, MD Associate Professor of Surgery Director of Aesthetic Surgery Plastic and Reconstructive Surgery Washington University School of Medicine St. Louis, MO, United States Sumeet S. Teotia, MD, FACS Professor, Department of Plastic Surgery Director, Breast Reconstruction Program Simmons Cancer Center University of Texas Southwestern Medical Center Dallas, TX, United States Eliora A. Tesfaye, MD Plastic Surgery M.D. Anderson Cancer Center Houston, TX; Virginia Commonwealth University Richmond, VA, United States Dinesh Thekkinkattil, MD Oncoplastic Breast Surgeon Lincoln County Hospital Lincoln, UK Mark L. Venturi, MD, FACS Founding Partner National Center for Plastic Surgery McLean, VA, United States Raghavan Vidya, MD Oncoplastic Breast Surgeon Royal Wolverhampton Hospital Birmingham University Birmingham, UK Brittany L. Vieira, MD Resident Physician Division of Plastic and Reconstructive Surgery Massachusetts General Hospital Boston, MA, United States Veronica Vietti Michelina, MD Plastic and Reconstructive Surgery Department Regina Elena National Cancer Institute Rome, Italy

Liza C. Wu, MD Associate Professor PRIVÉ Plastic Surgery Boca Raton, Florida, United States Louisa Yemc, PA-C Surgical Physician Assistant National Center for Plastic Surgery McLean, VA, United States VOLUME SIX Hee Chang Ahn, MD, PhD Professor Plastic and Reconstructive Surgery CHA University Bundang Medical Center Seongnam, Gyeonggi-do, Republic of Korea Nidal F. Al Deek, MD, MSc Consultant Plastic and Reconstructive Surgery Chang Gung Memorial Hospital Taipei, Taiwan Rita E. Baumgartner, MD Attending Physician Panorama Summit Orthopedics Frisco, CO, United States Aaron Berger, MD, PhD Chief/Medical Director of Programs in Pediatric Hand, Brachial Plexus and Peripheral Nerve Division of Plastic Surgery Nicklaus Children’s Hospital Miami, FL; Clinical Assistant Professor Division of Plastic Surgery Florida International University School of Medicine Miami, FL; Voluntary Assistant Professor Department of Orthopedic Surgery University of Miami Miller School of Medicine Miami, FL, United States Anna Berridge, MBBS, BSc, FRCS (Tr & Orth) Consultant Orthopaedic Hand and Wrist Surgeon Ipswich Hospital East Suffolk and North Essex Foundation Trust Ipswich, United Kingdom Randy R. Bindra, MChOrth, FRCS Professor Orthopaedic Surgery Griffith University and Gold Coast University Hospital Gold Coast, QLD, Australia Nathalie Bini, MD Pediatric Orthopedics Regina Margherita Hospital Turin, Italy Gregory H. Borschel, MD, FACS, FAAP, FAAPS James Harbaugh Professor of Surgery Indiana University School of Medicine Chief of Plastic Surgery, Riley Hospital for Children Indianapolis, Indiana, United States

xlv

Kirsty Usher Boyd, MD, FRCSC Associate Professor Division of Plastic Surgery The Ottowa Hospital University of Ottawa Ottawa, ON, Canada Gerald Brandacher, MD Scientific Director Plastic and Reconstructive Surgery Johns Hopkins University School of Medicine Baltimore, MD, United States Amanda Brown, MD Division of Plastic and Reconstructive Surgery St. Louis University School of Medicine St. Louis, MO, United States Hazel Brown, MSc Advanced Physiotherapy, BSc Hons Physiotherapy, Post Grad Dip Orthopaedic Medicine Clinical Specialist Physiotherapist Peripheral Nerve Injury Unit Royal National Orthopaedic Hospital Stanmore, United Kingdom Sara Calabrese, MD Plastic Reconstructive and Aesthetic Surgery Resident Plastic, Reconstructive and Aesthetic Surgery Department Careggi University Hospital Florence, Italy Ryan P. Calfee, MD, MSc Professor Orthopedic Surgery Washington University School of Medicine in St. Louis St. Louis, MO, United States Logan W. Carr, MD Attending Physician Division of Plastic Surgery Westchester Medical Center Valhalla, NY; Associate Professor of Surgery New York Medical College Valhalla, NY, United States James K-K. Chan, MA(Cantab), DPhil(Oxon), FRCS(Plast) Consultant Hand, Plastic and Reconstructive Surgeon Department of Plastic Surgery Stoke Mandeville Hospital Aylesbury; Clinical Lecturer Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences University of Oxford Oxford, United Kingdom James Chang, MD Johnson & Johnson Distinguished Professor and Chief Division of Plastic Surgery Stanford University Medical Center Palo Alto, CA, United States

xlvi

List of Contributors

Robert A. Chase, MD Emile Holman Professor of Surgery (Emeritus) Department of Surgery Stanford University Stanford, CA, United States

Lars B. Dahlin, MD, PhD Professor Hand Surgery Department of Translational Medicine Malmö, Sweden

Paige M. Fox, MD, PhD Department of Surgery, Division of Plastic and Reconstructive Surgery Stanford University School of Medicine Stanford, CA, United States

Shanlin Chen, MD, PhD Professor and Consultant Orthopaedic Surgeon Chief, Department of Hand Surgery Beijing Ji Shui Tan Hospital National Center for Orthopedics Beijing, China

Soumen Das De, MBBS, FRCS, MPH Consultant Department of Hand and Reconstructive Microsurgery National University Health System Singapore

Jeffrey B. Friedrich, MD, FACS Professor of Surgery and Orthopedics Department of Surgery University of Washington Seattle, WA, United States

Harvey Chim, MD Professor Plastic and Reconstructive Surgery University of Florida College of Medicine Gainesville, FL, United States

Kristen M. Davidge, MD, MSc, FRCSC Plastic and Reconstructive Surgeon Department of Surgery Hospital for Sick Children Toronto; Assistant Professor Department of Surgery University of Toronto; Associate Scientist Child Health and Evaluative Sciences Sick Kids Research Institute Toronto, ON, Canada

Alphonsus K.S. Chong, MBBS Associate Professor Department of Orthopaedic Surgery National University of Singapore; Group Chief and Senior Consultant Department of Hand and Reconstructive Microsurgery National University Health Systems Singapore David Chwei-Chin Chuang, MD Professor Department of Plastic and Reconstructive Surgery Chang Gung Memorial Hospital, Linkou Branch Gueishan District, Taoyuan City, Taiwan Kevin C. Chung, MD, MS Professor of Surgery Section of Plastic Surgery University of Michigan; Chief of Hand Surgery University of Michigan Ann Arbor, MI, United States J. Henk Coert, MD, PhD Professor Plastic Surgery UMC Utrecht Utrecht, The Netherlands Christopher Cox, MD Orthopedic Hand Surgery Kaiser Permanente Walnut Creek, CA, United States Catherine Curtin, MD Professor Department of Surgery Palo Alto VA Palo Alto, CA; Professor Department of Surgery Stanford University Palo Alto, CA, United States Simeon C. Daeschler, MD, Dr. med Postdoctoral Fellow Neuroscience and Mental Health Program SickKids Research Institute, Hospital for Sick Children (SickKids) Toronto, ON, Canada

Paul C. Dell, MD Professor Department of Orthopaedic Surgery and Sports Medicine University of Florida College of Medicine Gainesville, FL, United States Jana Dengler, MD, MASc Assistant Professor Department of Surgery University of Toronto; Staff Physician Department of Surgery Sunnybrook Health Sciences Program Toronto, ON, Canada Gregory Ara Dumanian, MD Stuteville Professor of Surgery Division of Plastic Surgery Northwestern Feinberg School of Medicine Chicago, IL, United States Simon Farnebo, MD, PhD Professor Department of Biomedical and Clinical Sciences and Department of Plastic Surgery, Hand Surgery, and Burns Faculty of Medicine and Health Sciences Linköping University Linköping, Sweden Margaret Fok, MBChB, FRCSE(Ortho), FHKAM (Orthopaedic Surgery) Associate Consultant Department of Orthopaedics and Traumatology Queen Mary Hospital Hong Kong; Honorary Clinical Assistant Professor Department of Orthopaedics and Traumatology The University of Hong Kong Hong Kong Ida K. Fox, MD Professor of Plastic Surgery Department of Surgery Washington University School of Medicine in St. Louis St. Louis, MO, United States

Brittany N. Garcia, MD Hand and Upper Extremity Surgery University of Utah Department of Orthopedic Surgery Salt Lake City, UT, United States Charles A. Goldfarb, MD Executive Vice Chair Orthopedic Surgery Washington University School of Medicine in St. Louis; Professor Orthopedic Surgery Washington University School of Medicine in St. Louis St Louis, MO, United States Kimberly Goldie Staines, OTR, CHT Visiting Researcher Michael E. DeBakey Veterans Affairs Medical Center Houston, TX; Adjunct Faculty Department of Immunology, Allergy, and Rheumatology Baylor College of Medicine Houston, TX, United States Elisabeth Haas-Lützenberger, MD Division of Hand, Plastic and Aesthetic Surgery University Hospital LMU Munich Munich, Germany Steven C. Haase, MD, FACS Professor Surgery University of Michigan Health Ann Arbor, MI, United States Leila Harhaus, MD, Prof. dr. med. Chief, Department for Handsurgery, Peripheral Nerve Surgery and Rehabilitation Vice Chair, Department for Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center BG Trauma Hospital Ludwigshafen; Chair, Section Upper Extremity, Orthopedic University Hospital Heidelberg University of Heidelberg Heidelberg, Germany Elisabet Hagert, MD, PhD Associate Professor Department of Clinical Science and Education Karolinska Institute Stockholm, Sweden; Head of Hand Surgery Department of Surgery Aspetar Orthopedic- and Sports Medicine Hospital Doha, Qatar

List of Contributors

Warren C. Hammert, MD Professor of Orthopedic and Plastic Surgery Orthopedic Surgery Duke University Durham, NC, United States Dennis Hazell, RN, MChiro, Independent Prescriber Clinical Nurse Specialist Peripheral Nerve Injury Unit Royal National Orthopaedic Hospital Stanmore, United Kingdom Vincent Henta, MD Professor of Surgery, Emeritus Plastic Surgery Stanford University Stanford, CA, United States

Jason Hyunsuk Ko, MD, MBA, FACS Associate Professor Division of Plastic and Reconstructive Surgery Northwestern University Feinberg School of Medicine Chicago; Associate Professor Department of Orthopedic Surgery Northwestern University Feinberg School of Medicine Chicago, IL, United States

Vincent R. Hentz, MD Professor of Surgery, Emeritus Department of Plastic Surgery Stanford University Stanford, CA, United States

David A. Kulber, MD Professor of Surgery Cedars Sinai Medical Center and USC Keck School of Medicine; Director of Hand and Upper Extremity Surgery Program Director Marilyn and Jeffrey Katzenberg Hand Fellowship Department of Orthopedic Surgery, Cedars Sinai Medical Center; Director of the Plastic Surgery Center of Excellence Cedars Sinai Medical Center Los Angeles, CA, United States

Charlotte Jaloux, MD Assistant Professor Hand and Limb Reconstructive Surgery Timone University Hospital - APHM Marseille, France

Bhaskaranand Kumar, MBBS, MS (Ortho) Formerly Professor and Head Department of Orthopaedic Surgery Kasturba Medical College Manipal, India

Neil F. Jones, MD, FRCS, FACS Distinguished Professor of Plastic and Reconstructive Surgery Distinguished Professor of Orthopedic Surgery Ronald Reagan UCLA Medical Center and David Geffen School of Medicine University of California, Los Angeles; Consultant in Hand Surgery and Microsurgery Division of Plastic and Reconstructive Surgery Shriners Hospital for Children Los Angeles, CA, United States

Donald Lalonde, HonsBSc, MSc, MD, FRCSC, DSc Professor Plastic Surgery Dalhousie University Saint John, NB, Canada

Jonay Hill, MD Private practice Park City, Utah, United States

Sumanas W. Jordan, MD, PhD Division of Plastic and Reconstructive Surgery Northwestern University Chicago, IL, United States Ryosuke Kakinoki, MD, PhD Professor of Hand Surgery and Microvascular Reconstructive Surgery Orthopedic Surgery Kindai University Osaka-sayama Osaka, Japan Jason R. Kang, MD Kaiser Permanente Physician Orthopedics Department Garfield Specialty Care Center San Diego, CA, United States Marco Innocenti, MD Chairman and Professor of Plastic Surgery University of Bologna; Director of Orthoplastic Surgery Department Rizzoli Institute Bologna, Italy

Wee Leon Lam, MBChB, FRCS(Plast) Consultant Plastic and Hand Surgeon Department of Plastic and Reconstructive Surgery Royal Hospital for Children and Young People Edinburgh; Honorary Clinical Senior Lecturer University of Edinburgh Edinburgh, United Kingdom Caroline Leclerq, MD Consultant Hand Surgeon Institut de la Main Clinique Bizet Paris; Consultant Hand Surgeon Neuro-orthopaedic Rehabilitation CRN Coubert Coubert; Consultant Hand Surgeon Neuro-paediatric Rehabilitation Hôpital National Saint Maurice Saint Maurice, France Dong Chul Lee, MD Attending Physician Plastic and Reconstructive Surgery Gwangmyeong Sungae Hospital Gwangmyeong, Gyeonggi-do, Republic of Korea

xlvii

W.P. Andrew Lee, MD Provost and Dean Office of Provost University of Texas Southwestern Medical Center Dallas, TX, United States Anais Legrand, MD Postdoctoral Research Fellow Plastic & Reconstructive Surgery Stanford University Medical Center Palo Alto, CA, United States Janice Liao, MBBS, MRCS, FAMS Consultant Department of Hand and Reconstructive Microsurgery National University Health Systems Singapore Christopher D. Lopez, MD Resident Physician Plastic and Reconstructive Surgery Johns Hopkins University School of Medicine Baltimore, MD, United States Joseph Lopez, MD, MBA Chief of Pediatric Head and Neck Surgery Head and Neck Surgery AdventHealth for Children Orlando, FL, United States Johnny Chuieng-Yi Lu, MD, MSCI Associate Professor Department of Plastic and Reconstructive Surgery Chang Gung Memorial Hospital, Linkou Branch Gueishan District, Taoyuan City, Taiwan Susan E. Mackinnon, MD, FRCSC, FACS Minot Packer Fryer Professor of Surgery Director of the Center for Nerve Injury and Paralysis Professor of Plastic and Reconstructive Surgery Division of Plastic and Reconstructive Surgery Washington University School of Medicine St. Louis, MO, United States Brian A. Mailey, MD Associate Professor of Surgery Division Chief Plastic and Reconstructive Surgery Chief Pediatric Plastic Surgery Cardinal Glennon Children’s Hospital Pandrangi Family Endowed Professor of Plastic Surgery St. Louis University School of Medicine St. Louis, MO, United States Minnie Mau, OT, CHT/L Occupational Therapist, Certified Hand Therapist Hand Therapy Stanford Health Care Redwood City, CA, United States Steven J. McCabe, MD, MSc, FRCS(C) Director of Hand Program Department of Surgery University of Toronto Toronto, ON, Canada Meghan C. McCullough, MD, MS Plastic and Reconstructive Surgery Cedars Sinai Hospital Los Angeles, CA, United States

xlviii

List of Contributors

Kai Megerle, MD, PhD Professor and Chief Center for Hand Surgery, Microsurgery and Plastic Surgery Schoen Clinic Munich Munich, Germany Amy M. Moore, MD Professor and Chair Plastic and Reconstructive Surgery The Ohio State University Columbus, OH, United States Wendy Moore, OTR/L, CHT Assistant Manager Rehab Services Hand Therapy Stanford Health Care Redwood City, CA, United States Steven L. Moran, MD Professor of Plastic Surgery and Orthopedic Surgery Mayo College of Medicine and Science Mayo Clinic, Rochester, MN, United States Jagdeep Nanchahal, BSc, PhD, FRCS(Plast) Professor Kennedy Institute of Rheumatology, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences University of Oxford Oxford, United Kingdom David T. Netscher, MD Professor Division of Plastic Surgery, Department of Orthopedic Surgery Baylor College of Medicine Houston, TX, United States Michael W. Neumeister, MD Professor and Chairman Surgery SIU School of Medicine; The Elvin G. Zook Endowed Chair in Plastic Surgery SIU School of Medicine, Springfield, IL, United States Christianne A. van Nieuwenhoven, MD, PhD Plastic Surgeon/Hand Surgeon Plastic and Reconstructive Surgery and Hand Surgery Erasmus Medical Center Rotterdam Rotterdam, The Netherlands Kerby C. Oberg, MD, PhD Professor and Vice Chair Pathology and Human Anatomy Loma Linda University Loma Linda, CA, United States Andrew O’Brien, MD, MPH Clinical Instructor, Housestaff Plastic and Reconstructive Surgery The Ohio State University Medical Center Columbus, OH, United States

Eugene Park, MD Pediatric Hand and Plastic Surgeon Plastic Surgery Shriners Children’s Philadelphia; Clinical Assistant Professor Orthopedic Surgery Sidney Kimmel Medical Center of Thomas Jefferson University Philadelphia, PA, United States Mitchell A. Pet, MD Assistant Professor Surgery Washington University School of Medicine in St. Louis St. Louis, MO, United States Karl-Josef Prommersberger, Prof. dr. Professor Krankenhaus St. Josef Clinic for Elective Hand Surgery Schweinfurt, Germany Tom J. Quick, MB, MA(hons)Cantab, FRCS(Tr & Orth) Associate Professor Institute of Orthopaedics and Musculoskeletal Science University College London London; Consultant Surgeon Peripheral Nerve Injury Unit Royal National Orthopaedic Hospital London, United Kingdom Parashar Ramanuj, MBBS, BSc(Hons) London Spinal Cord Injury Centre Royal National Orthopaedic Hospital Stanmore; Clinical Director Mental Health and Community Programmes Imperial College Health Partners London; Senior Research Fellow RAND Europe Cambridge, United Kingdom Carina Reinholdt, MD, PhD Senior Consultant in Hand Surgery Center for Advanced Reconstruction of Extremities Sahlgrenska University Hospital Mölndal; Assistant Professor Department of Hand Surgery Institute for Clinical Sciences Sahlgrenska Academy Göteborg, Sweden Justin M. Sacks, MD, MBA, FACS Shoenberg Professor of Plastic Surgery Chief, Division of Plastic and Reconstructive Surgery Director – Microsurgery Fellowship Division of Plastic and Reconstructive Surgery Department of Surgery Washington University in St. Louis School of Medicine St. Louis, MO, United States

Douglas M. Sammer, MD Professor Plastic Surgery and Orthopedic Surgery University of Texas Southwestern Medical Center at Dallas Dallas, TX, United States Brinkley K. Sandvall, MD Assistant Professor Department of Plastic Surgery Texas Children’s Hospital Baylor College of Medicine Houston, TX, United States Ellen Satteson, MD Assistant Professor, Research Director Plastic and Reconstructive Surgery University of Florida Gainesville, FL, United States Subhro K. Sen, MD Clinical Associate Professor Plastic Surgery Stanford University Medical School Palo Alto, CA, United States Pundrique Sharma, BSc(Hons) PhD, MBBS, FRSC(Plast) Consultant Plastic Surgeon Alder Hey Children’s Hospital Liverpool, United Kingdom Xiao Fang Shen, MD Vice-Director Pediatric Orthopedic (Hand Surgery) Children’s Hospital Affiliated to Soochow University Suzhou, Jiangsu, China Jamie T. Shores, MD Clinical Director of Hand and Upper Extremity Transplantation Plastic and Reconstructive Surgery Johns Hopkins University School of Medicine Baltimore, MD, United States S. Raja Sabapathy, MS, MCh, DNB, FRCSE, FAMS, Hon FRCSG, Hon FRCS, Hon FACS, DSc (Hon) Chairman Department of Plastic Surgery, Hand and Reconstructive Microsurgery and Burns Ganga Hospital Coimbatore, Tamil Nadu, India Vanila M. Singh, MD, MACM Clinical Associate Professor Anesthesiology, Perioperative, and Pain Medicine Stanford University Stanford, CA, United States Gillian D. Smith, MBBCh Consultant Hand and Plastic Surgeon Plastic Surgery Great Ormond Street Hospital London, United Kingdom Kashyap K. Tadisina, MD Assistant Professor Division of Plastic and Reconstructive Surgery Department of Surgery University of Miami Miller School of Medicine Miami, FL, United States

List of Contributors

Amir H. Taghinia, MD, MPH Attending Surgeon Department of Plastic Surgery Boston Children’s Hospital; Associate Professor of Surgery Harvard Medical School Boston, MA, United States David M.K. Tan, MBBS, MMED (Surgery) Senior Consultant Department of Hand and Reconstructive Microsurgery National University Health Systems Singapore Jin Bo Tang, MD Professor and Chair Department of Hand Surgery Affiliated Hospital of Nantong University; Chair The Hand Surgery Research Center Affiliated Hospital of Nantong University Nantong, Jiangsu, China Johan Thorfinn, MD, PhD Associate Professor Department of Biomedical and Clinical Sciences and Department of Plastic Surgery, Hand Surgery, and Burns Faculty of Medicine and Health Sciences Linköping University Linköping, Sweden Xiaofei Tian, MSc Professor Department of Burns and Plastic Children’s Hospital of Chongqing Medical University Chongqing, China

Michael Tonkin, MBBS, MD, FRACS, FRCSE(Orth) Professor Emeritus University of Sydney Medical School University of Sydney Sydney, NSW, Australia Joseph Upton, MD Attending Surgeon Shriners Children’s Hospital; Professor of Surgery Harvard Medical School Boston, MA, United States Francisco J. Valero-Cuevas, PhD Professor of Biomedical Engineering Professor of Biokinesiology and Physical Therapy The University of Southern California Los Angeles, CA, United States Hari Venkatramani, MS, MCh, DNB, EDHS Senior Consultant Plastic Surgery, Hand and Reconstructive Microsurgery Ganga Hospital Coimabatore, Tamil Nadu, India Nicolas B. Vedder, MD Professor of Surgery and Orthopedics Chief of Plastic Surgery Department of Surgery University of Washington Seattle, WA, United States

xlix

Celine Yeung, MSc, MD, FRCSC Plastic, Reconstructive and Aesthetic Surgery Department of Surgery University of Toronto Toronto, ON, Canada Fu-Chan Wei, MD, FACS Professor Plastic and Reconstructive Surgery Chang Gung Memorial Hospital Kweishan, Taoyuan, Taiwan Paul M.N. Werker, MD, PhD, FEBOPRAS, FEBHS Professor and Chair Plastic Surgery University Medical Centre Groningen Groningen, The Netherlands Jeffrey Yao, MD Professor Orthopedic Surgery Stanford University Medical Center Menlo Park, CA, United States Jung Soo Yoon, MD, PhD Assistant Professor Plastic and Reconstructive Surgery Dongguk University Ilsan Hospital Goyang, Gyeonggi-do, Republic of Korea

Acknowledgments My wife, Gabrielle Kane, continues to encourage me in my work but gives constructive criticism bolstered by her medical expertise as well as by her knowledge and training in education. I can never repay her. The editorial team at Elsevier have made this series possible. Belinda Kuhn, once again, leads the group and is the Content Strategist. Through the years I’ve been involved with this project Belinda has been a constant support, an amazing resource, and a good friend. Unlike the previous editions which were managed through the London office, this edition has been directed through the Philadelphia office led by Katie De Francesco. The Elsevier production team, as always, has been vital in moving this project along. The volume editors, Geoff Gurtner and Andrea Pusic in Volume 1, Peter Rubin and Alan Matarasso in Volume 2, Richard Hopper and Joe Losee in Volume 3, David Song and JP Hong in Volume 4, Mo Nahabedian in Volume 5, and Jim Chang in Volume 6, have shaped and refined this 5th edition, making vital changes to keep the series relevant and up to date. Dan Liu has, once again, taken masterful charge of the media content. This series is a team effort and wouldn’t exist without these wonderful people. This is the last edition I will edit. It has been an honor, an enormous privilege, and a work of love to do so. Peter C. Neligan, MB, FRCS(I), FRCSC, FACS

To my family, with love: my wife, Julie, whose unwavering support and encouragement make everything possible; and our wonderful children, Eliana, Liviya, Zachary, and Talya, who bring joy to our lives. To my mother, Annette, a model of resilience. To the memory of my father, Leonard R. Rubin, MD, whose approach to surgical innovation continues to inspire me. To my respected colleagues in aesthetic surgery who have shared their tremendous expertise in this volume. To the residents and faculty of the Department of Plastic Surgery at the University of Pittsburgh; your passion for excellence and creativity shapes the future of our specialty and improves the lives of our patients. J. Peter Rubin, MD, MBA, FACS To my family, for their love, support, and sacrifices they have made in order to make my career possible. My parents, Ethel and Daniel ben Avraham. My wife, Melissa, and twins, Emma and Dana. Alan Matarasso MD, FACS

Dedication Dedicated to all teachers, peers, and trainees in Plastic Surgery

1 Managing the aesthetic surgery patient Michelle B. Locke and Foad Nahai

SYNOPSIS















ƒ Societal interest in plastic surgery is increasing: • The number of plastic surgery procedures as reported by The Aesthetic Society (American Society for Aesthetic Plastic Surgery [ASAPS]) has increased 82% since 1997 • Women between the ages of 35 and 50 consistently comprise the largest group of patients for both surgical and non-surgical procedures. ƒ Understanding the patients’ motivations for surgery and their expectations of the outcomes are the keys to achieving satisfied patients postoperatively: • Managing the patients’ expectations requires detailed information and full patient education • Second consultations are almost always necessary preoperatively • Be sure to discuss your policy for revisional surgery during the preoperative period. ƒ Postoperative follow-up should include detailed written instructions for appropriate activity level and wound care as well as the surgeon’s contact details: • Regular follow-up visits are needed during the early postoperative period to assist the patient through the recovery • Unhappy patients or those with unsatisfactory outcomes should be seen more often to improve communication.

Understanding the motives, expectations, and desires of a patient seeking cosmetic surgery is at least as important as manual dexterity for achieving consistently satisfactory results.1

Societal interest in cosmetic surgery The concept of beauty What is beauty? The concept of attractiveness seems to be innate and is similar across cultures and religions. While it can be

influenced somewhat by social trends and advertising, research shows that subjective attractiveness is largely biological, overlaid with only a small amount of personal preference. Studies looking at the consistency of physical attractiveness ratings across cultural groups agree that facial attractiveness is species-specific, not race-specific.2,3 Research in the US has shown that the ratings provided by Asians, Hispanics, Caucasians, and African Americans correlate well for facial attractiveness overall, although features such as expression and sexual maturity influenced some cultural groups more than others.3 Also, Caucasians and African Americans differed on their judgment of bodies. Judgments can potentially be influenced by cultural norms; for example, the classical Roman nose is very different in size and shape to the African-American nose, so what may be considered a deformity in one person may be attractive on another. There is no simple answer to the question of what constitutes beauty, or even an attractive face. In order to ascertain what makes an attractive face, some researchers have assessed facial features by judging individual faces, then comparing the results with computer-generated composite faces, averaging the individuals.4,5 This research showed there was a trend toward the composite face being more attractive than the faces individually, producing a claim that “attractive faces are only average”. Others have disputed this claim, saying that a mathematically averaged face is not the same as an average face.6,7 Interestingly, functional magnetic resonance imaging scanning of subjects during judgment on the facial attractiveness of strangers has shown that perceived facial attractiveness increases with eye contact rather than with increased physical attractiveness per se.8,9 These studies have also shown that facial attractiveness is a fundamental condition that a stranger can read rapidly. In fact, it takes only 150 milliseconds and no eye movement to judge a stranger’s attractiveness. Over 2000 articles on the study of facial attractiveness have been published in the past 30 years. Social and psychological literature from the 1970s and 1980s extensively studied the response to physical attractiveness and showed that physical

2

CHAPTER 1  • Managing the aesthetic surgery patient

attractiveness has a statistically significant effect on the person’s self-esteem and well-being.2 This implies that beauty has influence which is more than “just skin deep”.10 Pediatric studies have revealed that parents provide better parenting to attractive children and respond more positively to cuter infants.11 Studies have also shown that attractive women receive more dates and are perceived to have more positive social attributes. Housman suggested that physically attractive people are offered greater opportunities for success and happiness throughout their life.10 Attractive individuals are more likely to be hired, promoted, and earn higher salaries than their less-attractive counterparts. As the potential benefits go far beyond improved self-esteem, it is perhaps not surprising that individuals are attending their plastic surgeons with requests for surgical and non-surgical options in an attempt to increase their perceived attractiveness or correct a deformity.

Increasing societal acceptance of cosmetic surgery The specialty of plastic surgery is rooted in reconstructive surgery for congenital abnormalities and acquired injuries. Surgery for purely aesthetic reasons was incorporated into the field somewhat later. Research from across the US has shown that societal acceptance of plastic surgery is increasing. The 2010 American Society for Aesthetic Plastic Surgery (ASAPS) Quick Facts consumer attitudes survey found that 53% of women and 49% of men approved of cosmetic surgery, while 27% of married Americans and 33% of unmarried Americans would consider cosmetic surgery for themselves in the future.12 If you compared those attitudes with previous results, 20% of Americans were more favorably disposed toward cosmetic surgery than 5 years earlier. More recently, a consumer attitudes survey was commissioned by RealSelf.com (an online social media-style community for learning and sharing information about cosmetic surgery procedures) and conducted by Zeitgeist Research in December 2014.13 They found that more than 30% of the women surveyed would be prepared to undergo plastic surgery to change the appearance of a body part while 7% had in fact already done so.13 This increased acceptance may be related to the extensive media coverage in recent years, which essentially normalizes plastic surgery and increases the perceived benefits of cosmetic surgery.14 This includes celebrities openly discussing their plastic surgical procedures, as well as popular television programs such as the series Nip/Tuck and reality programs Dr  90210 and Extreme Makeover, which have been on our screens since 2002. Even E! Entertainment television’s latest show Botched, which focuses on cosmetic surgery gone wrong, is unlikely to negatively influence viewers’ attitudes toward cosmetic surgery as plastic surgery is still portrayed as an effective method to transform the unhappy patient’s body back to the ideal. The downside of making plastic surgery a form of mainstream entertainment is the misrepresentation of the significance, complexity, downtime, and potential complications of undergoing surgery. These issues increase the chance that the patient will present with unrealistic expectations, which must be clearly addressed by the plastic surgeon at preoperative consultations.

The role of social media In addition to televised media, the rise in social media sites such as Facebook, Instagram, and TikTok over the past decade has meant that this field has grown rapidly in importance. According to the January 2019 We Are Social report, 3.484 billion people actively use social media – that is 45% of the world’s population.15 This past decade has seen a massive increase in younger patients taking regular videos or “selfies” and posting these on a social media site, often with the benefit of a built-in filter to enhance their appearance. This is also magnified by the rise of social media influencers, usually celebrities with huge numbers of engaged, enthusiastic followers whose decision making will be influenced by the behavior of the celebrity. This has led to “The Kardashian Effect”, an unofficial term for the rise in the number of young people seeking noninvasive plastic surgery treatments in an attempt to emulate their idols, in this case members of the Kardashian family who flaunt their idealized beautiful bodies and faces on Instagram. Unfortunately, many young people do not understand that the images they see online can be heavily amended by Photoshop or built-in filters. Added to this, it has been suggested that imperfections can appear magnified by the camera lens, prompting the younger generation to turn to cosmetic surgery to correct or enhance their appearance16 due to the perceived discrepancy between what they see in their camera lens and how they believe others look.

The role of video conferencing In addition to social media, there has been a huge increase in the use of video conferencing software such as FaceTime (Apple, Inc., Cupertino, CA) and Zoom (Zoom Video Communications, Inc., San Jose, CA). Zoom generated $2.6 billion revenue in 2020, a 317% increase year-on-year, driven in large part by coronavirus 2019 (COVID-19) disease restrictions on personal interactions. Anecdotally, some plastic surgeons have reported a “Zoom Boom” – an increase in facial cosmetic procedures fueled by patients’ dislike of their features and now seeing themselves for hours at a time on video conferencing calls. A survey analyzing respondents’ feelings about their facial appearance during video conferencing found that the majority of subjects reported a concerning facial area, with the nose being most common. Despite many respondents not having any prior facial cosmetic treatments, 40.6% of respondents planned to pursue treatments based on concerns from their video conference appearance alone, with neurotoxin and filler injections being the most common.17 One survey of patients who underwent facial plastic surgery procedures in Canada in 2020 concluded that patients were more aware of their nose than any other facial feature due to video conferencing during COVID-19-related lockdowns compared with before the pandemic.18 This was reflected in the respondents most common procedure being rhinoplasty. Those who had surgery during the 2020 pandemic noted the advantages of this, including having ample privacy from family, friends, and co-workers (77%) and not requiring extended leave of absence from work (69%) during the postoperative recovery period. This trend was echoed around the globe, with research from The Clinic in London finding an 80% increase in facial plastic surgery procedures after the lifting of nationwide lockdown measures mid-2020 compared with the same timeframe

Societal interest in cosmetic surgery

pre-pandemic in 2019.19 The authors agreed that both privacy at home and time to recover were contributary. They also postulated that household expenditure of holidays and outings decreased during lockdown; thus, extra disposable income may have also played a part in the rise in cosmetic procedures.

The Aesthetic Society statistics While the 2020 statistical data from The Aesthetic Society is currently available, as mentioned above it is likely to be skewed significantly by the global COVID-19 pandemic and it may not be appropriate to compare it with previous years. Therefore we have chosen to focus on the 2019 data as the most recent non-pandemic year at time of printing. Statistics for surgical procedures performed in 2019 show that the most

commonly performed plastic surgery operations are breast augmentation (280,692 procedures) and liposuction (270,670 procedures) (Fig. 1.1).20 Compared with the surgical statistics from 1997, there has been a significant increase in these procedures (Fig. 1.2). This is in line with the overall almost 100% increase in plastic surgical operations performed over this period. Over this same time period there has also been a significant rise in non-surgical cosmetic procedures, such as injectables (botulinum toxin, hyaluronic acid, and so forth), laser hair removal, and skin-resurfacing techniques, which have outpaced the growth in surgical procedures.20 This trend also highlights the public’s acceptance of cosmetic procedures overall, and the popularity of non-surgical procedures may indicate a pool of potential patients who will consider operative procedures in the future.

Top Five Surgical Procedures in 2019

270,670

280,692

146,711

140,381 113,229

LIPOSUCTION

BREAST AUGMENTATION

TUMMY TUCK

EYELID SURGERY

BREAST LIFT

Figure 1.1  Top five surgical procedures in 2019. (American Society for Aesthetic Plastic Surgery, 2019 data.)

Change in Procedure Numbers 1997–2016 280,692

270,670

176,863 159,232

146,711

137,053 140,381 113,229

101,176

19,882 LIPOSUCTION

BREAST AUGMENTATION

TUMMY TUCK 1997

EYELID SURGERY

2019

Figure 1.2 Change in procedure numbers between 1997 and 2019. (American Society for Aesthetic Plastic Surgery, 2019 data.)  

3

BREAST LIFT

CHAPTER 1  • Managing the aesthetic surgery patient

4

Table 1.1  Age distribution of plastic surgery patients

17 years and under

19–34 years

35–50 years

51–64 years

65+ years

Surgical procedures

0.90%

20.20%

40.00%

28.70%

10.20%

Non-surgical procedures

0.70%

15.10%

37.10%

32.80%

14.30%

The Aesthetic Society, 2019 data.

Table 1.2  Gender distribution of plastic surgical patients

Female

Male

Number

Percentage

Number

Percentage

Surgical procedures

1,366,914

93.00%

102,838

7.00%

Non-surgical procedures

2,818,219

90.30%

303,221

9.70%

Overall

4,185,133

406,059

The Aesthetic Society, 2019 data.

For many years now, the largest age group of patients undergoing surgical and non-surgical procedures is between 35 and 50 years of age, with 40% of procedures being performed in this age group in 2019 (Table 1.1). The Aesthetic Society statistics show that patients in the age group younger than this (19–34 years) are undergoing surgical procedures less commonly than those in the older age bracket (51–64 years) (20.2% and 28.7%, respectively), which is a change from 2016 when these numbers were essentially equivalent in each group.20 Prior to its closure, a reader survey by More! magazine in the UK revealed that 72% of women in their twenties would like to have plastic surgery.21 However, perhaps this interest is not translating to operative procedures at present. Not surprisingly, the majority of surgical and non-surgical patients are female (93.0% and 90.3%, respectively) (Table 1.2).

Surgeon advertising When aesthetic plastic surgery first developed, advertising the surgeon’s services was considered distasteful and was frowned upon by most practitioners. However, as times have changed, advertising of services has become commonplace. In these authors’ opinion, advertising should be discreet, professional, and truthful. A professional, thorough website, which can be accessed by public search engines and via links from the websites of professional bodies with whom the surgeon is affiliated, is essentially a common form of advertising. Having an informative and aesthetically pleasing website is the first step to patient engagement with your practice (Algorithm 1.1). Many patients say they wish to see “before and after” photos if possible. Some registration agencies such as the Medical Council of New Zealand (MCNZ) have specific guidelines on adverting and the use of “before and after” photographs.22 These Standards acknowledge that photographs have a significant potential to mislead or to convey inappropriately high expectations of a successful outcome. The MCNZ specifically states that any practitioner displaying before and after photos must ensure any photos:   Are there solely for the purpose of providing accurate and useful information to patients.

  Show

a realistic portrayal of the outcome that can reasonably and typically be expected.   Only depict patients who have undergone the advertised procedure while under your (or your services’) care.   Have not been altered in any way.   Use the same lighting, contrast, background, framing, camera angle, exposure, and other photographic techniques in both the “before” and “after” images. These are well-stated standards by which all reputable surgeons should adhere. Of course, maintaining patient privacy and ensuring appropriate consent has been obtained for the use of any patient photograph in such a fashion is essential. As a minimum, the website should cover the surgeon’s personal philosophy and procedures offered, and provide contact details and a location map. Additionally, advertising in local magazines or newspapers may be appropriate. However, it is important that plastic surgery is not seen to be trying to sell a service to the patient, but instead is advertised as available and able to meet the patient’s needs and requirements with competence and care. The American Board of Plastic Surgery, the American Society of Plastic Surgeons (ASPS), and ASAPS all have ethical codes and guidelines governing advertising to which diplomats and members must adhere. These specifically prohibit misrepresentation of the surgeons’ qualifications or expected results.

Patient motivation for cosmetic surgery As Greer stated in 1984, “Understanding the motives, expectations, and desires of a patient seeking cosmetic surgery is at least as important as manual dexterity for achieving consistently satisfactory results.”1 The patient may seek cosmetic surgery for any number of reasons. Elucidating the patient’s motivation is a goal of your first patient encounter. The best reason for wanting plastic surgery is for self-improvement. However, there are many other potential reasons. Patients may feel that surgery will alter their life in some way, perhaps make them more outgoing, help them secure a partner, or save their marriage. The surgeon must be wary of patients with

Patient motivation for cosmetic surgery

5

Algorithm 1.1 Patient online search You have an informative and aesthetically pleasing website

Your online information is poor

Your practice

Another practice

First contact

No reply Unhelpful or impolite response

Email or phone call Polite, prompt, helpful response Any red flags?

First appointment

Receptionist

Medical or psychiatric assessment as required Second and subsequent appointment(s)

Surgery

Surgeon

Nurse

Photography Garment fitting

Practice manager

Postoperative appointment(s)

Practice management algorithm.

hidden agendas, as an excellent surgical outcome may still not result in a happy patient postoperatively. During the initial consultation, the surgeon must attempt to ascertain what the patient actually wants. This may be different from what the spouse or partner or parents want. If the patient is not initiating the surgery, then beware operating on the patient. If the patient has attended the first appointment with his or her partner and the surgeon feels the partner is the driving force behind the consultation, a second appointment should be scheduled with the patient alone. It is important to ensure that it is the patient who wants the surgery and that s/ he fully understands the ramifications of surgery before going ahead with any procedures. Another potential warning sign regarding patient motivation is “doctor shopping”. While we encourage any patient to seek a second, or even third, opinion if they wish, if the surgeon is aware that the patient has seen several doctors already, this should strike a warning bell. The surgeon should inquire as to the reason for this. Perhaps the patient’s request

for surgery has been declined by other surgeons with good reason. The patient’s expectations may be excessively high and unrealistic. The patient may simply be indecisive. The surgeon should be cautious about offering surgery to these patients unless there is a thorough understanding about the reasons for that patient shopping around.

The ideal patient The ideal patient for cosmetic plastic surgery is one with whom the surgeon can develop rapport and understanding. Patients should be pleasant to the surgeon and the office staff, have effective communication skills, and be intelligent, well educated, and well informed regarding their potential treatment. They must have an identifiable deformity for correction, with realistic expectations of the outcome and a full understanding of potential complications. They should be sensible and compliant with pre- and postoperative instructions. Unfortunately, not all of our patients fit this profile!

CHAPTER 1  • Managing the aesthetic surgery patient

6

Special patient groups The male cosmetic surgery patient In the past two decades, the number of cosmetic procedures performed on men has increased more than 250%. Currently, male patients account for 7.0% of all cosmetic surgery in the US, and men underwent over 100,000 cosmetic surgery operations in 2019.20 The most common operations include liposuction, male breast reduction (for gynaecomastia) and eyelid surgery (blepharoplasty), with tummy tuck (abdominoplasty) and nose surgery (rhinoplasty) rounding out the top five surgical procedures for men (Fig. 1.3). However, overall men represented a significant proportion of patients undergoing facial aesthetic surgery, making up 34.8% of ear surgeries performed, as well as 16.6% of all eyelid surgeries, 14.0% of the chin augmentations performed and 16.4% of all necklift procedures in 2019.20 Importantly, men are often overrepresented in the complication data for their procedures, particularly hematoma rates. This should be thoroughly discussed with patients before surgery. The reported incidence of hematoma following male rhytidectomy ranges from 8% to 13% in most series, twice as high as for females. This may be related to the greater vascularity of the male facial skin, with a higher number of microvessels to supply the hair follicles.23 The senior author believes that strict perioperative blood pressure control may be the most important aspect of care to reduce this rate. To this end, we routinely give all male patients clonidine 0.1 mg postoperatively unless contraindicated. Clonidine is a centrally acting, alpha-2 adrenergic receptor agonist, which is long-acting, with a half-life of about 12 hours. We believe this medication helps stabilize the patient’s blood pressure to reduce the risk of postoperative bleeding.

The young aesthetic surgery patient How young is too young for aesthetic surgery? This is not a straightforward question, and the answer usually depends on the reason for the surgery and the degree of patient deformity

and concern. The number of teenage patients is small – only 0.9% of all patients undergoing plastic surgical procedures in 2019, down from 1.6% in 2016.20 Data from the last 20 years of reporting from both the ASAPS and the ASPS show similar rates every year over the time period, ranging between 1% and 3%. In 2019, liposuction was the most common surgery for teenagers overall, with 3571 procedures performed on patients 17 and under. While these data show that only 1.2% of all breast augmentations were performed on women 17 years of age and under, this was the second most common type of operation performed in this age group, with 3329 performed in 2019. This is despite the fact that the US Food and Drug Administration (FDA) only approves saline-filled breast implants for cosmetic augmentation in women aged 18 years and over and silicone-filled implants for women 22 years and older. The FDA states that this restriction is placed because “breasts continue to develop through late teens and early 20 s and because there is a concern that a young woman may not be mature enough to make an informed decision about the potential risks”. Ear set-back surgery (otoplasty) was the third most common surgery for teenagers, with breast reduction and nose surgery (rhinoplasty) completing the top five most common procedures (Fig. 1.4). As the FDA implies in their statement on breast augmentation, the greatest concern when operating on a young patient is that the teen will have unrealistic expectations from the surgery. Clearly, plastic surgeons need to assess the emotional maturity as well as the physical maturity of younger patients before undertaking any surgical procedures. The young patient must understand that the surgery itself results in a permanent change. In particular, patients must understand that there will be permanent scars and there are potential complications that will be with them for life. A thorough preoperative assessment of why the young patient wishes to have the surgery, and what difference the patient thinks it will make to their life, should be undertaken. Any unrealistic expectations of the changes that the surgery may make should warn the surgeon against operating until the patient is more emotionally mature and may prompt a psychological referral instead. In almost all of the US, individuals are considered minors and therefore unable to consent to surgery until they reach the

Top Five Cosmetic Surgeries for Men 2019 32,827

21,407 18,751

LIPOSUCTION

MALE BREAST REDUCTION

EYELID SURGERY

5037

5831

NOSE SURGERY

TUMMY TUCK

Figure 1.3 Top five cosmetic surgeries for men in 2019. (American Society for Aesthetic Plastic Surgery, 2019 data.)  

Special patient groups

age of 18. State legislation requires parental consent for surgery on any patient under 18 years. However, the state recognizes that the legal age of majority is arbitrary and that there are minors who are competent and others, of legal age, who are not. While this can be confusing, the fundamental basis of the legislation is to protect minors from the consequences of poor decisions. A responsible plastic surgeon also has a role to play in protecting young patients from the consequences of unnecessary surgery, even if the patient is over the age of majority. First and foremost, it is the surgeon’s job to care about the patient’s overall well-being. Younger patients need support people during and after surgery as much, or even more, than older adults. During the preoperative assessments, make note of who attends with the patient. Is it a parent or caregiver? Or is it a boyfriend or girlfriend? While patients over 18 are not required to inform their parents of their request for surgery, it can show a level of maturity if the patient has discussed the surgery with parents and has family support before going ahead. Contrast this with young patients who do not want to tell anyone they are undergoing surgery. Who will look after them during their postoperative recovery period? Who will bring them to their follow-up visits? Who will support them if there are complications? Also, plastic surgery for aesthetic purposes is not normally covered by insurance, raising the question of how patients will pay for the primary surgery and what arrangements they can make to pay for revisions and complications. Parental and family support assists both emotionally and physically, and the plastic surgeon should be wary of operating on a young patient without an obvious support network.

Friends or family as your aesthetic surgery patient It is a strong endorsement of your skills and reputation as a plastic surgeon when friends or family consult you and desire

your surgical expertise. However, this flattery can be expensive, as family and friends often have an expectation of free or heavily discounted procedures. Not only does such discounting generate little revenue to help meet the overheads of the practice, it also takes up time in your surgical schedule that could have been spent operating profitably on another patient. It is important to have a clear policy to manage these expectations ahead of time. If you do not wish (or cannot afford) to discount your surgery, one strategy is to explain to the patient that you provide a professional service and therefore there will be a bill for your services. However, as the individual is an important person to you, you will endeavor to provide added value in different ways. For example, increasing your availability to see the patient outside your regular office hours, such as evenings or weekend, may be very valuable to a friend or medical colleague who works full-time. The cost of this, even if you pay a practice nurse overtime to see the patient with you, can be significantly less than discounting the surgery. It is the practice of the senior author to discount my surgical fee for family, friends, other healthcare professionals, and office staff. However, the amount of discount that is offered will vary with the relationship. It can be embarrassing and challenging to discuss this face-to-face with the patient. To avoid this, I provide a letter to the patient explaining my position on this matter, which is a modified version of one which Dr. Tom Rees shared with me years ago (Fig. 1.5 ). Of course, these comments ignore the ethical issue of whether one should operate on one’s family and friends. The American Medical Association (AMA) Code of Medical Ethics states that physicians should not, except in emergencies or when the illness is minor, treat themselves or anyone with whom they have a relationship, such as their spouse or child. This is due to the fact that your emotional bond with the patient and your personal feelings may unduly influence your professional medical judgment. What many might not realize is that the reasons for this apply equally to treating friends.

Percentage of Patients 18 Years and Under

3571 3329

2588

1777

EAR SURGERY

NOSE SURGERY

1949

BREAST REDUCTION BREAST AUGMENTATION

LIPOSUCTION

Figure 1.4 Total number of surgical procedures performed on patients 18 years and under in 2019. (American Society for Aesthetic Plastic Surgery, 2019 data.)  

7

Special patient groups

Figure 1.5  Example letter to friends and family regarding surgical discount.

7.e1

8

CHAPTER 1  • Managing the aesthetic surgery patient

The AMA Code of Medical Ethics provides additional guidance on dealing with care requests from friends and relatives, such as opinion 1.2.1, “Treating Self or Family”.24 Despite this, operating on family seems to be common in our profession. If you do undertake this surgery, ensure that you can do so safely and to a high standard. If you feel that your judgment may be impaired by the relationship, do not hesitate to refer the patient to a colleague.

The initial consultation First contact with the office Algorithm 1.1 shows the flow of a potential patient through your practice. Although your website may well be the patient’s first contact with, and first impression of, your practice and you, the receptionist is usually the first person the patient will have contact with in the office. It is important that the reception staff leave a favorable first impression on the patient. Make sure that the person answering your phone provides friendly, efficient, personal service. The receptionist should be able to answer questions about you and your facility, as well as provide information about the services you offer. This could include approximate cost information, as many patients wish to know this before they make an appointment. If the reception staff do not know the answers to the questions asked, they should be able to put potential patients through to someone who can answer them, possibly your patient coordinator, administrative assistant, or nurse. It is useful to have the reception staff inquire how the patient found out about you. They may have been referred from friends or family, have found you on an internet search, or seen your advertising. This information should be recorded and you should assess it regularly, to see whether your advertising dollar has been usefully spent. When the patient makes an appointment to see you, ensure that the receptionist checks how the patient prefers to be contacted. Some patients may not be happy to receive calls at their place of work or at home, or they may not want you to leave messages for them if they do not have a private voice mailbox. This information is especially important as new patient management systems are integrated into more and more practices. These can automatically contact the patient for you, to remind them of their appointment times or request feedback on their visit. If the preferred method of contact is not clearly indicated in the patient’s paper or electronic record, breaches of the patient’s privacy can occur. Once an appointment time has been made for the patient, an information pack is sent out from the office, although all the information may alternatively be available on a practice website. This includes information regarding the surgeon and the practice, including its location, a map, and parking instructions. A health questionnaire is included, which the patient is requested to complete and bring along to the appointment (Fig. 1.6 ). The pack can also be personalized to include a brochure on the procedure that the patient is considering. While all of this information is likely to be on your website, not all patients are computer-literate and printed material can be brought along at the time of the appointment to assist with directions.

Nurse assessment In the senior author’s practice, the first person to see and assess the patient is the nurse. The patient is brought into a private consultation room, and the nurse goes over the pre-assessment forms with the patient. This includes checking that the health questionnaire forms are accurately completed and that any allergies are correctly recorded, and confirming the reason for today’s appointment. Depending on the patient and the likely surgery, sometimes the nurse will spend time looking through pre- and postoperative photographs with the patient. At the end of this time, the nurse leaves the information for me to read over before I see the patient. The nurse can also provide valuable feedback on the patient. It is helpful to be warned about any potential issues with the patient before entering the room yourself. Also, some patients can be polite and sociable to the surgeon but rude to the other staff members, so it is always useful to be aware of the nurse’s first impression of the patient, along with your own.

Surgeon's assessment After reviewing the information, I then introduce myself and ask what I can do for the patient. I spend between 15 and 30 min with the patient. Initially we will discuss the patient’s goals and aims from surgery. This time helps me assess the patient and whether his or her expectations are reasonable, and whether I can meet them. It also develops rapport with the patient much more effectively than beginning the consultation with closed questions. Then I will review all the health information with the patient, including personal history of smoking and deep-vein thrombosis, as well as adding any pertinent procedure-specific questions. After reviewing the history, we return to the reason for the consultation. Throughout the appointment, I am assessing the patient by appearance, grooming, manner, body language, and enthusiasm for any surgery. I want to know whether the patient is a realistic person with reasonable expectations. Do I think that I can achieve these goals? Do I like the patient? If we have a complication, will I be happy to see the patient regularly in my clinic and will I be able to support him or her throughout the issue? I am sure that the patient will be making similar judgments about me, so I strive to be attentive, to maintain eye contact rather than looking at the notes, and to be friendly and caring in my demeanor. I always provide feedback at the end of the consultation regarding whether I think the patient is a suitable candidate for the procedure or not.

Photography Formal, standardized photographs are taken of the patient at the first appointment. These must be suitably consented and the intended use of the images should be clear to the patient on a signed consent form (Fig. 1.7 ). The consent could allow display of the images for the patient’s record only, for teaching purposes, for publications, website use, or to show other patients. I have a separate consent form for any patient who consents to the use of photographs on the website, to ensure complete understanding of this process and avoid any unwanted legal issues. My practice has a professional photographer who takes images and also provides digitally altered images to predict the postoperative appearance. This is particularly helpful for

The initial consultation

Figure 1.6 (A,B) Examples of preconsultation medical questionnaires.  

8.e1

Continued

8.e2

B

Figure 1.6, cont’d

CHAPTER 1  • Managing the aesthetic surgery patient

The initial consultation

PHOTOGRAPHIC CONSENT I hereby voluntarily grant permission to __________________ Plastic Surgery Center and/or their designated employees to take and use any pre-operative, intra-operative, or post-operative photos of myself for purposes of record, research, education, and medical publication, as well as assisting others in making their surgical decisions. Any of these uses may be eliminated from this form. I further understand that no form of compensation shall become payable to me for the use of these photographs. I hereby release ______________ Plastic Surgery Center and its agents from any and all claims and demands arising out of or in conjunction with the use of these photographs.

__________________________________________ Signature

______________ Date

__________________________________________ Print Name

I hereby certify that I am a parent or the person legally responsible as the guardian of the above patient, a minor person, and that I also hereby provide authorization and grant the releases described above in this document. __________________________________________ Parent/Legal Guardian Signature __________________________________________ Print Name

Figure 1.7  Example photographic consent form.

______________ Date

8.e3

Saying “no” to a potential patient

9

rhytidectomy and rhinoplasty procedures. Often rhinoplasty patients will be offered more than one postoperative option, so that they can see how their nose might look if set further back or with more hump reduction. This is helpful to ensure that both you and the patient have similar goals in mind for the surgery. However, it is important to make it clear to the patient that these photographs do not guarantee the outcome.

Patient coordinator After seeing me and having photographs taken, the patient then sees my patient coordinator. While I do not pressure the patient to make any decisions at the first appointment, the issue of fees and the waiting time for scheduling are covered. If an overnight stay is being considered, the patient is shown photographs of the overnight suites, or tours the facilities if there are empty rooms available for viewing. The coordinator will also go over the surgery, complications, and recovery time with the patient again. The coordinator then becomes the liaison person for the patient, to answer questions and schedule surgery or further appointments.

After the appointment The patient is always given written material to take home regarding the procedure and the facility. Once the patient has left, I dictate a letter to the patient at the same time as my clinical note. This letter reiterates our discussions and the potential surgical plan (Fig. 1.8 ). I routinely request that the patient comes back for a second appointment at no charge, prior to scheduling surgery.

Second and subsequent consultations A second appointment allows me the opportunity of answering any further questions and reviewing my surgical plan with the patient. It also provides another chance to go over the limitations of each procedure, the scars, and potential complications for a second time. We also discuss the possibility of revisional surgery being required and the financial implications of this. I often give my patients some “homework” for this second visit: I request that my facial aesthetic patients bring in a photograph of themselves from about 15–20 years previously, that rhinoplasty patients bring in pictures from magazines of noses that they like, and breast augmentation patients bring in any pictures they find that they like, and so forth. These help me visualize what I am trying to achieve with the surgery, and ensure that the patient and I have similar goals. If surgery is going to go ahead, it is usually booked by the end of the second appointment. Courtiss writes of a “three strikes” rule – this means to beware of the patient who requests three or more preoperative appointments with you.25 This can be a red flag for indecisiveness or uncertainty, which indicates that this is not the ideal patient for you to operate on.

Saying “no” to a potential patient Saying “no” to a patient can be difficult but is sometimes necessary. You should heed your intuition and be cautious. If you have concerns, do not offer the patient surgery. After all, plastic surgery is truly elective surgery, so do not undertake it if you feel that it is not in the patient’s best interest.

Figure 1.9  Gorney’s patient selection guide.

When to say “no” The surgeon may consider the patient unsuitable for a number of reasons. According to Gorney and Martello, the patient may be either anatomically or psychologically unsuitable for the procedure.26 From an anatomic viewpoint, the feature that the patient wishes to have altered must be visible to the surgeon and able to be corrected. Some patients perceive with a significant degree of concern a deformity that the surgeon may consider to be minor or trivial. The ideal patient fits around the diagonal of Gorney’s patient selection graph (Fig. 1.9).26,27 However, studies on patients requesting rhinoplasty have failed to demonstrate a significant correlation between the extent of the deformity and the degree of psychological disturbance the deformity causes the patient.28 This implies that, just because the surgeon feels that the deformity is only minor, the significance to the patient and therefore the likelihood of improving the patient’s self-esteem following corrective surgery is not necessarily also minor. Reasons for declining to operate on a patient include:   You (or your staff) do not like the patient.   You do not think the patient likes you.   The patient is unreasonably demanding or has unrealistically high expectations.   You believe the patient has a psychological problem such as body dysmorphic disorder (BDD).   You feel that the patient has emotional instability and would not cope with the surgery. BDD is covered in detail elsewhere in this textbook (Vol. 1, Ch. 3), but it is suitable to discuss it briefly here as it is particularly relevant to patient selection. BDD is considered by the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, as a somatoform disorder defined by repetitive behaviors or mental acts in response to preoccupations with a perceived defect or flaw in physical appearance.29 If a physical anomaly is present, the patient’s concern is markedly excessive. To qualify as BDD the condition must be severe enough to impair the patient’s social or other functioning. The incidence in the general population is unknown but is thought to be between 0.5% and 2%. Reported rates among people seeking cosmetic surgery are thought to be much higher, with studies

Saying “no” to a potential patient

Figure 1.8  Example of a generic follow-up letter after consultation.

9.e1

10

CHAPTER 1  • Managing the aesthetic surgery patient

suggesting that BDD occurs in anything from 7% to 15% of patients.30,31 The most common symptom seen by the plastic surgeon during consultation is excessive concern or distress over a minor imperfection, manifested by spending a long time describing the defect in great detail.30 The patient may appear to have a depressed mood and speak in a monotone. He or she may also show dissatisfaction with previous surgical procedures, or request repeated surgery. Other, less common features which may be apparent in the plastic surgeon’s office include camouflaging and skin picking. As the diagnosis of BDD requires the patient to have impaired functioning because of the defect, it is important that the plastic surgeon specifically asks the patient what effect that defect has on social or daily functioning. The importance of identifying these patients in your practice before operating on them cannot be overstated, as surgery may exacerbate the problem.32 If surgery is performed, more than 75% will report dissatisfaction with the outcomes, and this can potentially produce a malpractice lawsuit or even violence toward the operating surgeon. Performing surgery on these patients has also been shown to lead to anything from never-ending requests for more surgery to psychosis and suicidal ideation. Unfortunately, plastic surgeons do not always identify these patients in advance. Sarwer published the results of a survey of ASAPS members in 2002, in which most respondents (84%) indicated that they had operated on a patient whom they initially believed was a suitable candidate for surgery, only to discover postoperatively that the patient suffered from BDD.33 Of these, 43% indicated that the patient seemed to be more preoccupied with the defect after surgery than they had been before, while another 39% reported that the patient was less preoccupied with the initial defect but was now focused on a different perceived defect. Most concerning, 40% of respondents indicated that a patient with BDD had threatened them, either legally or physically, or both. Given these risks, it is probably sensible to consider BDD to be a contraindication to plastic surgery. Aside from this, there may also be other psychosocial issues that should be considered relative contraindications to surgery. A recent systematic review identified narcissistic and obsessive personality disorders as being associated with unsatisfactory outcomes for both the patient and the surgeon, while young age, male sex, minor deformity, and unrealistic expectations were also found to be predictors of poor outcomes.34 Referral for psychiatric consultation and treatment would be appropriate prior to reconsidering the idea of plastic surgery if you felt that patient had a personality disorder.1,30 If you are concerned about a patient’s ability to cope with surgery emotionally, Sykes suggests trying less-invasive procedures first.35 For example, if the patient presents for facial rejuvenation, if it is appropriate you could trial temporary treatments such as toxins or fillers to see how well the patient tolerates these. If the patient copes well, attends regularly for follow-up, and behaves in a reasonable fashion afterward, this can help to reassure the surgeon that the patient may cope with the surgery. Similarly, poor post-treatment behavior can help unmask a difficult patient before you make the mistake of operating on this person.

How to say “no” Once you have decided not to operate on the patient, you must be clear and honest about this. Do not be ambivalent in

your wording, leaving the patient hope that you might change your mind. Do not blame the patient but instead, if necessary, take the blame yourself. Phrases such as “I am not prepared to operate on you because I don’t think I can achieve the result you are looking for” are most suitable.

Saying “yes”: what is involved? Managing surgical expectations Assuming that you understand the patient’s goals and desires and feel that you are able to meet them, surgery can be scheduled. Managing the patient’s expectations requires full patient education. Patients should be given a clear indication of the risk-to-benefit ratio for the surgery, as well as information covering the likely time course for the operation and recovery. I tell my patients to, “Forget the word cosmetic, remember the word surgery”, and that all surgery carries risk. It is helpful to show photographs of other patients at different time points following similar surgery, to provide them with an idea of what they might expect. This can be particularly relevant before procedures such as chemical peels, which can be associated with significant short-term postoperative morbidity that the patient must accept before going ahead with the procedure. I provide all my patients with written information about the procedure, as well as postoperative care instructions. They are encouraged to contact me or my patient coordinator if they have any further questions before their operation.

Managing financial expectations Prior to any surgery going ahead, the patient receives clear documentation of all the costs involved from my patient coordinator. We make it clear that insurance coverage is unlikely for most cosmetic procedures, and that they will be responsible for the bill themselves. My practice has a policy of this bill being paid in full 14 days prior to their operation. This preoperative financial discussion also includes clear knowledge of who pays for the treatment of any complications or necessary revisions. It is also made quite clear to the patient that the bill is an estimate only. While I do not alter my surgical fee if the operation runs longer than expected, patients will be responsible for any additional operating room or anesthesia charges. While some practices offer referrals to financial lending institutes to arrange loans to pay for surgery, this is not my practice and I consider it a (relative) contraindication to perform elective plastic surgery on a patient who struggles to afford it or takes a loan to pay the bill.

Informed consent Informed consent is a process, not a piece of paper. I clearly explain the general and specific risks in terms that the patient can understand, and I do not downplay the likely downtime postoperatively. The risks are reiterated by my surgical coordinator and by myself at the patient’s second consultation. Each procedure has a specific in-depth consent form (Fig. 1.10 ). The patient is required to read and initial each page and sign on the last page. This includes the policy on paying for revisions, which must also be read and initialed, as has been suggested in the literature.36

Saying “yes”: what is involved?

Figure 1.10  Example surgery consent form.

10.e1

10.e2

Figure 1.10, cont’d

CHAPTER 1  • Managing the aesthetic surgery patient

The unsatisfactory outcome

Preoperative regime for the patient Preoperatively, I make it clear to my patients, both verbally and in the consent forms, that they must stop smoking (not just cut down) prior to their surgery. I also request that they cut down on any alcohol in the immediate preoperative period. Depending on the procedure, my nurse will discuss a skincare regime, such as starting retinoids in the preoperative period as appropriate. All my facial aesthetic patients are started on arnica and bromelain 1 week preoperatively to decrease their bruising. All patients are given a complete list of medications to avoid in the 2 weeks prior to their surgery, including aspirin, vitamin E, and analgesics containing nonsteroidal anti-inflammatories such as ibuprofen (Fig. 1.11 ). They are also asked to stop any herbal remedies or dietary supplements.

Anesthesia consultation As all cosmetic surgery is elective, in the interests of patient safety all patients are required to have clearance from their internist prior to surgery. They also meet with one of our anesthesiologists for a preoperative check-up and discussion of anesthesia care (Fig. 1.12 ). Further investigations are ordered by the internist or anesthesiologist as required, and surgery is deferred if necessary until clearance has been received. These visits ensure that the patient is a suitable candidate for surgery, as well as confirming the patient’s suitability for treatment in our office-based, credentialed operating suites. It also allows patients the opportunity to become familiar with the anesthesia plan and facilities prior to their operation. This familiarity helps avoid delays and alleviates anxiety on the day of surgery.

Postoperative follow-up Following surgery, the patient may be discharged home from the recovery room or stay overnight in a private suite. Occasionally we arrange for the patient to stay at a hotel with an overnight nurse. Patients who stay overnight are reviewed in the evening by myself or a colleague and cared for overnight by qualified nursing staff. The following morning I check the patient, answer any questions, and arrange discharge. Drains may be removed prior to leaving or at a postoperative follow-up visit as suitable. All patients are given a prescription for analgesic medications and instructions on what to look out for in terms of complications (Fig. 1.13 ). Contact details are provided prior to leaving. These calls come through to the office during working hours. After hours, an answering service takes and forwards any calls to the surgeon. If patients go home from the recovery room, they are called that evening and the next morning by myself or my nursing staff, to check on them and answer any questions. They are always given an appointment time and date for a follow-up visit prior to leaving the office.

Follow-up consultations My practice has a separate internal waiting room for facial surgery patients so they do not have to spend time in the main waiting room with preoperative patients. As a matter of courtesy I always endeavor to see my patients as promptly as possible. I sit with them in the consultation room, focusing on the patient, not the clinical records, asking after recovery,

11

comfort levels, and so forth. Then I take down the dressings and examine the wounds. I discuss progress, and at this stage the patient has an opportunity to ask questions. Often the patient brings in a list of questions, and I take time to go over all these concerns. During the first 1–2 postoperative weeks, when the swelling and bruising are maximal, the patient may have doubts about the wisdom of the surgery. After all, patients usually look worse, not better, during this period! Therefore I support them through this time by seeing them often, sometimes twice a week or more if necessary, and then space out their follow-up appointments over time. Postoperative photographs are always taken for the records. I encourage patients to continue to consult with me regularly until we can see the final outcome, perhaps 6 months to a year. Once patients have completely recovered and settled from their surgery, I offer them follow-up appointments for as long as they want to see me, usually on an annual basis.

The unsatisfactory outcome In an ideal world, both the patient and the surgeon are happy with the results. Three unsatisfactory outcomes are possible: 1. The patient is happy, the surgeon is unhappy. 2. Both the patient and the surgeon are unhappy. 3. The patient is unhappy, the surgeon is happy.

The patient is happy If the patient is happy, then no further treatment is indicated, even if the surgeon feels that this was far from his or her best result. A happy postoperative patient whose expectations have been met is the goal of plastic surgery. However, under these circumstances, the surgeon should suggest further follow-up to review the patient in the future, in case the patient changes his or her mind about the suitability of the outcome.

Both the patient and the surgeon are unhappy When the outcome is unsatisfactory, you must put personal feelings aside, difficult as it may be. Do not take complications or poor outcomes personally. Accept that unhappy patients following surgery happen to everyone who practices plastic surgery.36 Under these circumstances, further surgery is likely. During your postoperative consultations, reassure patients that you understand their dissatisfaction, that you can see what they are concerned about, that you are not happy with it either, and that you will do your utmost to fix it for them. If a complication has occurred, be upfront with the patient and explain what happened. In private, undertake an honest self-appraisal of your operative technique in your primary surgery and attempt to ascertain what produced the unsatisfactory outcome. Ask yourself, “What went wrong?” and “How will I prevent this happening again?” Next, ask yourself whether you are able to fix the problem. If you do not feel comfortable with operating again, consider referring the patient for a second opinion or to a subspecialist plastic surgeon if appropriate. The cost of further surgery should also be discussed. This conversation is easier if it has been covered preoperatively. My practice has a policy of providing free

The unsatisfactory outcome

Figure 1.11  Example list of medication patient is told to avoid preoperatively.

11.e1

11.e2

CHAPTER 1  • Managing the aesthetic surgery patient

Figure 1.12  Example pre-surgery anesthesia evaluation form.

The unsatisfactory outcome

Figure 1.12, cont’d

11.e3

11.e4

CHAPTER 1  • Managing the aesthetic surgery patient

Figure 1.13  Example discharge advice form.

Continued

The unsatisfactory outcome

Figure 1.13, cont’d

11.e5

11.e6

Figure 1.13, cont’d

CHAPTER 1  • Managing the aesthetic surgery patient

The unsatisfactory outcome

Figure 1.13, cont’d

11.e7

11.e8

Figure 1.13, cont’d

CHAPTER 1  • Managing the aesthetic surgery patient

The unsatisfactory outcome

Figure 1.13, cont’d

11.e9

11.e10

Figure 1.13, cont’d

CHAPTER 1  • Managing the aesthetic surgery patient

The unsatisfactory outcome

Figure 1.13, cont’d

11.e11

11.e12

Figure 1.13, cont’d

CHAPTER 1  • Managing the aesthetic surgery patient

The unsatisfactory outcome

Figure 1.13, cont’d

11.e13

11.e14

Figure 1.13, cont’d

CHAPTER 1  • Managing the aesthetic surgery patient

12

CHAPTER 1  • Managing the aesthetic surgery patient

revisional surgery. Your policy may be different, but in general you should waive your surgical fee, though the patient may be liable for any facility and anesthetic fee. If you are sending the patient for a second opinion, expect to cover (or at least contribute to) the other surgeon’s fee yourself. Above all, provide patients with a clear explanation of the management plan and ensure that their concerns have been addressed.

The patient is unhappy but the surgeon is happy This is a very bad outcome as it usually indicates a breakdown in communication between the surgeon and the patient or poor patient selection. First, assess what went wrong. Did you have similar goals initially? Does the patient have a psychological disturbance such as BDD that you did not discover during your preoperative evaluation? Most importantly, can you see and appreciate what the patient is unhappy about? If you cannot, then you will never be able to fix it or make the patient happy. If you can see the deformity or defect that the patient is unhappy with, further surgery may be indicated. Otherwise, it may be appropriate to refer the patient for a second opinion, to a specialist colleague, or even to a psychiatrist for further assessment.

Managing the unhappy patient Managing the dissatisfied patient is challenging and time-consuming. It requires patience and tact on the part of the plastic surgeon. Most patient dissatisfaction is based on failure of communications and poor patient selection, rather than technical errors.37 Obviously, improving your patient evaluation and selection skills can help limit the number of unhappy patients you deal with. However, when unhappiness occurs, underlying the dissatisfaction is normally a breakdown in rapport between the patient and surgeon.26 This means that effective communication is the key in managing these patients. Spend time listening with empathy and compassion to patients’ concerns. Try to elicit the specific reason(s) for the dissatisfaction and make sure that their issues are heard, accepted, and understood.38

Managing a colleague's unhappy patient The unhappy patient could be your own or a colleague’s. It is important never to criticize your colleagues on a personal or professional basis, or to criticize what took place during the previous surgery. The patient should be managed as any new patient to your practice would be, with a full history and physical evaluation. Almost always, I can explain to the patient what I find, say that I have seen it before, and explain how it can be revised. Sometimes the patient simply requires a second opinion, in which case I encourage the patient to return to the primary surgeon if they still have a rapport. If the patient insists that s/he will not return to the primary surgeon, then I will discuss the cost of the surgery. As the primary surgery was not with me, any revisional surgery will cost the patient the full fee. I explain that the patient will likely receive a lesser fee if s/he returns to the primary surgeon. If the patient wants to schedule surgery with me, I make every effort to contact

Access the reference list online at   Elsevier eBooks+

the primary surgeon for information and receive old notes (including preoperative photographs) if possible. Bear in mind that you cannot contact the other surgeon or discuss the patient’s care with anyone without the patient’s consent.

Managing your own unhappy patient As mentioned above, the key to improving patient satisfaction is improved communication. When a patient is unhappy or has an unsatisfactory result, I see the patient more frequently in my clinic (even though the staff and I might want to see the patient less!). I attempt to provide emotional support and reassurance to the patient. If it is appropriate to the situation, I will express regret that the outcome was not what the patient wished. Throughout these visits, any possible consultation fees are waived. It is helpful to have other staff (for example, your most senior nurse) attend all the consultations with you and develop a rapport with the patient if possible. The patient may tell the nurse information that he or she would not tell you, and if the relationship between you and the patient breaks down, the nurse can be helpful in relaying information to the patient. For similar reasons, the patient should be encouraged to bring a friend or family member along to the consultations. For everyone’s safety and to avoid later confusion, ensure that you document all visits and discussions clearly in the patient record. It can be helpful to send the patient a letter at the end of each consultation summarizing any discussions that were held and any decisions that were made.

Conclusion Patient selection in plastic surgery is challenging. Patient evaluation can be difficult to teach during residency and unfortunately is often learned through trial and error while in practice. Your ability to recognize patients who are unsuitable for surgery physically, or who may not cope emotionally with the surgery, is an integral part of running a successful practice. Time spent with patients preoperatively, ensuring that they understand the potential benefits, risks, and complications, pays dividends postoperatively as their expectations are more likely to be met. As plastic surgeons, our prime responsibility is to the safety of our patients, as well as their comfort and satisfaction. I will not undertake surgery that I do not feel is in the best interest of my patients. Focusing on the welfare of the patient, utilizing good communication skills, and carrying out a thorough evaluation of the patient preoperatively can prevent postoperative dissatisfaction.

Bonus images for this chapter can be found online at Elsevier eBooks+ Fig. 1.5 Example letter to friends and family regarding surgical discount. Fig. 1.6 (A,B) Examples of preconsultation medical questionnaires. Fig. 1.7 Example photographic consent form. Fig. 1.8 Example of a generic follow-up letter after consultation. Fig. 1.10 Example surgery consent form. Fig. 1.11 Example list of medication patient is told to avoid preoperatively. Fig. 1.12 Example pre-surgery anesthesia evaluation form. Fig. 1.13 Example discharge advice form.

References

References 1. Greer DM. Psychiatric consultation in plastic surgery: the surgeon’s perspective. Psychosomatics. 1984;25:470. 2. Bashour M. History and current concepts in the analysis of facial attractiveness. Plast Reconstr Surg. 2006;118:741–756. Bashour provides an interesting discussion of the history of facial attractiveness with reference to the neoclassical canons, anthropology, and cephalometrics. He provides insights into social psychology and the components of facial attractiveness. 3. Cunningham MR, Roberts AR, Barbee AP, et al. “Their ideas of beauty are, on the whole, the same as ours”: consistency and variability in the cross-cultural perception of female physical attractiveness. J Pers Soc Psychol. 1995;68:261–279. 4. Langlois JH, Roggman LA. Attractive faces are only average. Psychol Sci. 1990;1:115–121. 5. Langlois JH, Roggman LA, Musselman L. What is average and what is not average about attractive faces? Psychol Sci. 1994;5:214–220. 6. Alley TR, Cunningham MR. Averaged faces are attractive, but very attractive faces are not average. Psychol Sci. 1991;2:123–125. 7. Perrett DI, May KA, Yoshikawa S. Facial shape and judgements of female attractiveness. Nature. 1994;368:239–242. 8. Kampe KK, Frith CD, Dolan RJ, Frith U. Reward value of attractiveness and gaze. [Erratum appears in Nature. 2002; 416:602.] Nature. 2001;413:589. 9. Aharon I, Etcoff N, Ariely D, et al. Beautiful faces have variable reward value: fMRI and behavioral evidence. Neuron. 2001;32:537–551. 10. Housman SB. Psychosocial aspects of plastic surgery. In: McCarthy JG, ed. Plastic Surgery. 1. Philadelphia: WB Saunders Company; 1990:113–118. 11. Hildebrandt KA, Fitzgerald H. The infant’s physical attractiveness: its effects on bonding and attachment. Infant Ment Health J. 1983;4:3. 12. Cosmetic Surgery National Data Bank Statistics, Consumer Attitudes Survey; 2010. http://www.surgery.org/sites/default/ files/Stats2010_1.pdf. 13. PRNewsWire. New study reveals one in five women plan to pursue cosmetic surgery. Seattle, USA: RealSelf.com; 2015. http://www. prnewswire.com/news-releases/new-study-reveals-one-in-fivewomen-plan-to-pursue-cosmetic-surgery-300034188.html. 14. Lee S-Y. The effect of cosmetic surgery realty shows on women’s beliefs of beauty privileges, perceptions of cosmetic surgery, and desires for cosmetic enhancements. Am Commun J. 2014;16:1–14. 15. Global digital 2019 reports but By We Are Social.inc, 32 Avenue of the Americas, 4th Floor, New York NY 10013. https://wearesocial. com/blog/2019/01/digital-2019-global-internet-use-accelerates. 16. West K. “The ‘Art’ Of The Selfie: Are Millennials Getting Plastic Surgery To Look Better In Social Media Pics?”. BeautyWorldNews. com; May 19, 2015. Available from. https://www.beautyworldnews. com/articles/17972/20150519/the-art-of-the-selfie-are-millennialsgetting-plastic-surgery-to-look-better-in-social-media-pics.htm. 17. Cristel RT, Demesh D, Dayan. SH. Video conferencing impact on facial appearance: looking beyond the COVID-19 pandemic. Facial Plastic Surgery & Aesthetic Medicine. 2020;22(4):238–239. 18. Sharma GK, Asaria J. The impact of COVID-19 on patient interest in facial plastic surgery. Plast Reconstr Surg Glob Open. 2021;9(10):e3890. 19. Imam SZ, Karanasios G, Khatib M, Cavale N, Amar O, Mayou B. Resumption of cosmetic surgery during COVID – experience of a specialised cosmetic surgery day-case hospital. J Plast Reconstr Aesthet Surg. 2021;74(11):3178–3185. https://doi.org/10.1016/j. bjps.2021.03.070. 20. 2019 Cosmetic Surgery National Data Bank Statistics, American Society for Aesthetic Plastic Surgery. https://surgery.org/sites/ default/files/Aesthetic-Society_Stats2019Book_FINAL.pdf.

12.e1

21. Mathews K. 72% of young women want plastic surgery. RealSelf. com; 2011. http://www.realself.com/blog/72-young-womenplastic-surgery-poll-finds#.VWzhf0bdejK; 2011. 22. Medical Council New Zealand Statement on Advertising 1 November 2016. https://www.mcnz.org.nz/assets/ standards/21146e764a/Statement-on-advertising.pdf. 23. Baker DC, Stefani WA, Chiu ES. Reducing the incidence of hematoma requiring surgical evacuation following male rhytidectomy: a 30-year review of 985 cases. Plast Reconstr Surg. 2005;116:1973–1985. 24. American Medical Association (AMA). Treating self or family. Available at https://www.ama-assn.org/delivering-care/ethics/ treating-self-or-family. 25. Courtiss EH. Patient counseling. In: Gradinger G, Kaye B, eds. Symposium on Problems and Complications in Aesthetic Plastic Surgery of the Face. St Louis: Mosby; 1984. 26. Gorney M, Martello J. Patient selection criteria. Clin Plast Surg. 1999;26:37–40. The authors discuss the features of a suitable compared with an unsuitable patient for cosmetic surgery, and provide their visual representation graph of deformity vs concern level, to aid in patient selection. 27. Gorney M. Mirror, mirror on the wall: the interface between illusion and reality in aesthetic surgery. Facial Plast Surg Clin North Am. 2008;16:203–205. 28. Hay GG. Psychiatric aspects of cosmetic nasal operations. Br J Psychiatry. 1970;116:85–97. 29. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013. 30. Ende KH, Lewis DL, Kabaker SS. Body dysmorphic disorder. Facial Plast Surg Clin North Am. 2008;16:217–223. The authors provide an excellent description of body dysmorphic disorder and how to identify it in patients presenting to a cosmetic surgery practice. Management strategies, including psychiatric referral and treatment prior to considering surgery, are covered. 31. Rinker B, Donnelly M, Vasconez HC. Teaching patient selection in aesthetic surgery: use of the standardized patient. Ann Plast Surg. 2008;61:127–131. discussion 32. 32. Hanes KR. Body dysmorphic disorder: an underestimated entity? Australas J Dermatol. 1995;36:227–228. 33. Sarwer DB. Awareness and identification of body dysmorphic disorder by aesthetic surgeons: results of a survey of American Society for Aesthetic Plastic Surgery members. Aesthet Surg J. 2002;22:531–535. 34. Herruer JMMD, Prins JBPD, van Heerbeek NMDPD, et al. Negative predictors for satisfaction in patients seeking facial cosmetic surgery: a systematic review. Plast Reconstr Surg. 2015;135:1596–1605. 35. Sykes JM. Managing the psychological aspects of plastic surgery patients. Curr Opin Otolaryngol Head Neck Surg. 2009;17:321–325. 36. Goode RL. The unhappy patient following facial plastic surgery: what to do? Facial Plast Surg Clin North Am. 2008;16:183–186. Goode covers how to be a better patient selector and how to manage an unhappy patient. He clearly covers his program for dealing with a patient who has a flawed result, as well as one who has a good outcome but is still unsatisfied. 37. Blackburn VF, Blackburn AV. Taking a history in aesthetic surgery: SAGA – the surgeon’s tool for patient selection. J Plast Reconstr Aesthet Surg. 2008;61:723–729. 38. Sykes JM. Patient selection in facial plastic surgery. Facial Plast Surg Clin North Am. 2008;16:173–176. Sykes summarizes the process of patient selection and refusing services to plastic surgery patients with useful management suggestions and comments on the role of the plastic surgeon.

2

Principles of practice management and social media for cosmetic surgery Ashley N. Amalfi, Josef G. Hadeed, and Smita R. Ramanadham

Identifying your brand: a roadmap to your entire practice A successful practice begins before a business plan is created, before the doors are open, and long before the first patient is even seen. As plastic surgeons, while we have an extremely specific and unique skill set, we must not only set ourselves apart from our colleagues but also from other specialties, in order to be truly successful. This starts by building a brand that highlights what it is that sets us apart. This brand should reflect our personalities, our goals, and how we want to be perceived by our patients and the community. The two major components of our brand are our brand identity and our mission statement. In brief, a brand identity is externally directed to the consumer in the market. The mission, on the other hand, is a statement that is internally focused to inspire employees from within the organization. Both should be consistent and reflective of each other.1 Your medical practice is a business, and every business must have a clear image and personality among its consumers. This should be identified from the very beginning by you, so it is not identified for you by the market. It should identify what value you bring to the market and should be intentional and unique.2 As Jeff Bezos has said, “Branding is what people say about you when you’re not in the room”.3 Your brand tells your consumer what to expect. Is this a high-end boutique plastic surgery practice where customer service is paramount and patients are paying a high dollar for their full experience, or is it primarily insurance and reconstructive-based and the extra frills are unnecessary? Three important questions that can help you identify your brand are the following: What specific services am I providing (cosmetic, non-surgical, general reconstructive, breast reconstruction, hand, etc.)? Who is my ideal consumer for these services (age, gender, zip code, profession, income bracket, etc.)? What do they value (expertise, price, efficiency, surrounds, etc.)? Answering these questions should be the first step when opening your practice.

Your brand can be further subdivided into brand strategy. This acts as a blueprint for the future growth and direction of your practice. Brand identity is how you convey your image to the public. It includes any visuals, marketing, or experiences. Your logo, colors, website, designs, and advertising identify your practice and should be consistent across all avenues. They should all invoke the same feelings among your consumers. Finally, brand marketing is how you communicate this to your consumer and inform them about your products and services.4,5 Consistency is important; there should be no question that the consumer is interacting with any other company other than yours, irrespective of where they see you. Your brand and mission are the first and, arguably, the most important step in creating your practice. Once this has been established, it should serve as a roadmap for building the rest of your practice. The office staff, office design, website, marketing, and social media should be consistent and reflective of this brand.

Staffing First impressions matter, and your staff sets the tone for the entire patient experience. From the very first phone call, the people they interact with should directly reflect your brand, your image, and your mission. This can be a taxing endeavor but having the right employees will help you work more efficiently and improve the overall patient experience. Your work does not end with finding and hiring your staff: it is then extremely important to retain them by offering support and promotion. As the adage says, ‘hire slowly and fire quickly’. It is most important to do your due diligence with the interview process to vet the candidates for the proposed job. Reviewing references is an essential next step to ensure they have the skills to not only accomplish the job but that they culturally fit and will integrate well in your practice. An employee who is well qualified for their job, but a poor cultural fit, will disrupt the flow

14

CHAPTER 2  • Principles of practice management and social media for cosmetic surgery

and efficiency of the office. Some practices have implemented personality testing to determine how the individual will work and perform alongside the current team. When looking for new staff, it is often a good exercise to think about your best employee and list the attributes which make them exemplary. This will help you evaluate just what characteristics are valued and lead to success in your organization. It is a good exercise to choose three to five of these values, and to vet new hires against these core principles to make sure they are a good cultural fit for the job. This will help balance the typical qualifications looked for in applicants and help attract individuals that align with your values and will complement the team and mission of the practice. Once you have hired the right individuals, coaching and managing staff to perform at the highest level also takes a consistent message. When dealing with an underperforming staff member, it is important to first evaluate that that individual is the right person for the job. Do they have the motivation, determination and the qualifications needed to fill that role? If so, then coaching that individual on their responsibilities and meeting regularly with them to give both positive and negative feedback will help cultivate a successful work relationship. When giving feedback, focus on behaviors and reactions to situations, and isolate the areas where further coaching is needed. Try to refrain from making feedback feel personal and focus instead on the job at hand. As a leader or manager in your organization, you want to cultivate the right individuals for your practice and support them to be successful at their jobs. It is also important to discuss their goals and career trajectory. By engaging them in this forward-thinking behavior and supporting them, you will more likely retain them and have the foresight to adapt and meet their needs as they grow with the practice. A team is successful when there is a culture of safety and comfort which allows employees to take risks and reach their potential. Make the roles and responsibilities of each member of your staff clear and well defined. This will help in coaching these individuals to reach their potential and fulfill their jobs within the practice. Choosing individuals who share your values will lead to healthy relationships and effective teams. As a physician, it is important that your staff feels comfortable coming to you with questions or concerns, and with the authority our titles carry, this can often be difficult in the workplace. Remain open and approachable, and actively engage your team for their own feedback to foster engagement and equality. Breaking down typical barriers creates a more fostering environment for effective teamwork and workplace efficiency. When dealing with a problematic staff member, the loss of that individual may seem daunting to the practice initially. But often in these situations, staff members who are a poor cultural fit require more time and energy, which hinders the team’s success. It is almost always true that the person who you eventually replace that employee with will bring more to the team than the underperformer who required such extensive coaching and intervention. Learning from mistakes with past hires and focusing on growth will continue to drive your practice to success.

Physical space There are many reasons why someone may choose a plastic surgeon, including board-certification, experience, specialty

procedures, and personality, among others. An often overlooked, but vital, component that factors into the selection process for the patient is the atmosphere created by the physical space of the office setting. This environment should reflect your brand and mission. It should be aesthetically pleasing. It should be tidy and neat. This is a direct reflection on your work and your attention to detail as a surgeon for the observer. The physical environment should reinforce your patients’ trust in you and contribute positively to them choosing you as their surgeon. If a patient has an uneasy feeling about the appearance of your office, chances are you will not see them again. Just as your mission statement and office staff should reflect your brand, so too should your workspace. Do you prefer a busy waiting area with a television playing, or a quiet space with soft music in the background? Put yourself in your patient’s shoes by sitting in your waiting room and asking yourself “Is this someplace where I would want to spend time waiting to see the doctor?” The color schema you select is a powerful way to communicate your brand and how it reflects your values. As examples, you may consider blues or grays for a calming and soothing environment, or you may prefer something more energetic and brighter if that complements your personal style and brand. Office décor can likewise convey your practice’s culture. Items such as furniture and artwork should be synergistic with your branding efforts and can make your office feel like a cohesive extension of you as a surgeon. As with anything else, the location of your office and the local market will play a role in influencing the development of your brand. For example, a flashy office with sleek modern furniture may seem out of place in a rural area, while consideration to a more rustic appearance may be more appropriate. Your primary objective should be to create an ideal experience for your target patient population and integrate your brand into every aspect of your business.

Digital marketing and website Historically, plastic surgery was a slow adopter to the use of a practice website as a valuable and ethical part of marketing. It is hard now to envision a successful practice without the use of digital marketing. Most potential patients begin their search for surgeons online, the way we search for any good or service. When searching for a physician, 93% of the population head to the internet to begin their search. Without a website, you are effectively only marketing and selling to 7% of the population, which is clearly not an effective way to build your business.6 A well-designed and informative website is essential to any new practice. It allows you to break into your market beyond word of mouth and referrals, allows for a broader geographical reach, and provides a way to collect data to continue to hone your marketing efforts. Your website should be professional, informative, easy to navigate and reflective of your practice and brand. For most patients searching for their surgeon online, your website is their first glimpse into your practice. It also allows you to highlight your work; before-and-after galleries are arguably the most important aspect of your website. Patient reviews, blogs, logistical information about the practice, links to social media, and an easy way to capture leads are also necessary facets. Let us dive a little further into these key components of a successful website.

Reputation management

Design and ease of use Patients want easy and fast access to information. The majority of patients are actually doing their research on smartphones, so it is incredibly important to have a website that translates well to a mobile device. There should not be any lag in uploading, and it needs to be easy and logical to navigate.7 Similar to the style of your office, the color scheme, font, and general aesthetics of the website should be consistent with your brand.

Content Your website should contain information about your credentials, your practice, location, and how to contact your office. It should also provide the consumer with relevant information about various procedures and services you provide. While there is a plethora of information about plastic surgery on the internet, most of it is inaccurate. Our practice websites provide a good platform to provide reliable information. Blogs are a great way to do this using approachable language for the patient and answering questions patients commonly ask on various search engines. This leads to organic traffic to your website and increases search engine optimization (SEO.) Blogs also allow you to increase your keyword use, which is another opportunity for your content to appear during online searches. Additionally, if your content is invaluable, other more reputable websites may then backlink to your content, further increasing traffic on your website. When your practice becomes ubiquitous with trustworthy and credible information, this increases your patient’s confidence and leads to increased conversions.7,8

Media: photographs and video Visual data is one of the most effective ways for website visitors to understand and process information.9 It is therefore no surprise that before-and-after photographs are arguably the most important aspect of your website. Patients want to see your work. It is important that these photographs are uniform, consistent, and showcase a variety of diverse patients and body types. Patients want to be able to scroll through and find someone that looks like them so they can then envision what their own result will be. Lighting, background, positioning, and overall quality should all be consistent. While information about standard photography itself is beyond the scope of this chapter, it is important to familiarize yourself with this to maintain the highest level of quality when it comes to your gallery. Often, offices may have one dedicated photographer or a well-equipped photo room to best accomplish this. These photographs should also be searchable by using popular keywords to increase traffic. Videos are a useful media when introducing yourself, your office, or your staff. It makes you more approachable and personable to the potential patient and can help showcase you as a leading expert in the field. They should be entertaining, educational, and engaging. These videos should be good quality with clear audio, and they should not slow down your site, especially your mobile platform. Additionally, longer viewership on your website may increase your SEO.

Search engine optimization (SEO) SEO: the three most important letters when it comes to your website. SEO is how effective your website is at optimizing

15

its content so that it can be found on search engines (Google, Yahoo, Bing, etc.). Most searches do not make it past the first page; furthermore, the first five results on Google get 67% of the clicks.10 If your website is not optimized, it will not be visible and will get lost on the world wide web. It will not be found unless someone is specifically looking you up by name or practice. There are various ways to optimize your SEO, including keywords, blogs, backlinks from other reputable websites, and domain authority. The actual content, number of words, titles and structure of each page, how long each viewer stays and clicks through pages within your website also contribute to SEO. It is extremely important to follow the analytics and be fluid as you build and maintain your SEO and website, as this will continuously ebb and flow in real time. As your practice grows, investing in a consultant to help manage your own website SEO may be worthwhile to maintain and increase your visibility.

Reputation management Your reputation is a key element in the health and growth of your practice. As plastic surgeons who perform elective surgery, we rely upon patients to share their experience with friends and family and draw more referrals into our practice. In today’s age, instant web accessibility for patients requires plastic surgeons to implement new reputation management practices to grow their business. Patients will use the power of social media to promote a practice as well as leave online reviews detailing their experiences. Having an effective reputation management system in place will leverage your online presence to your practice’s benefit. Patients who are happy with their experience overall are more likely to leave a positive review. Thus, your reputation extends beyond just your surgical skill, results, and bedside manner to include the entire surgical experience for your patients. Establishing a patient-centric foundation to your practice will ensure a higher satisfaction rate and is an important part of building your reputation in the community. Simply put, brand reputation is the public’s perception of your brand. Since most patients obtain their information from the internet, your online reputation will largely define how successful you are. Patients will leverage your digital reputation to influence their decision on whether to schedule a consultation with your practice. According to one study, almost 92.4% of consumers use online reviews to guide most of their ordinary purchasing decisions.11 In fact, healthcare actually has the highest influence of online reputation as compared to any other business type or industry. Approximately 60% of patients indicated that they have selected a physician based on positive reviews, and a nearly identical percentage say they have avoided doctors based on negative reviews. Your online reputation is a powerful tool, and this should be a focus to maintain the health of your practice.

How to solicit positive reviews Online reviews may happen organically, but it is a very slow process. It is in your best interest to proactively solicit reviews from your patients. Happy patients are not as likely to leave reviews as those who are unsatisfied. In fact, negative reviews can dominate your online reputation if you do not have an

16

CHAPTER 2  • Principles of practice management and social media for cosmetic surgery

effective digital reputation management system in place. Additionally, you must know where patients go to read your reviews and focus your efforts on those key arenas. Currently, Google reviews dominate the marketplace; however, this industry is constantly under flux. Google reviews are not only very visible in online searches but also they rank higher in SEO. However, it is important to not solicit reviews on just one site and have a variety of platforms and sites to recommend to your patients to remain diverse. Soliciting reviews can be done with traditional methods such as a verbal ask, mail, or in a more automated process via SMS text message or email. Patient testimonials are a key element to improving your online reputation. The more personal the story from your patient, the more details a prospective patient can relate to when reading about their positive experience. Videos can also provide a more personalized experience whereby the patient shares their journey or can simply be a conversation between the patient and the physician or staff. Embedding these testimonials on your website is crucial, as this is where patients go to assess your brand and they will help establish confidence in the physician and staff.

How to handle negative reviews It is inevitable that some patients may not have the best experience despite your best efforts to provide them with one. It is critical to have a process in place whereby your patients feel they are heard and understood when they do have a complaint. Ignoring a patient’s complaint is a surefire way to generate a negative review. Some patients may even leave negative reviews from what may appear to be a trivial matter to you. Responding to negative reviews may be more important than replying to positive ones. When addressing a negative review, do not be confrontational or sound defensive. Consumers will pick up on this and will usually sympathize with the person who left the review. Instead, thank the reviewer for their comment, acknowledge their concerns, and direct them to contact your office directly to address their concerns. Do not engage further online and certainly do not turn the issue around on the patient. Communicating directly with this patient offline avoids the need to divulge criticisms in a public forum. Most patients are amenable to discussing their grievances directly. Do not be argumentative with the patient. Make them feel like they are involved with the performance improvement process for your practice by asking them for their input. Ultimately, patients want to feel like they are being heard, and by acknowledging the issues that led to their concerns and discussing changes to minimize future similar occurrences, you will mitigate any possible future negative reviews arising from the same issue. This demonstrates transparency, sincerity, as well as a commitment to process improvement for prospective patients.

Social media Participating in social media is no longer an option for a practice to remain current and competitive. The public remains the most dominant contributor to plastic surgery content on social media, and, as the experts, we must remain engaged in social media on a variety of platforms to deliver factual

and professional information to our patients.12 Just as website advertising met some initial pushback in the 1990s, the use of social media has quickly overcome the skeptics and emerged as one of the main facets of current marketing. One of the first steps to implementing social media successfully into your practice is to identify your target demographic. The various platforms differ greatly in their users, and this information can be used to engage in the platforms that your patients are on. Once you choose your platforms, the social persona created should align with your brand and mission and, more importantly, should remain authentic. It is pivotal to maintain professionalism in all your posts, both on your practice social accounts, and on your personal accounts. When posts contain any patient content, confidentiality and informed consent are critical prior to posting. Patients should also be aware that once a post is made public, you cannot control the dissemination of that content, even if you subsequently remove the post. It is also important to be aware of your facility or institutional policies as they relate to photography and engagement on social media and abide by these specific parameters.13,14 What you post is just as important as where you post, and generated content should be varied, engaging, and attract your specific audience. Patients report that the top three most valued types of posts are contests or promotions to win free products, before-and-after photographs, and insider information about the practice. Educational posts and video content also rank highly among patients, giving them more information about the types of procedures you offer.15 When building a social media presence, the surgeon or a designated staff member may be responsible for posting to and managing the accounts. However, as your digital footprint grows, it may be beneficial to consider a digital marketing position within the practice to harness all of the benefits of social media for your practice. Analytics are critical to evaluate engagements, impressions, and reach for your posts. Engagement demonstrates how your followers have interacted with a post, including likes, shares, comments, and clicks. Impressions show how often your post shows up in the viewer’s feed, and reach measures the potential of a given post based on your own viewership and shared followers. Marketing dollars can also be put behind specific posts, and ‘boosting’ posts in this way can be a very cost-effective way to increase your reach. Social media engagement will often demonstrate a strong return on investment when incorporated into a plastic surgery practice and remains one of the strongest marketing tools in the current milieu.16 An additional benefit of social media is that it can serve as a powerful networking tool and conduit for mentorship. Meaningful relationships can be started and can mature online in this manner. These relationships can connect us as a specialty across geographic barriers and can be used to learn from one another. By following along and engaging with peers and colleagues, good insight can be obtained into a variety of approaches and styles that you may want to incorporate into your own social media. This is especially important as a learning tool if not exposed to social media as residents when most first learn about best practices of ethical and professional standards of engagement that can then be carried over to their own professional accounts in practice.17 Social media is invaluable in practice promotion and growth, public education, professional networking and personal fulfillment.

Conclusion

As with any portrayal of our specialty, we must maintain the utmost professionalism and ethical behavior as the voice of our specialty18 Other media should not be overlooked when evaluating a marketing plan for your practice. A regional market analysis is essential, and may identify other modalities such as radio, television, and print marketing that would benefit your practice. Partnering with other local businesses with a similar target demographic is an excellent opportunity to build a local reputation and engage in meaningful events and publications to attract patients. Podcasts have also emerged as a growing trend, and this is an excellent opportunity to educate and share information with potential patients. Creating engaging content and promoting listenership will offer your patients another opportunity to better understand your brand and your mission and help them feel more comfortable even before they step foot in your office.

Conclusion In an ever-changing world, it is imperative that plastic surgeons continue to adapt to remain competitive. Societal expectations and behaviors are constantly changing, technology is advancing, and patients have different

Access the reference list online at    Elsevier eBooks+

17

expectations of their surgeons and overall behaviors when searching for these surgeons. To start and run a successful medical practice, we must understand what these changes are and be fluid in our responses to them. The first step is understanding what our own goals and missions are as a plastic surgeon and as a practice. We must then identify our ideal market and patients and understand their behaviors. Everything else we do from that point should be targeted toward building a trusting relationship with them. This includes staff and an office that will appeal to them, a marketing strategy that will draw them in, and a social media presence that they can learn and engage with. Additionally, this is imperative not only to stay ahead of the competition but also to assert yourself as an authoritative voice in the specialty of plastic surgery. In this digital age with the ubiquity of social media, our patients are coming to us empowered with information about their desired surgical procedures, our practices, and us, as surgeons. They expect and require a connection before they even step foot in our doors. Digital marketing allows us to develop this relationship by authentically portraying our true brand and our mission. Creating a cohesive brand and mission that encompasses all steps of the patient journey is essential to practice management in the digital age and the building of a successful and sustainable plastic surgery career.

References

References 1. Dobies C. What is the difference between a brand promise and mission statement? Dobies Health Marketing. November 16, 2015. https://www.dobieshealthmarketing.com/blog/2015/11/ what-is-the-difference-between-a-brand-promise-and-missionstatement/#:~:text=You%20create%20a%20mission%20 statement,delivering%20a%20consistent%20customer%20 experience. Accessed February 25, 2021. 2. Business Owner’s Playbook. Define your Brand. https://www. thehartford.com/business-insurance/strategy/business-branding/ defining-business-brand#:~:text=Define%20Your%20Brand,you%20 intend%20it%20to%20be.&text=Discover%20how%20to%20get%20 your,competitors%20in%20a%20positive%20way. Accessed 25 February, 2021. 3. Wheeler K. How to develop a unique (& memorable) brand identity in 2021. HubSpot. https://blog.hubspot.com/agency/ develop-brand-identity. Accessed 25 February, 2021. 4. Williams J. The basics of branding. Entrepreneur. https://www. entrepreneur.com/article/77408. Accessed 25 February, 2021. 5. Gregory S. Business branding: top 10 things you need to create a brand. Fresh Sparks. February 18, 2020. https://freshsparks.com/ business-branding/. Accessed February 3, 2021. 6. Profitworks. Importance of website. https://profitworks.ca/ blog/297-why-having-a-website-is-important. Accessed May 4, 2021. 7. Crystal Clear Digital Marketing. Plastic surgery websites: what your site needs to succeed. https://crystalcleardigitalmarketing. com/plastic-surgery-websites-site-needs-succeed/. Accessed May 4, 2021. 8. Agency H. What makes a plastic surgery blog fantastic? https:// agencyh.com/makes-plastic-surgery-blog-fantastic/#:~:text=A%20

9.

10. 11. 12. 13. 14.

15. 16. 17. 18.

17.e1

blog%20exists%20not%20only,them%20interested%20in%20 your%20practice. Accessed May 4, 2021. Brandignity. Why before and after images could drastically improve website conversions. October 24, 2015. https://www. brandignity.com/2017/02/improve-website-conversions-beforeafter/#:~:text=blog-,Why%20Before%20and%20After%20 Images%20could%20Drastically%20Improve%20Website%20 Conversions,your%20company%20has%20to%20offer. Accessed May 4, 2021. Patel N. SEO Made simple: a step-by-step guide for 2021. https:// neilpatel.com/what-is-seo/. Accessed May 4, 2021. Ibbotson A. Patients trust online reviews as much as doctor recommendations—and other shocking facts about transparency in healthcare. https://nrchealth.com/patients-trust-online-reviews/. Branford O, Kamali P, Rohrich RJ, et al. #PlasticSurgery. Plast Reconstr Surg. 2016;138:1354. Cho MJ, Furnas H, Rohrich R. A prime on social media use by young plastic surgeons. Plast Reconstr Surg. 2019;143:1533. Bennett K, Berlin NL, MacEachern MP, Buchman SR, Preminger BA, Vercler CJ. The ethical and practice use of social media in surgery: a systematic review of the literature. Plast Reconstr Surg. 2018;142:388e. Sorice C, Li AY, Gilstrap J, Canales FL, Furnas HJ. Social media and the plastic surgery patient. Plast Reconstr Surg. 2017;140:1047. Vardanian A, Kusnezov N, Im DD, Lee JC, Jarrahy R. Social media use and impact on plastic surgery practice. Plast Reconstr Surg. 2013;131:1184. Chandawarkar A, Gould D, Stevens WG. Insta-grated plastic surgery residencies: the rise of social media use by trainees and responsible guidelines for use. Aesthet Surg J. 2018;38(10):1145–1152. Chen A, Furnas H, Lin S. Tips and pearls on social media for the plastic surgeon. Plast. Reconstr Surg. 2020;145:988e.

 

SECTION I •  Aesthetic Anesthesia Techniques

3 Essential elements of patient safety in aesthetic plastic surgery Jeremy T. Joseph, Gabriele C. Miotto, Felmont F. Eaves III, and Galen Perdikis

SYNOPSIS

ƒ The importance of patient safety has been acknowledged for centuries. However, medical errors still happen and are usually explained by the “Swiss cheese model” of sentinel events. ƒ Aesthetic surgery is generally elective, and patient safety is of paramount importance. ƒ The three pillars of safety – tools and evidence (evidence-based medicine), systems and processes, and culture and communication – can help us understand patient safety and errors and suggest ways that aesthetic surgeons can change their practice to improve patient safety. ƒ Quality is intimately associated with safety, and the factors that improve patient safety are precisely the same factors that improve the quality of care that we deliver in aesthetic surgery.

Introduction The concept of patient safety has existed for centuries. In its original form, the Hippocratic Oath charged physicians to “refrain from doing injury or wrong,” clearly acknowledging the potential for harm from medical treatment. Furthermore, the maxim, often attributed to the same author, primum non nocere or “first, do no harm” emphasizes the importance of safety when administering care to a patient.1 However, the ensuing centuries gave us countless examples of medical treatments that proved to be harmful or even lethal, highlighting shortcomings with respect to patient safety.2 In 1999, the Committee on Quality of Healthcare in America of the Institute of Medicine (IOM) published a landmark report, To Err Is Human: Building a Safer Health System.3 The report highlighted the fact that approximately 44,000 to 98,000 people die in hospitals each year from preventable medical errors. The cost of adverse events in the United States was estimated at $37.6 billion, with $17 billion of that amount attributed to preventable adverse events.

Surgeons have always recognized the importance of patient safety and have sought to find ways to reduce errors. Many surgical procedures are performed for the immediate health of the patient, but aesthetic surgery is generally elective, performed to enhance appearance rather than treat a life-threatening condition. Consequently, patient safety is of paramount importance.

Why do medical errors happen? A medical error has been defined as “an act of omission or commission in planning or execution that contributes or could contribute to an unintended result”.4 Until recently, medical mistakes were viewed as individual provider issues, and the response was typically to address the poor performance of the responsible provider by way of punishment, retraining, or other measures aimed at preventing the recurrence of the error on an individual basis.5 Although a punitive response may be appropriate in rare cases of deliberate malfeasance, most errors are committed by caring, competent providers and are due to system failures or failures of communication. For these reasons, simply admonishing the individual to be more careful is unlikely to prevent errors from occurring again. Traditionally, disseminating knowledge was the logical next step toward improvement. However, the IOM report and many others show that most patient safety and quality of care issues in modern medicine stem not from a lack of knowledge but from deficient systems, processes, and environments.6,7 According to the Joint Commission, more than 70% of patient safety sentinel events are related to these factors.8 When an error occurs, it is often due to multiple faults that occur together in an unanticipated interaction, creating a chain of events in which the faults grow and evolve.9,10 Perhaps the most widely known model of safety is the “Swiss cheese model” proposed by Reason.6,11 This model represents layers of protection and vulnerability at different levels as slices of Swiss cheese. A process within the patient’s care can be

The three pillars of patient safety

Nurse forgets to place SCDs before the start of anesthesia (SYSTEM) Patient tries to call doctor to report shortness of breath, message left (COMMUNICATION and SYSTEM)

Patient doesn’t tell surgeon she will be traveling the day of surgery (COMMUNICATION) Patient suffers a PE, arrests and dies

Inadequate VTE prophylaxis used (EVIDENCE)

Figure 3.1   A graphic demonstration of the “Swiss cheese model” of patient safety. The holes in the cheese represent potential errors. Typically, a sentinel event, such as the failure to prevent or treat a venous thromboembolism (VTE), involves a series of care points (slices), and only when the errors (holes) align does the event occur. By developing a culture of safety that embraces evidence, systems, culture and communication, the error potentials (holes) get smaller and the number of layers increase. PE, pulmonary embolism.

represented as several slices of Swiss cheese stacked together (Fig. 3.1). The holes represent potential active or latent errors in the care of the patient, while the protective, solid parts of the cheese represent where errors do not occur. Although each level of protection is incomplete, as represented by the holes in any given slice, it is unusual to have perfectly aligned holes once several slices are stacked together. For an adverse event to occur, typically, several errors must align in order to pass through each of the layers of protection without being stopped. If the system provides good protection, the holes will be small, and they will only rarely line up. However, in some systems, at some times, the holes align, allowing errors to propagate and resulting in harm to the patient. One of the most important concepts to come out of this model is that in complex systems, a single error is rarely sufficient to cause an adverse event or harm. This model also highlights the need to focus on more than just perfecting human behavior (an impossible task): creating a system with multiple overlapping layers of protection will minimize the potential for patient harm resulting from errors. Like knowledge, processes can be taught, improved, and refined. Systems themselves can become a mechanism for ongoing safety and quality advancements. Tools like checklists, double-loop learning, problem-solving techniques, error management, and organizational routines can help us improve patient safety in aesthetic plastic surgery.

The three pillars of patient safety The concept of the three pillars of patient safety has been useful in understanding not only the factors that impact patient safety and errors but also how aesthetic surgeons can make changes in their practice to improve patient safety.12

19

Pillar 1 Tools and resources: evidence-based medicine/best practices The first pillar of patient safety concerns having and using optimal tools and resources. This is a broad category and includes many components. Experienced, well-trained personnel and proper, well-maintained equipment are obvious examples. However, one of the most potent resources available to optimize patient safety is the evidence on which practice decisions are based. Identifying and leveraging the most valid and relevant evidence in patient care equates to the practice of evidence-based medicine. The group at McMaster University, led by Dr. David Sackett, founded the modern evidence-based medicine (EBM) movement. Sackett defined EBM as “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.”13 Sackett and his colleagues reduced the concept of EBM to five steps: 1. Convert the need for information into an answerable question. 2. Identify the best available evidence. 3. Evaluate the evidence for validity, impact, and applicability to the question at hand. Critical analysis skills are applied in the assessment of the evidence. The levels of evidence can be helpful as an initial guideline to assess the risk of bias within individual publications, but proper assessment also requires an analysis of the study methodology to look for flaws that might compromise the validity of the information. It is also important to determine whether this evidence is impactful and whether it applies to the patient care decision that is being made. A level of evidence pyramid has been adopted by certain plastic surgery journals as a visual way of promoting and advancing EBM in the field (Fig. 3.2).14 4. Integrate evidence with clinical experience and individual patient characteristics and needs. 5. Continually review and refine Steps 1–4. As new evidence becomes available, some better evidence should displace older, less valid evidence. As noted by Dr. Sackett, EBM is a way of “helping smart doctors stop prescribing dumb treatments”.13 Even with knowledge of the best evidence, the implementation of best practices often requires complex changes that come with potential barriers at various levels that need to be addressed. For example, barriers to change may include a lack of awareness or knowledge, reinforcement, control, social norms, leadership, or facilities.15 Effectively improving the delivery of safe patient care in aesthetic surgery requires that the appropriate systems and processes are in place.

Pillar 2 Systems and processes Much of our current understanding of systems comes from the work of Charles Perrow and James Reason. According to Reason, “a system is a set of interdependent elements interacting to achieve a common aim. The elements may be both human and non-human (equipment, technologies, etc.).”6 Systems and processes are the mechanism by which we apply our tools, the way in which we get things done. Systems

20

SECTION I

CHAPTER 3  • Essential elements of patient safety in aesthetic plastic surgery

II

II III

DIAGNOSTIC

THERAPEUTIC

RISK

Figure 3.2  The level of evidence pyramid, showing the level of evidence (I through V) and the clinical question addressed by the article. Left: Diagnostic clinical question addressed with level of evidence of II. Center: Therapeutic clinical question addressed with level of evidence of III. Right: Risk clinical question addressed with level of evidence of II. (Reproduced with permission from Sullivan D, Chung KC, Eaves FF 3rd, Rohrich RJ. The level of evidence pyramid: indicating levels of evidence in Plastic and Reconstructive Surgery articles. Plast Reconstr Surg. 2011;128:311–314.)

BOX 3.1  Systems and processes: common elements Define the task to be done – This should be based on the best available evidence and desired best clinical practice. Evaluate the available resources – Is the proper equipment in place? Are team members properly trained? In order to fulfill the task, do additional resources need to be procured? Plan – Working with team members, define a process by which the task will be done. Who will do the task? When will it be done? Where will it be done? How will it be done? Logistics – Logistics are the details of the plan: for instance, how to get the right resources in the right place at the right time. Training – Team members need to be trained in the new process or system. They need to know not only their own role but also the roles of the other team members. Practice, potentially including simulation, can significantly increase reliability when implementing a new process. System tools – These include checklists, time outs, pass-offs, and organizational routines. Assessment, monitoring and modification – In order to monitor whether a system is working, the outcome must be measured by appropriate metrics. When the desired outcome is not achieved, a root cause analysis can demonstrate where the system failed and why. Changes in the system can be implemented through this knowledge, including a reassessment of the underlying issues, a process known as double-loop learning. In this way, the system is continually improved, leading to ongoing error reduction.

and processes – and their implementation – can be simple or complex, but they share common elements (Box 3.1). One tool that has proved particularly useful in modern healthcare systems is the checklist. The use of checklists in healthcare was adapted from the aviation industry – another high-stakes industry that requires intense attention to detail from all crew members to prevent catastrophic consequences. The benefits of checklists in healthcare were demonstrated by the implementation of a simple central line insertion checklist as part of the Pittsburgh Regional Healthcare Initiative (PRHI). The Centers for Disease Control and Prevention (CDC) estimates that bloodstream infections arising from the insertion of a central line affects up to 250,000 patients a year in the United States, killing 15% or more.16 Furthermore, the cost of additional care per infection is estimated in the tens of thousands of dollars. However, between 2001 and 2004, two dozen Pittsburgh hospitals participating in the PRHI were able to reduce the incidence of central line infections by more than 50%. Some hospitals, in fact, reduced them by more than 90%.17

According to the New England Journal of Medicine (NEJM) report,18 the total number of central line–related complications during the initiative decreased from 27.3 (95% confidence interval [CI], 25.9 to 28.7) to 16.7 (95% CI, 15.6 to 17.9), for an absolute risk reduction of 10.6 (95% CI, 8.7 to 12.4). The proportion of patients with one or more complications decreased from 15.4% to 10.6% (P120kg) cefazolin given 30–60 min before incision. For patients with allergic contraindications, clindamycin or vancomycin are alternate options. • Repeat dose 4-12 h after initial dose depending on antibiotic choice. • Antimicrobial prophylaxis should not be continued beyond 24 h. 6. Pre-warming the patient for 30–60 min before surgery and maintenance of normothermia (temperature above 36°C) during the perioperative period. • Use active warming devices during surgery (air blankets, warm pads). • Strongly consider room temperature above 70°F. • Increase ambient room temperature to 72°F–75°F when significant patient exposure occurs such as prepping, draping and re-prepping. 7. Meticulous aseptic technique with chlorhexidine 0.5%–2% in alcoholic solution for body procedures and povidone–iodine 10% for facial procedures. Perineal area should be prepped with aqueous solution (either PVI or chlorhexidine). 8. Intraoperative and postoperative serum glucose control in diabetic patients.

(EBM, systems, and procedures) and cultural factors (safety = T × C). Efforts to promote safety have mostly focused on the technical aspects of care and largely ignored the cultural aspects, leaving patients at massive risk for errors. In assessments of medical errors, 70% of the time someone knew something was wrong and did not speak up. We assume that people will speak up in our own practices, but have we ever taken the time to discuss how we need to communicate as a team with our team? When last did you ask your staff if they would speak up if they saw you about to make an error even if they were not sure? Do you have a safe, comfortable system in place in your practice where members of your staff can bring up safety concerns, solutions, and even practice improvement suggestions? Empowering your team to speak up and fostering a safe culture gives them the ability to detect gaps in the system. Part of this effort involves cultivating a work environment of empowerment, respect, and team communication that focuses on the importance of the human element.19 In a constrained, blame environment, communication and innovation are stifled.

21

Changing culture requires complete buy-in from leadership and lead physicians in practices. It is a long journey and not a quick fix. Contemporary efforts to promote team-based structures have created space for potential errors to be discussed in an environment of professional respect without fear of punitive consequences. Attention to the design of healthcare systems is likely to be the most effective approach to preventing errors, mitigating their effects, and reducing the likelihood of harm. The preoperative “timeout” combines the previously mentioned notion of checklists along with this systems-based approach to improve communication among team members with the goal of reducing morbidity and mortality. The World Health Organization surgical safety checklist includes recommendations for three separate timepoints in the perioperative period: before anesthetic induction, before skin incision, and before the patient leaves the operating room. It is imperative that all members of the operating room team stop work on any tasks so that communication is optimal during these critical moments. The application of checklist utilization in time­outs in the operating room has revealed decreases in total complications (absolute risk reduction of 10.6 [95% CI, 8.7 to 12.4]), proportion of patients with complications (15.4% before to 10.6% after [P70 years, functional capacity of 2 mg/dL).22 Each of these factors in the RCRI confers a point to the patient’s index, and the risk of major cardiac events occurring in the perioperative period increases significantly with each point increase. Patients with a RCRI of 3 or more or those with a RCRI of 1–2 with poor functional capacity or active anginal symptoms should be referred for cardiac evaluation (Algorithm 3.1).23 For patients on anticoagulation or antiplatelet therapy, a discussion with the prescribing provider should take place in order to determine if and when the optimal timing for cessation prior to surgery would be. Venous thromboembolism (VTE) events are one of the most morbid conditions the aesthetic plastic surgeon will encounter. Prevention of VTE is crucial, but data in aesthetic surgery are limited and determining the optimal VTE prophylaxis protocol is case-dependent. The Caprini Risk Assessment Model (Fig. 3.3)24 has been validated in plastic surgery and Pannucci et al. report 11.3% postoperative VTE rates in patients with a Caprini score >8.25 One recommended approach based on the patient’s Caprini score and available literature24–30 is provided in Algorithm 3.2. A common reason for hesitancy of using VTE chemoprophylaxis is bleeding; however, the data associating bleeding with VTE chemoprophylaxis are unclear.31,32 In women

taking estrogen-containing drugs, this should be paused in conjunction with the prescribing provider, ideally 2–4 weeks prior to surgery to reduce the risk of VTE.23

Pulmonary considerations Respiratory complications can arise in healthy or diseased individuals, but older patients and those with chronic lung disease have increased risk due to impaired ventilation and/ or oxygenation.33–35 Patients with an active upper respiratory tract infection are thought to have increased airway reactivity, but, in the adult population, this remains unclear. Until there is more evidence, it is perhaps optimal to avoid general anesthesia with an active infection in the respiratory tract if it is feasible to do so. Other specific risk factors for postoperative pneumonia and respiratory failure include atelectasis,36,37 type of surgery, serum albumin 30 mg/dL, poor functional status, chronic obstructive pulmonary disease (COPD), age >60 years, obesity, chronic illness (diabetes, CHF, CVA), and longer surgical duration.23,38,39 Obstructive sleep apnea (OSA) is a condition that may be undiagnosed at the time of surgical presentation and if suspected should be discussed with your anesthesia team as this may indicate a difficult airway. Preoperative pulmonary function testing is not recommended in patients undergoing non-thoracic procedures.23,34,36 While chest radiography is utilized more often to assess pulmonary risk, many studies suggests this practice is excessive and probably is only helpful to assess unexplained respiratory symptoms, and those with concern for respiratory infection.40,41 Smoking cessation should be strongly encouraged preoperatively to minimize airway reactivity, and should occur 8 or more weeks prior to surgery.42 Practically, this may be difficult and patients may deny smoking even when they continue to do so in order to prevent delays for their desired procedure. Cotinine tests are useful to objectively confirm smoking cessation. Patients should be counseled to continue avoiding smoking after surgery, as well. Some simple postoperative maneuvers that can be employed to decrease postoperative atelectasis and pneumonia includes incentive spirometry, directed coughing, and deep breathing.

Algorithm 3.1 Calculate Revised Cardiac Risk Index2

0–2

No symptoms

3+

Active angina or other cardiac symptoms

No further preoperative cardiac evaluation indicated

Preoperative cardiac evaluation for aesthetic procedures requiring general anesthesia.

Referral for medical optimization/cardiac testing

The three pillars of patient safety

23

Figure 3.3  Elements of the Caprini Risk Assessment Model. (Caprini JA. Thrombosis risk assessment as a guide to quality patient care. Dis Mon. 2005;51(2–3):70-8. doi:10.1016/j.disamonth.2005.02.003.)

Hypothermia Perioperative hypothermia is associated with numerous complications including SSIs and hemorrhage/hematoma. Additionally, as the blood temperature declines, several consequences to the coagulation cascade occur,45,46 leading to increased bleeding events in surgical patients.47 It is recommended to keep the patient’s body temperature normothermic (at least 36°C) by maintaining warmer ambient operating room temperature and utilizing active warming devices such as forced warm-air blankets.48 Box 3.2 includes more information on other actionable items to prevent SSIs.

Other important patient factors Hypertension and diabetes are important in general anesthesia and aesthetic surgery. Hypertension is known to increase bleeding and hematoma risk.49 Perioperative hypertension can

have many causes, including pain, anxiety, postoperative catecholamine surge, nausea, and vomiting; treatment should be directed by etiology. Diabetes increases the risk for complications, particularly infection, and glycemic control is important to prevent these complications. Therefore, fasting blood glucose and hemoglobin A1c levels should be assessed in all patients with diabetes and, in those with elevated levels, glucose control should be achieved prior to surgery.50 It may be valuable to discuss management of the night before and day of surgery with the provider managing the patient’s diabetes. Diabetic patients should have their glucose levels confirmed in the preoperative area on arrival. Intraoperatively, glucose levels should be monitored at least every hour, and a sustained glucose level of >200 mg/dL warrants intravenous insulin infusion.23 Continue close monitoring postoperatively and have insulin and dextrose available for injection. Attempt to transition back to the patient’s home regimen as soon as it is feasible.

24

SECTION I

CHAPTER 3  • Essential elements of patient safety in aesthetic plastic surgery

Algorithm 3.2 General anesthesia and >45 min procedure

No

Yes

Contraindications/patient refuses chemoprophylaxis or already on active anticoagulation

Yes No Calculate Caprini score (Figure 3.3)

3–4

1–2

0

5–6

Chemoprophylaxis rarely recommended (surgeon/patient decision – poor ambulatory status + high–risk surgery*) during hospitalization and up to 7 days First dose within 8 hours postop

Consider chemoprophylaxis during hospitalization and up to 7– 10 days depending on ambulatory status and surgery risk First dose within 8 hours postop

7–8

Chemoprophylaxis recommended for 7–10 days or at least until baseline ambulatory status achieved First dose within 8 hours postop

9+

Chemoprophylaxis for hospitalization or up to 30 days First dose within 2 hours preop

Discuss Early and frequent ambulation, frequent oral hydration, ankle flexion/extension, graduated co mpression stockings, sequential compression devices

Venous thromboembolism prophylaxis in aesthetic surgery. Most commonly recommended anticoagulation for prophylaxis is low-molecular-weight heparin or low-dose unfractionated heparin. Direct and indirect factor Xa inhibitors as well as direct thrombin inhibitors are alternatives used for those with a history of heparin-induced thrombocytopenia. *Including body contouring and abdominoplasty.

Telemedicine Healthcare has evolved significantly with the implementation of technological advances. One important consideration is the increase in telemedicine visits. The advantages and disadvantages must be considered in determining whether a telemedicine evaluation is an appropriate medium for a patient visit. Prior to any procedure, especially in those requiring general anesthesia, an in-person examination with the surgeon should be performed. Postoperatively, some follow-up appointments may be conducted virtually to allow efficient and more frequent visits while making it less cumbersome for patients. Appropriate use of chaperones as in an in-person visit is also an important consideration. These virtual follow-ups should be used to alert the surgeon to any potential developing complications that may indicate the need for an in-person visit.

Conclusions One important perspective shift in recent years is the recognition that practice efficiency and quality improvement are

Access the reference list online at

 

 

Elsevier eBooks+

synonymous with patient safety. Factors that improve patient safety – namely, defined systems and processes, a continuous quality improvement culture, and safe, communicative, and professional working environments – are precisely the same factors that improve the quality of care that we deliver. Safe care is quality care, and quality care is safe. In order to optimize patient safety in aesthetic surgery, professional organizations, training programs, journals and, most importantly, aesthetic plastic surgeons need to change their attitudes and reframe their educational focus. Traditionally, aesthetic education has been focused primarily on procedural technique optimization; however, as demonstrated by the Joint Commission data, this is not where errors typically occur, as the overwhelming majority of errors are related to systems, culture, and communications failures. Optimizing patient safety requires that surgeons embrace education directed toward continually improving the evidence used in decision making, the systems and processes they employ to execute these intentions, and the cultures within which they work.

References

References 1. Shelton JD. A piece of my mind: the harm of “first, do no harm”. JAMA. 2000;284(21):2687–2688. https://doi.org/10.1001/jama. 284.21.2687. 2. Spear SJ. Fixing health care from the inside, today. Harv Bus Rev. 2005;83(9):78–91, 158. 3. Institute of Medicine Committee on Quality of Health Care in America. In: Kohn LT, Corrigan JM, Donaldson MS, eds. To Err is Human: Building a Safer Health System. Washington, DC: National Academies Press (US); 2000. 4. Grober ED, Bohnen JM. Defining medical error. Can J Surg. 2005; 48(1):39–44. 5. Wachter RM. Understanding Patient Safety. New York: McGraw-Hill; 2008. 6. Reason J. Human Error. Cambridge: Cambridge University Press; 1990. 7. Leape LL. Errors in medicine. Clin Chim Acta. 2009;404(1):2–5. https://doi.org/10.1016/j.cca.2009.03.020. 8. Chang A, Schyve PM, Croteau RJ, O’Leary DS, Loeb JM. The JCAHO patient safety event taxonomy: a standardized terminology and classification schema for near misses and adverse events. Int J Qual Health Care. 2005;17(2):95–105. https://doi.org/10.1093/ intqhc/mzi021. 9. Perrow C. Normal Accidents: Living with High-Risk Technologies. New York: Basic Books; 1984. 10. Bogner M. Human Error in Medicine. Hillsdale, NJ: L. Erlbaum Assoc; 1994. 11. Reason J. Managing the Risks of Organizational Accidents. Routledge; 2016. 12. Eaves FF 3rd. An integrated model of patient safety and quality of care. Aesthet Surg J. 2011;31(6):714–715. https://doi.org/10.1177/109 0820x11416922. 13. Thoma A, Eaves FF 3rd. A brief history of evidence-based medicine (EBM) and the contributions of Dr David Sackett. Aesthet Surg J. 2015;35(8):Np261–Np263. https://doi.org/10.1093/asj/sjv130. 14. Sullivan D, Chung KC, Eaves FF 3rd, Rohrich RJ. The level of evidence pyramid: indicating levels of evidence in Plastic and Reconstructive Surgery articles. Plast Reconstr Surg. 2011;128(1): 311–314. https://doi.org/10.1097/PRS.0b013e3182195826. 15. Grol R, Wensing M. What drives change? Barriers to and incentives for achieving evidence-based practice. Med J Aust. 2004;180(S6):S57– S60. https://doi.org/10.5694/j.1326-5377.2004.tb05948.x. 16. Burke JP. Infection control – a problem for patient safety. N Engl J Med. Feb 13 2003;348(7):651–656. https://doi.org/10.1056/ NEJMhpr020557. 17. Centers for Disease Control and Prevention Reduction in central line-associated bloodstream infections among patients in intensive care units – Pennsylvania, April 2001–March 2005. MMWR Morb Mortal Wkly Rep. Oct 14 2005;54(40):1013–1016. 18. Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355(26):2725–2732. https://doi.org/10.1056/ NEJMoa061115. 19. Sexton JB, Makary MA, Tersigni AR, et al. Teamwork in the operating room: frontline perspectives among hospitals and operating room personnel. Anesthesiology. 2006;105(5):877–884. https://doi.org/10.1097/00000542-200611000-00006. 20. de Vries EN, Prins HA, Crolla RM, et al. Effect of a comprehensive surgical safety system on patient outcomes. N Engl J Med. 2010;363(20):1928–1937. https://doi.org/10.1056/NEJMsa0911535. 21. Goldman L, Caldera DL, Nussbaum SR, et al. Multifactorial index of cardiac risk in noncardiac surgical procedures. N Engl J Med. 1977;297(16):845–850. https://doi.org/10.1056/ nejm197710202971601. 22. Lee TH, Marcantonio ER, Mangione CM, et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation. Sep 7 1999; 100(10):1043–1049. https://doi.org/10.1161/01.cir.100.10.1043.

24.e1

23. Young VLB, R. Patient Safety in Plastic Surgery. Quality Medical Publishing, Inc. 2009:213–291. 24. Caprini JA. Thrombosis risk assessment as a guide to quality patient care. Dis Mon. 2005;51(2-3):70–78. https://doi.org/10.1016/j. disamonth.2005.02.003. 25. Pannucci CJ, Bailey SH, Dreszer G, et al. Validation of the Caprini risk assessment model in plastic and reconstructive surgery patients. J Am Coll Surg. 2011;212(1):105–112. https://doi. org/10.1016/j.jamcollsurg.2010.08.018. 26. Pannucci CJ. Venous thromboembolism in aesthetic surgery: risk optimization in the preoperative, intraoperative, and postoperative settings. Aesthet Surg J. 2019;39(2):209–219. https://doi.org/10.1093/ asj/sjy138. 27. Pannucci CJ, Swistun L, MacDonald JK, Henke PK, Brooke BS. Individualized venous thromboembolism risk stratification using the 2005 Caprini score to identify the benefits and harms of chemoprophylaxis in surgical patients: a meta-analysis. Ann Surg. 2017;265(6):1094–1103. https://doi.org/10.1097/sla.00000000 00002126. 28. Bahl V, Hu HM, Henke PK, Wakefield TW, Campbell Jr. DA, Caprini JA. A validation study of a retrospective venous thromboembolism risk scoring method. Ann Surg. 2010;251(2): 344–350. https://doi.org/10.1097/SLA.0b013e3181b7fca6. 29. Murphy RX Jr, Alderman A, Gutowski K, et al. Evidence-based practices for thromboembolism prevention: a report from the ASPS Venous Thromboembolism Task Force. Plast Reconstr Surg. 2012; 130(1):168e-175e. 30. Pannucci CJ, MacDonald JK, Ariyan S, et al. Benefits and risks of prophylaxis for deep venous thrombosis and pulmonary embolus in plastic surgery: a systematic review and meta-analysis of controlled trials and consensus conference. Plast Reconstr Surg. 2016;137(2):709–730. https://doi.org/10.1097/01. prs.0000475790.54231.28. 31. Seruya M, Venturi ML, Iorio ML, Davison SP. Efficacy and safety of venous thromboembolism prophylaxis in highest risk plastic surgery patients. Plast Reconstr Surg. 2008;122(6):1701–1708. https://doi.org/10.1097/PRS.0b013e31818dbffd. 32. Hatef DA, Kenkel JM, Nguyen MQ, et al. Thromboembolic risk assessment and the efficacy of enoxaparin prophylaxis in excisional body contouring surgery. Plast Reconstr Surg. 2008;122(1):269–279. https://doi.org/10.1097/PRS.0b013e3181773d4a. 33. Sprung J, Gajic O, Warner DO. Review article: age related alterations in respiratory function – anesthetic considerations. Can J Anaesth. 2006;53(12):1244–1257. https://doi.org/10.1007/ bf03021586. 34. Wong DH, Weber EC, Schell MJ, Wong AB, Anderson CT, Barker SJ. Factors associated with postoperative pulmonary complications in patients with severe chronic obstructive pulmonary disease. Anesth Analg. 1995;80(2):276–284. https://doi.org/10.1097/00000539199502000-00013. 35. Warner DO, Warner MA, Barnes RD, et al. Perioperative respiratory complications in patients with asthma. Anesthesiology. 1996;85(3):460–467. https://doi.org/10.1097/00000542-19960900000003. 36. Warner DO, Warner MA, Offord KP, Schroeder DR, Maxson P, Scanlon PD. Airway obstruction and perioperative complications in smokers undergoing abdominal surgery. Anesthesiology. 1999;90(2): 372–379. https://doi.org/10.1097/00000542-199902000-00007. 37. Duggan M, Kavanagh BP. Pulmonary atelectasis: a pathogenic perioperative entity. Anesthesiology. 2005;102(4):838–854. https:// doi.org/10.1097/00000542-200504000-00021. 38. Arozullah AM, Daley J, Henderson WG, Khuri SF. Multifactorial risk index for predicting postoperative respiratory failure in men after major noncardiac surgery. The National Veterans Administration Surgical Quality Improvement Program. Ann Surg. 2000;232(2):242– 253. https://doi.org/10.1097/00000658-200008000-00015. 39. Arozullah AM, Khuri SF, Henderson WG, Daley J. Development and validation of a multifactorial risk index for predicting postoperative pneumonia after major noncardiac surgery. Ann Intern Med. 2001;135(10):847–857. https://doi.org/10.7326/ 0003-4819-135-10-200111200-00005.

24.e2

SECTION I

CHAPTER 3  • Essential elements of patient safety in aesthetic plastic surgery

40. Tape TG, Mushlin AI. How useful are routine chest x-rays of preoperative patients at risk for postoperative chest disease. J Gen Intern Med. 1988;3(1):15–20. https://doi.org/10.1007/bf02595750. 41. Joo HS, Wong J, Naik VN, Savoldelli GL. The value of screening preoperative chest x-rays: a systematic review. Can J Anaesth. 2005;52(6):568–574. https://doi.org/10.1007/bf03015764. 42. Warner MA, Offord KP, Warner ME, Lennon RL, Conover MA, Jansson-Schumacher U. Role of preoperative cessation of smoking and other factors in postoperative pulmonary complications: a blinded prospective study of coronary artery bypass patients. Mayo Clin Proc. 1989;64(6):609–616. https://doi.org/10.1016/ s0025-6196(12)65337-3. 43. American Society of Anesthesiologists and Anesthesia Patient Safety Foundation Joint Statement on Elective Surgery and Anesthesia for Patients after COVID-19 Infection. December 8, 2020; Anaesthesia Patient Safety Foundation. 44. COVIDSurgCollaborative Delaying surgery for patients with a previous SARS-CoV-2 infection. Br J Surg. 2020;107(12):e601–e602. https://doi.org/10.1002/bjs.12050. 45. Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten

46. 47.

48.

49. 50.

hospitalization. Study of Wound Infection and Temperature Group. N Engl J Med. 9. 1996;334(19):1209–1215. https://doi.org/10.1056/ nejm199605093341901. Sessler DI. Complications and treatment of mild hypothermia. Anesthesiology. 2001;95(2):531–543. https://doi.org/10.1097/ 00000542-200108000-00040. Rajagopalan S, Mascha E, Na J, Sessler DI. The effects of mild perioperative hypothermia on blood loss and transfusion requirement. Anesthesiology. 2008;108(1):71–77. https://doi. org/10.1097/01.anes.0000296719.73450.52. Tyvold SS. Preventing hypothermia in outpatient plastic surgery by self-warming or forced-air-warming blanket: A randomised controlled trial. Eur J Anaesthesiol. 2019;36(11):843–850. https://doi. org/10.1097/eja.0000000000001087. Trussler AP, Tabbal GN. Patient safety in plastic surgery. Plast Reconstr Surg. 2012;130(3):470e–478e. https://doi.org/10.1097/ PRS.0b013e31825dc349. Dronge AS, Perkal MF, Kancir S, Concato J, Aslan M, Rosenthal RA. Long-term glycemic control and postoperative infectious complications. Arch Surg. 2006;141(4):375–380. discussion 380. https://doi.org/10.1001/archsurg.141.4.375.

SECTION I  •  Aesthetic Anesthesia Techniques

4 Pain management in plastic surgery Anna R. Schoenbrunner and Jeffrey E. Janis

Introduction Postoperative pain management in plastic surgery remains a topic of increasing interest amidst heightened awareness of the opioid epidemic. Pain is defined as the sensory and emotional reaction to actual or perceived tissue injury.1 Nociceptive pain is due to stimulation of peripheral pain receptors at suprathreshold levels from damage to non-neural tissue.2 Inflammatory pain is due to peripheral pain sensitization from activation of the immune system via chemical mediators. Surgery results in nociceptive and inflammatory pain from tissue injury. Pathological pain results from dysfunction of the nervous system without tissue damage; this is maladaptive and serves no biological function.3 Uncontrolled postsurgical pain has been associated with worse surgical outcomes. This includes increased risk of poor pulmonary function, myocardial ischemia, ileus, thromboembolism, and impaired immune function.4,5 It has been associated with increased post-anesthesia care unit stays, prolonged admissions and increased readmission rates; this may affect reimbursement and patient satisfaction.6–11 Uncontrolled postsurgical pain has also been implicated in the development of persistent postsurgical pain (PPSP) as a result of maladaptive neuronal plasticity.12,13 PPSP is estimated to affect 20%–25% of mastectomy patients, 50%–85% of amputation patients, and 5%–35% of hernia repair patients.14,15 PPSP may have implications for long-term opiate use among patients affected. In the era of the American opioid epidemic, surgeons play a crucial role in optimizing postoperative pain and minimizing narcotic use. Enhanced Recovery After Surgery (ERAS) protocols were pioneered in the early 2000s by Ljungqvist and Fearson based on the work by Kehlet.16–18 These protocols are designed to enhance recovery after surgery through perioperative interventions focused on nutrition, pain control, and early mobilization. Non-pharmacologic pain management strategies such as mindfulness, massage, and acupuncture have been found to be effective pain management strategies and should be utilized.19 This chapter reviews pain

management strategies available to plastic surgeons based on therapeutic class of medication and provides a framework for pain management based on ERAS protocols.

Opioid epidemic The opioid epidemic within the US was declared a public health crisis by the Surgeon General in November 2016. The US accounts for 4.4% of the world’s population but consumes 80% of the world’s opiates.20 The opiate epidemic has claimed nearly 500,000 lives from 1999 to 2019 due to prescription and illicit opioids.21 It has been estimated to cost the US economy $100 billion per year in direct healthcare costs, lost productivity, and law enforcement support.22,23 The Centers for Disease Control and Prevention (CDC) divides the opioid epidemic into three phases: the first phase began in the 1990s with overdose deaths largely due to prescription drugs, the second phase began in 2010 with overdose deaths largely due to heroin, and the third phase began in 2013 with the rapid rise of overdose deaths linked to synthetic opiates (largely involving fentanyl).24–26 Opiate prescribing began to decrease in 2011 due to advocacy, legislation, and clinical practice guidelines.27 Despite this, overdose deaths continued to increase largely due to non-prescription opiates.21 Contrary to the national trend of decreasing opiate prescribing, surgical, dental, and emergency medicine specialties saw an increase in opiate prescribing from 2010 to 2016; surgery patients saw an increase of 70% in average total morphine equivalents during this period.27 Additionally, when analyzing the types of opiates prescribed to surgery patients, Larach et al. found that surgery patients were more likely to receive oxycodone and hydrocodone – more potent opiate formulations – than dental and emergency department patients.28 This trend is particularly worrisome as a systematic review into prescribing practices found that as many as 92% of surgery patients reported that 70% of their prescribed opiates went unused.29 Among plastic surgeons, Chu et al. reported that, on average, 52% of all opiate pills prescribed for patients undergoing plastic and

26

SECTION I

CHAPTER 4  • Pain management in plastic surgery

reconstructive surgery procedures went unused; this amounted to an average of 13 unused opiate pills per patient.30 This trend in opiate prescribing practices among surgeons is particularly troubling as new persistent use (defined as continued opiate prescription refills 3 months after the index procedure) is as high as 6.6% for patients undergoing general plastic surgery reconstructive procedures, 6.1% for patients undergoing body contouring, and 13% for patients undergoing hand surgery.31,32

Opioids Opioids are pervasive in today’s healthcare system. This class of analgesics primarily act on mu (μ) opioid receptors in the central nervous system.33 Opioids modify afferent pain signals by binding to opiate receptors, thereby decreasing the perception of pain. The mu opiate receptor not only has analgesic properties but also results in euphoria, sedation, anorexia, and respiratory depression; this explains the adverse effects associated with opiate use.34 The addictive potential of opioids has been well established and cannot be overstated, with estimates of postoperative chronic opiate use in previously opiate naïve patients ranging from 5% to 13%.32,35,36 Opioids are administered parenterally or orally. Intravenous administration has predictable peak plasma concentration with rapid time of onset and offset. Intravenous formulations of opioids allow for an effective method of analgesia in patients without enteral absorptive capacity, such as in patients with postoperative ileus. Patient-controlled analgesia (PCA) devices allow for repeated low doses of opioids to be administered by the patient. PCAs have gained popularity as they decrease time burden on nursing staff; however, PCAs have been shown to increase side effects such as nausea, vomiting, and pruritus.37 Oral administration of opioids has slower time of onset due to first pass metabolism through the liver; however, this slower enteral absorption allows for more steady and longer-lasting analgesic effects.38 Opioids should be used with caution in geriatric patients, patients with obstructive sleep apnea (OSA), and those with abuse history or potential. Surgeons must exercise caution in prescribing opioids to patients who use other sedative medications, such as benzodiazepines, antihistamines, or sleep aids, as these can have additive effects and cause respiratory depression.39 Opiates should also be used with caution in anyone with a history of excess alcohol consumption. We recommend minimizing opiate use postoperatively by employing a multimodal analgesic (MMA) approach to ambulatory and inpatient surgery patients.40 For patients who require opioids for acute postsurgical pain, we recommend the use of opioids without added acetaminophen to decrease risk of acetaminophen toxicity (maximum dose 4000 mg in 24 hours).

Acetaminophen, nonsteroidal anti-inflammatory drugs, and selective COX-2 inhibitors Acetaminophen Acetaminophen’s mechanism of action remains elusive, but it is believed to inhibit cyclooxygenase-1 (COX-1) and COX-2

enzymes in the central nervous system.41,42 This accounts for its analgesic and antipyretic effects.43,44 Acetaminophen does not affect peripheral COX enzymes and therefore does not have the same gastric ulceration and bleeding complications associated with nonsteroidal anti-inflammatory drugs (NSAIDs). A Cochrane review found that a single dose of acetaminophen postoperatively achieves a 50% reduction in pain over 4–6 hours.45 Acetaminophen is available in oral, rectal and intravenous formulations. Intravenous acetaminophen is more costly than oral acetaminophen and has not been shown to be significantly more effective in reducing postoperative pain scores compared with oral acetaminophen.46 Acetaminophen is metabolized by the liver and must be used with caution in patients with liver disease. The maximum dose of acetaminophen is 4000 mg in a 24-hour period.47 We recommend utilizing acetaminophen in all postoperative patients who do not have contraindications to its use.48,49 Acetaminophen should be scheduled around the clock in the first 48–72 hours following surgery. Prescribers must exercise caution and educate their patients who take medications containing acetaminophen, such as opioid combinations or cold medications, at home.

NSAIDs NSAIDs act through peripheral inhibition of COX-1 and COX-2 enzymes and inhibiting the synthesis of prostaglandin, a mediator of inflammation and vasodilation and thromboxane, a mediator of vasoconstriction and platelet aggregation.50 NSAIDs can cause gastric ulceration (particularly in postbariatric surgery patients), gastrointestinal (GI) bleeding, platelet dysfunction, asthma exacerbation, and renal impairment. Surgeons must be aware of the cardiovascular risks associated with NSAIDs and COX-2 inhibitors. These include myocardial infarction, stroke, heart failure, hypertension, atrial fibrillation, and venous thromboembolism in patients with and without known cardiovascular disease. These risks were reported through the landmark VIGOR and PRECISION trials.51,52 In 2015, the Food and Drug Administration (FDA) strengthened its warning against NSAIDs, warning against the use of these medications in patients with and without existing heart disease due to the increased risk of heart disease and stroke.53 Ketorolac tromethamine (Toradol; F. Hoffmann-La Roche AG, Basel, Switzerland) is an NSAID that is available in intravenous formulation and is widely used due to its rapid onset of action.54,55 Plastic surgeons have historically been hesitant to use this medication due to concerns for increased hematoma risk. However, a 2015 meta-analysis found that Toradol does not increase hematoma rates among patients undergoing aesthetic surgery (2.5% in patients receiving Toradol vs 2.4% in patients not receiving Toradol; P = 0.79).56 All six papers analyzed in the meta-analysis found a significant reduction in postoperative pain and narcotic use among patients who received Toradol. A recent multi-surgeon single-site retrospective cohort study did not find a significant increase in hematoma rates among patients undergoing breast reduction (4.0% in patients who received Toradol vs 3.2% in patients who did not receive Toradol; P = 0.711) and breast reconstruction (3.2% in patients who received Toradol vs 1.9% in patients who did not receive Toradol; P = 0.475).57

Adjuvant multimodal medications

27

COX-2 inhibitors

Muscle relaxants

The COX-2 enzyme plays a role in inflammation.58 Selective COX-2 inhibitors theoretically reduce the risk of GI bleeding but have many of the same contraindications as NSAIDs. Several studies investigating the GI benefits of selective COX-2 inhibitors found they have decreased risk of GI bleeding in comparison to NSAIDs; however, they were still associated with higher bleeding risk compared with placebo.51,59,60 A study investigating the effect of selective COX-2 inhibitors on platelet function found the drugs to have a similar, undetectable effect on platelet function as compared with placebo, whereas NSAIDs decreased platelet aggregation and increased bleeding time.61 Importantly, they carry the same FDA warnings in regard to cardiovascular risks as NSAIDs.62,63 We recommend selective use of NSAIDs or COX-2 inhibitors in appropriately selected patients.48,49 These medications should not be used in patients with known cardiovascular disease, renal impairment, or GI bleeding risk factors. Duration should be minimized to the acute postoperative setting and the lowest effective dosage should be used. We prefer the use of celecoxib dosed three times per day (TID).

Cyclobenzaprine is a commonly prescribed muscle relaxant. Despite its classification, cyclobenzaprine does not act on skeletal muscle. Rather, it is a centrally acting medication believed to act at the brainstem level on the locus ceruleus, decreasing the activity of serotonergic descending neurons, thereby decreasing muscle tone.73,74 The effect on the locus ceruleus may help to explain the sedating qualities of the medication. Cyclobenzaprine, and most other muscle relaxants, are renally metabolized and require dose adjustments for patients with renal impairment. For patients unable to take oral medications, methocarbamol can be administered intravenously. Within plastic surgery, muscle relaxant use has ambiguous evidence for improvement in pain control and postoperative narcotic use. A retrospective review study of thiocolchicoside use, a muscle relaxant with some GABA-receptor antagonist properties, in postmastectomy implant-based and autologous breast reconstruction found significantly decreased pain scores and opiate consumption.75 Of note, thiocolchicoside is not approved for use in the US. However, a more recent retrospective review study of scheduled cyclobenzaprine use after implant-based subpectoral breast reconstruction found muscle relaxant use did not significantly decrease pain scores or opiate consumption.76 Due to the lack of evidence of muscle relaxant use within an MMA protocol and given the risks of sedation in combination with opiates, we do not recommend the routine use of muscle relaxants as adjuncts in an MMA regimen. We recommend special caution in elderly patients as this class of medication can worsen fall risk and delirium.

Adjuvant multimodal medications Gabapentin Gabapentin binds post-synaptically to dorsal horn neurons, blocking voltage-gated calcium channels and thereby decreasing neurotransmitter release.64,65 The medication is administered orally. Gabapentin is not enterally metabolized and is renally excreted via first-order kinetics; patients with renal impairment may require dose adjustments.66,67 Gabapentin can cause somnolence, confusion, and dizziness. However, a recent retrospective review of gabapentin use in abdominal wall reconstruction did not find postoperative gabapentin use associated with dizziness, pre-syncopal episodes, altered mental status, hypotension, or falls.68 Nonetheless, gabapentin should be used cautiously in geriatric patients and those with OSA.69 High-dose gabapentin should be tapered as abrupt cessation can cause withdrawal symptoms similar to alcohol and benzodiazepine withdrawal.70 A meta-analysis of postoperative gabapentin use found a 35% reduction in total opioid use within 24 hours following surgery and a significant reduction in postoperative pain.71 However, a Cochrane Review on systemic medications for the prevention of chronic postoperative pain did not find a significant reduction of chronic postoperative pain with gabapentin.72 We recommend the use of gabapentin as an adjunctive multimodal medication for acute, postoperative pain in patients who have a risk for nerve-related pain.48,49 We advocate for a loading dose the evening before surgery as well as a preoperative dose prior to the operation. In patients less than 65 years old, we favor 300 mg orally (PO) TID, while for patients >65, we favor twice-daily dosing (BID). For those patients that cannot tolerate some of the side effects, the dose can be reduced from 300 mg to 100 mg. Gabapentin must be dose-adjusted for patients with renal impairment and used cautiously in geriatric patients and those with OSA.

Steroids Steroids have potent and well-known anti-inflammatory, immunomodulatory and antiemetic effects. Steroids have innumerable side effects beyond the scope of this chapter. In regard to plastic surgery applications, steroids cause delayed wound healing, increased surgical site infections, and hyperglycemia.65 A single dose of dexamethasone given pre- or intra-operatively has been found to decrease postoperative pain scores and narcotic usage.77,78 A perioperative dose of dexamethasone has been found to result in an approximately 34 mg/dL rise in blood glucose values in diabetic patients; however, this rise has not been found to be associated with a significant increase in postoperative surgical site infections.77,79 Two retrospective studies, a meta-analysis and a Cochrane Review, have not found significant wound healing complications or surgical site infections within 30 days after a single perioperative dose of dexamethasone; however, longterm studies are lacking.79–82 There should be no concern or hesitation when the use of dexamethasone is warranted for its anti-inflammatory or antiemetic effects by our anesthesiology colleagues, including in diabetic patients. This may be of benefit for aesthetic plastic surgery patients in ambulatory surgery settings. Of note, intravenous dexamethasone should be administered after the patient is asleep to avoid intense anal pruritus.83

Topical anesthetics Topical anesthetics are the topical version of local anesthetics. These classes of medications inactivate voltage-gated sodium

28

SECTION I

CHAPTER 4  • Pain management in plastic surgery

channels, raising the threshold required to generate an action potential rendering the area temporarily insensate.84 Their structure consists of a lipophilic aromatic group attached to an amine group with a chain of either an amide or ester.85 The amide or ester chain affects metabolism; amides are hepatically metabolized while esters are metabolized by plasma cholinesterase. Esters form the metabolite para-aminobenzoic acid (PABA), which is more commonly implicated in allergic reactions to local anesthetics.86 Topical and local anesthetics preferentially affect type C nerve fibers (pain fibers) over type A nerve fibers (proprioception and pressure fibers); patients may therefore continue to feel pressure sensation without feeling pain during the procedure.87 The most commonly used topical anesthetics include lidocaine patches, eutectic mixture of local anesthetics (EMLA) consisting of lidocaine and prilocaine, as well as a mixture of lidocaine, epinephrine, and tetracaine (LET). Time of onset, depth of penetration, and duration vary for each anesthetic based on the pKa, pH, solubility, and protein-binding potential.84 Skin penetration can be increased by exfoliating the skin and using alcohol to remove sebaceous material from the skin. Efficacy of topical anesthetics is dependent on skin permeation and has a delayed onset of action compared with injected local anesthetics. A Cochrane review investigating the use of topical anesthetics during repair of dermal lacerations found that they can play an important role in analgesia prior to laceration repair.88 The concentrations of each local anesthetic vary and must be carefully calculated to avoid local anesthetic systemic toxicity (LAST) (Table 4.1).89,90 Surgeons must be well versed in the management of LAST; guidelines are available from the American Society of Regional Anesthesia and Pain Medicine.91 The use of topical anesthetics for laceration repair is largely limited to pediatric patients. However, these topical anesthetics may be of special benefit in aesthetic patients undergoing filler injection for pre-procedure numbing.

Local anesthetics The most commonly used local anesthetics include lidocaine, bupivacaine, and ropivacaine. These anesthetics are often combined with epinephrine to decrease intra-operative blood loss. Lalonde has revolutionized wide-awake surgery with injection techniques that minimize discomfort and maximize efficacy.92–98 Local anesthetics not only allow for painless wide-awake office procedures but also minimize postoperative pain. A meta-analysis found that local anesthetic injected prior to incision decreases pain and decreases postoperative analgesic consumption and time to first rescue pain medication dose.99

Liposomal bupivacaine (Exparel; Pacira Biosciences Inc; Parsippany, NJ, US) contains bupivacaine within a lipid-based vehicle that results in diffusion of the drug over time with an initial peak at 0.25 to 2 hours and a second peak 12 to 24 hours after injection. Liposomal bupivacaine has been shown to provide pain relief over 48 to 72 hours.100 Liposomal bupivacaine remains under patent and thus costs more than standard bupivacaine. A study by Little et al. found decreased postoperative narcotic consumption, length of stay, direct and total costs, and 30-day readmission rate with liposomal bupivacaine compared with control patients undergoing abdominal wall, implant based and autologous breast reconstruction.101 A prospective, single-blinded, randomized controlled trial of a single surgeon utilizing liposomal bupivacaine in addition to an enhanced recovery protocol including preoperative regional block failed to detect a clinical difference in total opioid consumption, pain score, or length of stay.102 This suggests that the benefits of liposomal bupivacaine are more limited when combined with an enhanced recovery protocol that includes a regional or epidural analgesia. We recommend the use of short-acting local anesthetics for bedside procedures and long-acting local anesthetics for post-procedure pain control. For local anesthetic injected during abdominal surgery, we recommend 1–1.5 cc of local anesthetic be injected with a 22-gauge, 1.5-inch needle every 1–2 cm per surgical layer exposed (i.e. pre-peritoneum [when applicable], subfascial, and subdermal) while withdrawing the needle to avoid intravascular injection.103 In aesthetic plastic surgery patients undergoing ambulatory surgery without availability of regional or epidural analgesia, liposomal bupivacaine may provide substantial pain relief in the acute postoperative period warranting the increased cost.

Tumescent analgesia Tumescent analgesia involves the use of dilute lidocaine or bupivacaine in large volumes of carrier fluid with or without epinephrine. This technique was popularized by Klein in the late 1980s for use during liposuction.104 The practice has since been expanded to a number of plastic surgery procedures.105 Due to the lipid solubility and distributive properties of local anesthetics, tumescent analgesia allows for higher maximum concentrations of local anesthetics than traditional field blocks.87 Klein performed further studies measuring the maximum safe dosage of lidocaine in wetting solution and found this to be 35 mg/kg, with more recent reports showing safety profiles up to 55 mg/kg.106,107 The American Society of Plastic Surgeons Practice Advisory on Liposuction recommends limiting lidocaine to a maximum dose of 35 mg/kg (only when

Table 4.1  Local anesthetic dosing recommendations

Anesthetic

Onset

Duration of analgesia

Maximum dose without epinephrine

Maximum dose with epinephrine

Lidocaine

10–20 min

3–8 h

4.5 mg/kg

7 mg/kg

Mepivacaine

10–20 min

3–10 h

5 mg/kg

7 mg/kg

Ropivacaine

15–30 min

5–24 h

3 mg/kg

3.5 mg/kg

Bupivacaine

15–30 min

5–30 h

2.5 mg/kg

3 mg/kg

Epidural anesthesia

used as part of wetting solution) with adjustments for patients with metabolic conditions that may limit metabolism of local anesthetics.108 Tumescent analgesia is frequently used in abdominoplasty procedures with reports of the technique being used with deep sedation and conscious sedation.109 Tumescent techniques are frequently combined with liposuction during abdominoplasty, a technique known as lipoabdominoplasty. This procedure carries with it an inherent risk of vascular compromise due to the theoretical risk of disrupting blood supply to the abdominal skin flaps. This complication can be minimized by performing only selective undermining of the skin flaps to the central portion of the abdomen requiring rectus muscle plication, thereby preserving the lateral row of rectus muscle perforators.110–112 A 2019 systematic review of 17 lipoabdominoplasty studies encompassing 14,061 patients found fewer complications in the lipoabdominoplasty group compared with the traditional abdominoplasty group (RR 0.85; CI 0.71– 0.97; P = 0.017) with the lipoabdominoplasty group having a lower incidence of hematoma (RR = 0.56; 95% CI 0.36–0.86; P = 0.009) and seroma (RR = 0.69; 95% CI 0.57–0.85; P = 0.000) compared with the traditional abdominoplasty group.113 Tumescent analgesia can also be used for breast reduction, breast augmentation, implant removal, and capsulectomy. Breast reductions have been carried out under intravenous sedation with fentanyl, midazolam, and tumescent a­ nalgesia, with reports of 516–2948 g resection specimens.114 A 2012 meta-analysis of 13 articles of tumescent analgesia used during breast reduction found that patients who underwent tumescent analgesia infiltration had an average of 202 cc less blood loss compared with patients without tumescent analgesia (P < 0.001).115 There was also a significant reduction in the need for postoperative blood transfusion among patients who received tumescent analgesia (OR 0.05). Operative time and postoperative drainage were not significantly different between the two groups. Tumescent analgesia has also been reported for use in breast augmentation under intravenous sedation, including submuscular implant placement, with a higher than average mixture of tumescent analgesia (100 cc of 1% lidocaine with 1:100,000 epinephrine mixed with 250 cc of normal saline).116 Tumescent analgesia has also been reported as an adjunct to implant capsulectomy in technique papers to facilitate dissection through hydrodissection and to minimize intra-operative blood loss.117,118 Tumescent analgesia is routinely used for rhytidectomy to facilitate dissection and minimize intra-operative blood loss. Tumescent analgesia can also allow for rhytidectomy to be performed under oral or intravenous sedation in the office.105 The precise composition of the wetting solution varies widely between surgeons based on the total amount of wetting solution injected; standard guidelines for local anesthetic dosages should be respected. We recommend the routine use of wetting solution in a superwet manner with lidocaine or bupivacaine, as described by Fodor, within the safety profile of each respective local anesthetic for liposuction.119,120

Regional anesthesia Regional anesthesia anesthetizes entire dermatomes by injecting long-acting local anesthetic through continuous infusion

29

into a targeted area surrounding peripheral nerves supplying specific dermatomes. Regional anesthetics have been shown to decrease postoperative narcotic use, postoperative nausea/ vomiting, and length of stay.121–125 The most commonly used regional anesthetics within aesthetic plastic surgery include the pectoralis (PECS) I and II block and the erector spinae plane blocks (ESPBs) in breast surgery as well as the transversus abdominis plane (TAP) block for abdominal surgery. The PECS I block is performed by injecting long-acting local anesthetic into the fascial plane between the pectoralis major and minor muscle to blunt burning sensation from the pectoral and intercostobrachial nerves.126–128 The PECS II block is performed by injecting local anesthetic between the pectoralis minor and serratus anterior muscle to blunt intercostal nerves 3–6 and the long thoracic nerves.126–128 The PECS blocks are traditionally performed under ultrasound guidance but can also be performed under direct visualization. The PECS I block is performed by injecting 20 cc of local anesthetic in the plane between the pectoralis major and minor; if injected correctly, the local anesthetic will diffuse with minimal resistance.129 The PECS II block is performed by injecting 10–20 cc of local anesthetic between the pectoralis minor and serratus anterior at the level of the third rib.129 The ESPB block is performed under ultrasound guidance by injecting 20 cc of local anesthetic between the rhomboid major and erector spinae muscle; this provides anesthesia from the T2 to T9 level from the midclavicular line to 3 cm lateral of midline from the thoracic spine.130 The TAP block is performed by injecting local anesthetic between the internal oblique and transversus abdominis fascial planes, blunting the afferent sensory fibers of the terminal branches of T10–L1 sensory fibers.131 This is traditionally performed under ultrasound guidance; however, the TAP block can also be performed under direct visualization during abdominal wall reconstruction or abdominoplasty. To perform under direct visualization, local anesthetic is injected in the plane between the transversus abdominis and the internal oblique muscle to create a continuous bilateral field of coverage from the costal margin to the iliac crest.129 Because regional anesthesia utilizes local anesthetics, the same caution in regard to local anesthetic toxicity must be employed. We recommend the use of regional anesthesia whenever possible. Certain regional anesthetics, such as the ESPB block, requires skilled anesthetists; these capabilities may not be available in certain settings.

Epidural anesthesia Epidural anesthesia blocks the spinal nerve roots as they exit the spinal cord. This is done by injecting or infusing local anesthetic and narcotic medications into the epidural space. At typical doses, epidurals do not cause motor weakness and thus allow early postoperative ambulation.131 They are typically placed preoperatively and continued for 3–5 days postoperatively until the patient is able to tolerate an oral MMA regimen.132 Epidurals are only used for inpatient surgery. Outcomes data on epidural analgesia have been mixed, with few studies looking specifically at uses within plastic surgery. A 2016 Cochrane Review by Guay et al. comparing epidurals with local anesthetics to opioids administered systemically or via epidural in abdominal surgery found that epidurals with opioids decrease postoperative pain and

30

SECTION I

CHAPTER 4  • Pain management in plastic surgery

speed return of bowel function.133 A more recent Cochrane Review by Salicath et al. comparing epidural analgesia to intravenous opiate PCAs in intra-abdominal surgery noted the decrease in postoperative pain to be clinically insignificant, with higher chance of epidural failure due to technical error and episodes of hypotension requiring intervention.134 Khansa et al. studied the effect of preoperative epidural placement in a MMA regimen for abdominal wall reconstruction and found epidurals decreased postoperative narcotic requirements in comparison to patients who did not receive a preoperative epidural.132 Epidurals have rare, yet non-trivial complications related to technique. These include epidural hematomas, abscesses, peripheral neuropathy, and spinal headaches. Their use is also associated with hypotension due to efferent sympathetic blockade; this is seen in up to 33% of patients.135 Epidurals can also cause respiratory complications in patients with pre-existing pulmonary disease as the effect on intercostal and abdominal muscles can weaken forced exhalation.131 We recommend the use of epidural anesthesia in properly selected patients requiring inpatient reconstructive surgery.

We recommend the use of epidurals in combination with enhanced recovery protocols and MMA. They do not have current data to support their use in aesthetic surgery.

Putting it all together: multimodal analgesia (MMA) regimen In a time when the US faces an opiate epidemic, surgeons must be ever mindful of their postoperative analgesic approach. ERAS protocols opened the surgical community’s eyes to the benefits of preoperative nutritional and functional optimization, early postoperative liberalization of diet, and MMA.17,18,136 We have adapted the lessons learned from the ERAS protocols as well as our own institutional experience to develop an MMA regimen to treat postsurgical pain.132,137,138 Table 4.2 summarizes our recommendations for MMA options that can be customized, based on surgical procedure and patient characteristics. Table 4.3 summarizes our MMA recommendations for common plastic surgery procedures.

Table 4.2  Multimodal analgesia (MMA) options

Medication/ technique

Initiation

Dosage

Duration

Contraindications/caution

Epidural

Preoperatively

Per anesthesia acute pain team

3–5 days until patient able to tolerate PO MMA

Caution in patients with preexisting pulmonary disease, hypotension

Local and/or regional block

Pre- or intra-operatively

Attention to local anesthetic maximum dosage

Patient-controlled analgesia

Postoperatively as needed

Start at lowest dose without basal rate

Until patient able to tolerate CLD

Do not combine with epidural

Acetaminophen

Single re-operative dose / postoperatively when patient able to tolerate CLD

1000 mg/1000 mg q6 h

Continue 5 days after discharge

Liver disease

Celecoxib

Single re-operative dose/ postoperatively when patient able to tolerate CLD

400 mg/200 mg TID

Continue 5 days after discharge

Cardiac or renal disease; caution in patients at risk for GI bleeding

Gabapentin

600 mg loading dose evening 900 mg/300 mg TID before surgery/single preoperative dose/postoperatively when patient able to tolerate CLD

Continue 5 days after discharge

OSA; caution in patients with renal impairment

Cyclobenzaprine

Postoperatively PRN when patient able to tolerate CLD

5–10 mg TID

Continue 5 days after discharge if initiated inpatient

Caution in geriatric patients and in those requiring higher doses of opiates

Oxycodone

Single re-operative dose/ postoperatively PRN when patient able to tolerate CLD

5 mg/5 mg q3-4h PRN for breakthrough pain

Discontinue as soon as able

IV hydromorphone

Postoperatively PRN

0.5–1.0 mg hydromorphone q3h PRN breakthrough pain

Discontinue as soon as able

CLD, clear liquid diet; GI, gastrointestinal; IV, intravenous; PO MMA, oral multimodal analgesia; OSA, obstructive sleep apnea; PRN, as needed; TID, three times daily.

Putting it all together: multimodal analgesia (MMA) regimen

31

Table 4.3  MMA options for common plastic surgery procedures

Breast surgery

Duration

Contraindications/ caution

1000 mg/1000 mg q6 h

Continue 5 days after discharge

Liver disease

Single re-operative dose/postoperatively

400 mg/200 mg TID

Continue 5 days after discharge

Cardiac or renal disease; caution in patients at risk for GI bleeding

Gabapentin

600 mg loading dose evening before surgery/single preoperative dose/ postoperatively

900 mg/300 mg TID

Continue 5 days after discharge

OSA; caution in patients with renal impairment

Oxycodone

Single re-operative dose/postoperatively PRN

5 mg/5 mg q3–4 h PRN for breakthrough pain

Discontinue as soon as able

TAP block

Preoperatively

Attention to local anesthetic maximum dosage

Acetaminophen

Single re-operative dose/ postoperatively

1000 mg/1000 mg q6 h

Continue 5 days after discharge

Liver disease

Celecoxib

Single re-operative dose/postoperatively

400 mg/200 mg TID

Continue 5 days after discharge

Cardiac or renal disease; caution in patients at risk for GI bleeding

Gabapentin

600 mg loading dose evening before surgery/single preoperative dose/ postoperatively

900 mg/300 mg TID

Continue 5 days after discharge

OSA; caution in patients with renal impairment

Oxycodone

Single re-operative dose/postoperatively PRN

5 mg/5 mg q3–4 h PRN for breakthrough pain

Discontinue as soon as able

Tumescent

Klein solution

Intra-operatively

150 cc per side

Oral

Acetaminophen

Single re-operative dose/postoperatively

1000 mg/1000 mg q6 h

Continue 5 days after discharge

Liver disease

Celecoxib

Single re-operative dose/postoperatively

400 mg/ 200 mg TID

Continue 5 days after discharge

Cardiac or renal disease; caution in patients at risk for GI bleeding

Oxycodone

Single re-operative dose/postoperatively PRN

5 mg/5 mg q3–4 h PRN for breakthrough pain

Discontinue as soon as able

Medication/ technique

Initiation

Dosage

Regional block

PECS I or II block

Preoperatively

Attention to local anesthetic maximum dosage

Oral

Acetaminophen

Single re-operative dose/postoperatively

Celecoxib

Abdominoplasty Regional block Oral

Facelift

Max. safe dose 35 mg/kg

32

SECTION I

CHAPTER 4  • Pain management in plastic surgery

Table 4.3  MMA options for common plastic surgery procedures – cont’d

Hand surgery

Duration

Contraindications/ caution

1000 mg/1000 mg q6 h

Continue 5 days after discharge

Liver disease

Single re-operative dose/postoperatively

400 mg/200 mg TID

Continue 5 days after discharge

Cardiac or renal disease; caution in patients at risk for GI bleeding

Single re-operative dose/postoperatively PRN

5 mg/5 mg q3–4 h PRN for breakthrough pain

Discontinue as soon as able

Medication/ technique

Initiation

Dosage

Regional block

Supra- or infraclavicular blocks

Preoperatively

Attention to local anesthetic maximum dosage

Oral

Acetaminophen

Single re-operative dose/postoperatively

Celecoxib

Oxycodone

GI, gastrointestinal; MMA, multimodal analgesia; OSA, obstructive sleep apnea; PECS, pectoralis; PRN, as needed; TAP, transversus abdominis plane; TID, three times daily.

Access the reference list online at   Elsevier eBooks+

References

References 1. IASP terminology. In: International Association for the Study of Pain. 2019 edn. https://www.iasp-pain.org/resources/terminology/ 2. Fong A, Schug SA. Pathophysiology of pain: a practical primer. Plast Reconstr Surg. 2014;134:8S–14S. 3. Cohen SP, Mao J. Neuropathic pain: mechanisms and their clinical implications. BMJ. 2014;348:f7656. 4. Joshi GP, Ogunnaike BO. Consequences of inadequate postoperative pain relief and chronic persistent postoperative pain. Anesthesiol Clin North Am. 2005;23:21–36. 5. Baratta JL, Schwenk ES, Viscusi ER. Clinical consequences of inadequate pain relief: barriers to optimal pain management. Plast Reconstr Surg. 2014;134:15S–21S. 6. Pavlin DJ, Chen C, Penaloza DA, Buckley FP. A survey of pain and other symptoms that affect the recovery process after discharge from an ambulatory surgery unit. J Clin Anesth. 2004;16:200–206. 7. Herbst MO, Price MD, Soto RG. Pain related readmissions/revisits following same-day surgery: have they decreased over a decade? J Clin Anesth. 2017;42:15. 8. Coley KC, Williams BA, DaPos SV, Chen C, Smith RB. Retrospective evaluation of unanticipated admissions and readmissions after same day surgery and associated costs. J Clin Anesth. 2002;14:349–353. 9. Pavlin DJ, Chen C, Penaloza DA, Polissar NL, Buckley FP. Pain as a factor complicating recovery and discharge after ambulatory surgery. Anesth Analg. 2002;95:627–634. 10. Pavlin DJ, Rapp SE, Polissar NL, Malmgren JA, Koerschgen M, Keyes H. Factors affecting discharge time in adult outpatients. Anesth Analg. 1998;87:816–826. 11. Wu CL, Naqibuddin M, Rowlingson AJ, Lietman SA, Jermyn RM, Fleisher LA. The effect of pain on health-related quality of life in the immediate postoperative period. Anesth Analg. 2003;97:1078–1085. 12. Kehlet H, Jensen TS, Woolf CJ. Persistent postsurgical pain: risk factors and prevention. Lancet. 2006;367:1618–1625. 13. Beloeil H, Sulpice L. Peri-operative pain and its consequences. J Visc Surg. 2016;153:S15–S18. 14. Niraj G, Rowbotham DJ. Persistent postoperative pain: where are we now? Br J Anaesth. 2011;107:25–29. 15. Stark N, Kerr S, Stevens J. Prevalence and predictors of persistent post-surgical opioid use: a prospective observational cohort study. Anaesth Intensive Care. 2017;45:700–706. 16. Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth. 1997;78:606–617. 17. Ljungqvist O, Scott M, Fearon KC. Enhanced recovery after surgery: a review. JAMA Surg. 2017;152:292–298. 18. Ljungqvist O, Young-Fadok T, Demartines N. The history of enhanced recovery after surgery and the ERAS Society. J Laparoendosc Adv Surg Tech A. 2017;27:860–862. 19. Tick H, Nielsen A, Pelletier KR, et al. Evidence-based nonpharmacologic strategies for comprehensive pain care: The Consortium Pain Task Force White Paper. Explore (NY). 2018;14:177–211. 20. Opioids perception of pain. In M. D. o. Health ed., 2021. 21. Wide-ranging online data for epidemiologic research (WONDER). In N. C. f. H. S. CDC ed. Atlanta, GA, 2020. 22. Mallow PJ, Belk KW, Topmiller M, Strassels SA. Geographic variation in hospital costs, payments, and length of stay for opioid-related hospital visits in the USA. J Pain Res. 2018;11:3079–3088. 23. Rhyan C. The potential societal benefit of eliminating opioid overdoses, deaths, and substance use disorders exceeds $95 billion per year executive summary. 24. Vital signs: overdoses of prescription opioid pain relievers— United States, 1999–2008 Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep. 2011;60(43):1487–1492.

32.e1

25. Rudd R, Paulozzi L, Bauer M, et al. Increases in heroin overdose deaths—28 states, 2010 to 2012. MMWR Morb Mortal Wkly Rep. 2014:849. 26. 2019 National Drug Threat Assessment. Drug Enforcement Administration Strategic Intelligence Section. Drug Enforcement Administration U.S. Department of Justice, 2019. 27. Upp LA, Waljee JF. The opioid epidemic. Clin Plast Surg. 2020;47:181–190. 28. Larach DB, Waljee JF, Hu HM, et al. Patterns of initial opioid prescribing to opioid-naive patients. Ann Surg. 2020;271:290–295. 29. Bicket MC, Long JJ, Pronovost PJ, Alexander GC, Wu CL. Prescription opioid analgesics commonly unused after surgery: a systematic review. JAMA Surg. 2017;152:1066–1071. 30. Chu JJ, Janis JE, Skoracki R, Barker JC. Opioid overprescribing and procedure-specific opioid consumption patterns for plastic and reconstructive surgery patients. Plast Reconstr Surg. 2021;147:669e–679e. 31. Habermann EB. Are opioids overprescribed following elective surgery? Adv Surg. 2018;52:247–256. 32. Johnson SP, Chung KC, Zhong L, et al. Risk of prolonged opioid use among opioid-naive patients following common hand surgery procedures. J Hand Surg Am. 2016;41:947–957 e943. 33. Pasternak GW. Opiate pharmacology and relief of pain. J Clin Oncol. 2014;32:1655–1661. 34. Trescot AM, Datta S, Lee M, Hansen H. Opioid pharmacology. Pain Physician. 2008;11:S133–153. 35. Brummett CM, Waljee JF, Goesling J, et al. New persistent opioid use after minor and major surgical procedures in US adults. JAMA Surg. 2017;152:e170504. 36. Jiang X, Orton M, Feng R, et al. Chronic opioid usage in surgical patients in a large academic center. Ann Surg. 2017;265:722–727. 37. Roberts GW, Bekker TB, Carlsen HH, Moffatt CH, Slattery PJ, McClure AF. Postoperative nausea and vomiting are strongly influenced by postoperative opioid use in a dose-related manner. Anesth Analg. 2005;101:1343–1348. 38. Glare PA, Walsh TD. Clinical pharmacokinetics of morphine. Ther Drug Monit. 1991;13:1–23. 39. Funk RD, Hilliard P, Ramachandran SK. Perioperative opioid usage: avoiding adverse effects. Plast Reconstr Surg. 2014;134:32S–39S. 40. Janis JE, Joshi G. Introduction to the pain management supplement in plastic surgery. Plast Reconstr Surg. 2014;134:6s–7s. 41. Ghanem CI, Perez MJ, Manautou JE, Mottino AD. Acetaminophen from liver to brain: New insights into drug pharmacological action and toxicity. Pharmacol Res. 2016;109:119–131. 42. Gupta A, Jakobsson J. Acetaminophen, nonsteroidal antiinflammatory drugs, and cyclooxygenase-2 selective inhibitors: an update. Plast Reconstr Surg. 2014;134:24S–31S. 43. Flower RJ, Vane JR. Inhibition of prostaglandin synthetase in brain explains the anti-pyretic activity of paracetamol (4-acetamidophenol). Nature. 1972;240:410–411. 44. Engstrom Ruud L, Wilhelms DB, Eskilsson A, et al. Acetaminophen reduces lipopolysaccharide-induced fever by inhibiting cyclooxygenase-2. Neuropharmacology. 2013;71:124–129. 45. Toms L, McQuay HJ, Derry S, Moore RA. Single dose oral paracetamol (acetaminophen) for postoperative pain in adults. Cochrane Database Syst Rev. 2008 46. Harricharan S, Frey N. Intravenous acetaminophen for the management of short-term post-operative pain: a review of clinical effectiveness and cost-effectiveness. Ottawa (ON). 2018 47. Krenzelok EP, Royal MA. Confusion: acetaminophen dosing changes based on NO evidence in adults. Drugs RD. 2012;12:45–48. 48. Barker JC, Joshi GP, Janis JE. Basics and best practices of multimodal pain management for the plastic surgeon. Plast Reconstr Surg Glob Open. 2020;8:e2833. 49. Schoenbrunner AR, Janis JE. Pain management in plastic surgery. Clin Plast Surg. 2020;47:191–201.

32.e2

SECTION I

CHAPTER 4  • Pain management in plastic surgery

50. Cashman JN. The mechanisms of action of NSAIDs in analgesia. Drugs. 1996;52(Suppl 5):13–23. 51. Bombardier C, Laine L, Reicin A, et al. Comparison of upper gastrointestinal toxicity of rofecoxib and naproxen in patients with rheumatoid arthritis. VIGOR Study Group. N Engl J Med. 2000;343:1520–1528. 52. Nissen SE, Yeomans ND, Solomon DH, et al. Cardiovascular safety of celecoxib, naproxen, or ibuprofen for arthritis. N Engl J Med. 2016;375:2519–2529. 53. Drug FDA. Safety Communication: FDA strengthens warning that non-aspirin nonsteroidal anti-inflammatory drugs (NSAIDs) can cause heart attacks or strokes. Federal Drug Administration (FDA). 2015 54. Vadivelu N, Gowda AM, Urman RD, et al. Ketorolac tromethamine – routes and clinical implications. Pain Pract. 2015;15:175–193. 55. Plapler PG, Scheinberg MA, da Cunha Ecclissato C, Bocchi de Oliveira MF, Amazonas RB. Double-blind, randomized, doubledummy clinical trial comparing the efficacy of ketorolac trometamol and naproxen for acute low back pain. Drug Des Devel Ther. 2016;10:1987–1993. 56. Stephens DM, Richards BG, Schleicher WF, Zins JE, Langstein HN. Is ketorolac safe to use in plastic surgery? A critical review. Aesthet Surg J. 2015;35:462–466. 57. Nguyen BN, Barta RJ, Stewart CE, Heinrich CA. Toradol following breast surgery: is there an increased risk of hematoma? Plast Reconstr Surg. 2018;141:814e–817e. 58. Meade EA, Smith WL, DeWitt DL. Differential inhibition of prostaglandin endoperoxide synthase (cyclooxygenase) isozymes by aspirin and other non-steroidal anti-inflammatory drugs. J Biol Chem. 1993;268:6610–6614. 59. Simon LS, Weaver AL, Graham DY, et al. Anti-inflammatory and upper gastrointestinal effects of celecoxib in rheumatoid arthritis: a randomized controlled trial. JAMA. 1999;282:1921–1928. 60. Emery P, Zeidler H, Kvien TK, et al. Celecoxib versus diclofenac in long-term management of rheumatoid arthritis: randomised double-blind comparison. Lancet. 1999;354:2106–2111. 61. Leese PT, Hubbard RC, Karim A, Isakson PC, Yu SS, Geis GS. Effects of celecoxib, a novel cyclooxygenase-2 inhibitor, on platelet function in healthy adults: a randomized, controlled trial. J Clin Pharmacol. 2000;40:124–132. 62. Bresalier RS, Sandler RS, Quan H, et al. Cardiovascular events associated with rofecoxib in a colorectal adenoma chemoprevention trial. N Engl J Med. 2005;352:1092–1102. 63. Sibbald B. Rofecoxib (Vioxx) voluntarily withdrawn from market. CMAJ. 2004;171:1027–1028. 64. Chang CY, Challa CK, Shah J, Eloy JD. Gabapentin in acute postoperative pain management. Biomed Res Int. 2014. 2014:631756. 65. Low YH, Gan TJ. NMDA receptor antagonists, gabapentinoids, alpha-2 agonists, and dexamethasone and other non-opioid adjuvants: do they have a role in plastic surgery? Plast Reconstr Surg. 2014;134:69S–82S. 66. McLean MJ. Clinical pharmacokinetics of gabapentin. Neurology. 1994;44:S17–22. discussion S31–12. 67. Beydoun A, Uthman BM, Sackellares JC. Gabapentin: pharmacokinetics, efficacy, and safety. Clin Neuropharmacol. 1995;18:469–481. 68. Sarac B, Schoenbrunner AR, Brower K, Joshi G, Janis JE. Analysis of adverse effects of multimodal gabapentin in abdominal wall reconstruction. Plast Reconstr Surg. 2022;149(3):733–739. 69. Mao J, Chen LL. Gabapentin in pain management. Anesth Analg. 2000;91:680–687. 70. Norton JW. Gabapentin withdrawal syndrome. Clin Neuropharmacol. 2001;24:245–246. 71. Peng PW, Wijeysundera DN, Li CC. Use of gabapentin for perioperative pain control – a meta-analysis. Pain Res Manag. 2007;12:85–92. 72. Chaparro LE, Smith SA, Moore RA, Wiffen PJ, Gilron I. Pharmacotherapy for the prevention of chronic pain after surgery in adults. Cochrane Database Syst Rev. 2013

73. Kobayashi H, Hasegawa Y, Ono H. Cyclobenzaprine, a centrally acting muscle relaxant, acts on descending serotonergic systems. Eur J Pharmacol. 1996;311:29–35. 74. Honda M, Nishida T, Ono H. Tricyclic analogs cyclobenzaprine, amitriptyline and cyproheptadine inhibit the spinal reflex transmission through 5-HT(2) receptors. Eur J Pharmacol. 2003;458:91–99. 75. Bourazani M, Papageorgiou E, Zarkadas G, et al. The role of muscle relaxants – spasmolytic (thiocochlicoside) in postoperative pain management after mastectomy and breast reconstruction. Asian Pac J Cancer Prev. 2019;20:743–749. 76. Al Yafi MN, ElHawary H, Al-Halabi B, Alnaeem H, Xu L, Fouda-Neel O. Pain control following alloplastic breast reconstruction with muscle relaxant: a randomized controlled trial. J Plast Reconstr Aesthet Surg. 2021;74:407–447. 77. Waldron NH, Jones CA, Gan TJ, Allen TK, Habib AS. Impact of perioperative dexamethasone on postoperative analgesia and side-effects: systematic review and meta-analysis. Br J Anaesth. 2013;110:191–200. 78. De Oliveira GSJr, Almeida MD, Benzon HT, McCarthy RJ. Perioperative single dose systemic dexamethasone for postoperative pain: a meta-analysis of randomized controlled trials. Anesthesiology. 2011;115:575–588. 79. Polderman JA, Farhang-Razi V, Van Dieren S, et al. Adverse side effects of dexamethasone in surgical patients. Cochrane Database Syst Rev. 2018;11:CD011940. 80. Thoren H, Snall J, Kormi E, et al. Does perioperative glucocorticosteroid treatment correlate with disturbance in surgical wound healing after treatment of facial fractures? A retrospective study. J Oral Maxillofac Surg. 2009;67:1884–1888. 81. Snall J, Kormi E, Lindqvist C, et al. Impairment of wound healing after operative treatment of mandibular fractures, and the influence of dexamethasone. Br J Oral Maxillofac Surg. 2013;51:808–812. 82. Ali Khan S, McDonagh DL, Gan TJ. Wound complications with dexamethasone for postoperative nausea and vomiting prophylaxis: a moot point? Anesth Analg. 2013;116:966–968. 83. Neff SP, Stapelberg F, Warmington A. Excruciating perineal pain after intravenous dexamethasone. Anaesth Intensive Care. 2002;30:370–371. 84. Kumar M, Chawla R, Goyal M. Topical anesthesia. J Anaesthesiol Clin Pharmacol. 2015;31:450–456. 85. Park KK, Sharon VR. A review of local anesthetics: minimizing risk and side effects in cutaneous surgery. Dermatol Surg. 2017;43:173–187. 86. Becker DE, Reed KL. Essentials of local anesthetic pharmacology. Anesth Prog. 2006;53:98–108. quiz 109–110. 87. Becker DE, Reed KL. Local anesthetics: review of pharmacological considerations. Anesth Prog. 2012;59:90–101. quiz 102–103. 88. Tayeb BO, Eidelman A, Eidelman CL, McNicol ED, Carr DB. Topical anaesthetics for pain control during repair of dermal laceration. Cochrane Database Syst Rev. 2017;2:CD005364. 89. El-Boghdadly K, Pawa A, Chin KJ. Local anesthetic systemic toxicity: current perspectives. Local Reg Anesth. 2018;11:35–44. 90. Butterworth J. IV. Clinical pharmacology of local anesthetics. NYSORA (New York School of Regional Anesthesia). https:// www.nysora.com/foundations-of-regional-anesthesia/ pharmacology/clinical-pharmacology-local-anesthetics/. 91. Neal JM, Woodward CM, Harrison TK. The American Society of Regional Anesthesia and Pain Medicine checklist for managing local anesthetic systemic toxicity: 2017 version. Reg Anesth Pain Med. 2018;43:150–153. 92. Farhangkhoee H, Lalonde J, Lalonde DH. Teaching medical students and residents how to inject local anesthesia almost painlessly. Can J Plast Surg. 2012;20:169–172. 93. Lalonde D, Martin A. Epinephrine in local anesthesia in finger and hand surgery: the case for wide-awake anesthesia. J Am Acad Orthop Surg. 2013;21:443–447. 94. Lalonde DH, Wong A. Dosage of local anesthesia in wide awake hand surgery. J Hand Surg Am. 2013;38:2025–2028.

References

95. Lovely LM, Chishti YZ, Woodland JL, Lalonde DH. How much volume of local anesthesia and how long should you wait after injection for an effective wrist median nerve block? Hand (NY). 2018;13:281–284. 96. Strazar AR, Leynes PG, Lalonde DH. Minimizing the pain of local anesthesia injection. Plast Reconstr Surg. 2013;132:675–684. 97. Lalonde D, Wong A. Local anesthetics: What’s new in minimal pain injection and best evidence in pain control. Plast Reconstr Surg. 2014;134:40S–49S. 98. Lalonde DH. Latest advances in wide awake hand surgery. Hand Clin. 2019;35:1–6. 99. Ong CK, Lirk P, Seymour RA, Jenkins BJ. The efficacy of preemptive analgesia for acute postoperative pain management: a meta-analysis. Anesth Analg. 2005;100:757–773. 100. Chahar P, Cummings 3rd KC. Liposomal bupivacaine: a review of a new bupivacaine formulation. J Pain Res. 2012;5:257–264. 101. Little A, Brower K, Keller D, Ramshaw B, Janis JE. A Costminimization analysis evaluating the use of liposomal bupivacaine in reconstructive plastic surgery procedures. Plast Reconstr Surg. 2019;143:1269–1274. 102. Ha AY, Keane G, Parikh R, et al. The analgesic effects of liposomal bupivacaine versus bupivacaine hydrochloride administered as a transversus abdominis plane block after abdominally based autologous microvascular breast reconstruction: a prospective, single-blind, randomized, controlled trial. Plast Reconstr Surg. 2019;144:35–44. 103. Joshi GP, Janis JE, Haas EM, Ramshaw BJ, Nihira MA, Dunkin BJ. Surgical site infiltration for abdominal surgery: a novel neuroanatomical-based approach. Plast Reconstr Surg Glob Open. 2016;4:e1181. 104. Klein JA. Tumescent technique chronicles. Local anesthesia, liposuction, and beyond. Dermatol Surg. 1995;21:449–457. 105. Gutowski KA. Tumescent analgesia in plastic surgery. Plast Reconstr Surg. 2014;134:50S–57S. 106. Klein JA. Tumescent technique for regional anesthesia permits lidocaine doses of 35 mg/kg for liposuction. J Dermatol Surg Oncol. 1990;16:248–263. 107. Ostad A, Kageyama N, Moy RL. Tumescent anesthesia with a lidocaine dose of 55 mg/kg is safe for liposuction. Dermatol Surg. 1996;22:921–927. 108. Practice Advisory on Liposuction. Executive Summary. Arlington Heights, IL: American Society of Plastic Surgeons; 2003. 109. Kryger ZB, Fine NA, Mustoe TA. The outcome of abdominoplasty performed under conscious sedation: six-year experience in 153 consecutive cases. Plast Reconstr Surg. 2004;113:1807–1817. discussion 1818–1809. 110. Friedland JA, Maffi TR. MOC-PS(SM) CME article: abdominoplasty. Plast Reconstr Surg. 2008;121:1–11. 111. Nahai F. The Art of Aesthetic Surgery: Principles & Techniques. New York: Thieme; 2005. 112. Landair A, Rubin J. Applied Anatomy in Body Contouring. New York: Thieme; 2005. 113. Xia Y, Zhao J, Cao DS. Safety of lipoabdominoplasty versus abdominoplasty: a systematic review and meta-analysis. Aesthetic Plast Surg. 2019;43:167–174. 114. Zukowski ML, Ash K, Klink B, Reid D, Messa A. Breast reduction under intravenous sedation: a review of 50 cases. Plast Reconstr Surg. 1996;97:952–956. discussion 957–958. 115. Hardwicke JT, Jordan RW, Skillman JM. Infiltration of epinephrine in reduction mammaplasty: a systematic review of the literature. Plast Reconstr Surg. 2012;130:773–778. 116. Gart MS, Ko JH, Heyer KS, Mustoe TA. Breast implant procedures under conscious sedation: a 6-year experience in 461 consecutive patients. Plast Reconstr Surg. 2013;131:1169–1178. 117. Solomon MP. Tumescent technique as an adjunct to breast implant removal and capsulectomy. Ann Plast Surg. 2000;44:495–497. 118. Silfen R, Vilan A, Wohl I, Leviav A. Tumescent technique in capsulotomies: a useful adjunct. Plast Reconstr Surg. 2004;114:602.

32.e3

119. Rohrich RJ, Kenkel JM, Janis JE, Beran SJ, Fodor PB. An update on the role of subcutaneous infiltration in suction-assisted lipoplasty. Plast Reconstr Surg. 2003;111:926–927. discussion 928. 120. Horton JB, Reece EM, Broughton 2nd G, Janis JE, Thornton JF, Rohrich RJ. Patient safety in the office-based setting. Plast Reconstr Surg. 2006;117:61e–80e. 121. Schnabel, Reichl SU, Kranke P, Pogatzki-Zahn EM, Zahn PK. Efficacy and safety of paravertebral blocks in breast surgery: a meta-analysis of randomized controlled trials. Br J Anaesth. 2010;105:842–852. 122. Tahiri Y, Tran DQ, Bouteaud J, et al. General anaesthesia versus thoracic paravertebral block for breast surgery: a meta-analysis. J Plast Reconstr Aesthet Surg. 2011;64:1261–1269. 123. Rivedal DD, Nayar HS, Israel JS, et al. Paravertebral block associated with decreased opioid use and less nausea and vomiting after reduction mammaplasty. J Surg Res. 2018;228:307–313. 124. Fayezizadeh M, Majumder A, Neupane R, Elliott HL, Novitsky YW. Efficacy of transversus abdominis plane block with liposomal bupivacaine during open abdominal wall reconstruction. Am J Surg. 2016;212:399–405. 125. Rundgren J, Mellstrand Navarro C, Ponzer S, Regberg A, Serenius S, Enocson A. Regional or general anesthesia in the surgical treatment of distal radial fractures: a randomized clinical trial. J Bone Joint Surg Am. 2019;101:1168–1176. 126. Blanco R. The ’pecs block’: a novel technique for providing analgesia after breast surgery. Anaesthesia. 2011;66:847–848. 127. Blanco R, Fajardo M, Parras Maldonado T. Ultrasound description of Pecs II (modified Pecs I): a novel approach to breast surgery. Rev Esp Anestesiol Reanim. 2012;59:470–475. 128. Bashandy GM, Abbas DN. Pectoral nerves I and II blocks in multimodal analgesia for breast cancer surgery: a randomized clinical trial. Reg Anesth Pain Med. 2015;40:68–74. 129. ElHawary H, Joshi GP, Janis JE. Practical review of abdominal and breast regional analgesia for plastic surgeons: evidence and techniques. Plast Reconstr Surg Glob Open. 2020;8:e3224. 130. ElHawary H, Abdelhamid K, Meng F, Janis JE. Erector spinae plane block decreases pain and opioid consumption in breast surgery: systematic review. Plast Reconstr Surg Glob Open. 2019;7:e2525. 131. Momoh AO, Hilliard PE, Chung KC. Regional and neuraxial analgesia for plastic surgery: surgeon’s and anesthesiologist’s perspectives. Plast Reconstr Surg. 2014;134:58S–68S. 132. Khansa I, Koogler A, Richards J, Bryant R, Janis JE. Pain Management in abdominal wall reconstruction. Plast Reconstr Surg Glob Open. 2017;5:e1400. 133. Guay J, Nishimori M, Kopp S. Epidural local anaesthetics versus opioid-based analgesic regimens for postoperative gastrointestinal paralysis, vomiting and pain after abdominal surgery. Cochrane Database Syst Rev. 2016;7:CD001893. 134. Salicath JH, Yeoh EC, Bennett MH. Epidural analgesia versus patient-controlled intravenous analgesia for pain following intra-abdominal surgery in adults. Cochrane Database Syst Rev. 2018;8 135. Carpenter RL, Caplan RA, Brown DL, Stephenson C, Wu R. Incidence and risk factors for side effects of spinal anesthesia. Anesthesiology. 1992;76:906–916. 136. Temple-Oberle C, Shea-Budgell MA, Tan M, et al. Consensus review of optimal perioperative care in breast reconstruction: enhanced recovery after surgery (ERAS) Society Recommendations. Plast Reconstr Surg. 2017;139:1056e–1071e. 137. Barker JC, DiBartola K, Wee C, et al. Preoperative multimodal analgesia decreases postanesthesia care unit narcotic use and pain scores in outpatient breast surgery. Plast Reconstr Surg. 2018;142:443e–450e. 138. Khansa I, Jefferson R, Khansa L, Janis JE. Optimal pain control in abdominal wall reconstruction. Plast Reconstr Surg. 2018;142:142S–148S.

 

 

SECTION I • Aesthetic Anesthesia Techniques

5 Anatomic blocks of the face and neck Stelios C. Wilson and Barry Zide

Access video lecture content for this chapter online at Elsevier eBooks+

Introduction

Anatomic blocks of the face

Surgeons who understand the anatomy of nerve blockade will be able to effectively anesthetize large areas of the face safely in a comfortable, reproducible, and expeditious manner. These blocks allow the surgeons to choose noninvasive modalities, office-based treatments, and dermatologic reconstructions without hospital involvement. This is especially important given the increasing trends in the aesthetic market.1 Being facile at blocks of the face will allow patients to receive fillers, laser treatments, dermabrasions, and chemical peels all while avoiding costly and time-consuming trips to the operating room. While outside the scope of this chapter, the choice of local anesthesia will depend on specific goals, duration of expected discomfort, patient allergies, and estimated anesthetic volume required. A surgeon need not reflexively use the same anesthetic each time. For instance, lidocaine with epinephrine may be effective in some situations but for an infraorbital block prior to lip fillers, plain lidocaine may be preferred to avoid the extra few hours of anesthesia after the procedure. In addition, there are several well-described modifications to local anesthetics that make the entire process more comfortable. For instance, adding sodium bicarbonate to alkalinize the otherwise acidic local anesthetic reduces injection site pain.2 Also, local anesthesia is sometimes more easily tolerated if it is warmed.3 Alternatively, vibration devices have also helped mitigate some of the discomfort associated with the injection of local anesthesia.4 Furthermore, the use of a small amount of hyaluronidase has been shown to expedite blockade with a small amount of local anesthesia in situations when overfill would obscure tissues.5 Regardless of the preferred method, surgeons can combine these strategies or others with the content of this chapter to more accurately, efficiently, and reproducibly anesthetize their patients. The chapter offers the most commonly performed blocks of the face (Table 5.1, Fig. 5.1). Each section is broken down into anatomy, technique, and distribution of effect.

Section 1: Infraorbital nerve block Anatomy The infraorbital nerve block has become increasingly more important given the recent popularity of lip injections and perioral rejuvenation. The infraorbital foramen can be found by dropping a line straight down from the medial limbus of the iris. On this line, the foramen is between 5 mm and 8 mm below the orbital rim (Fig. 5.2).6 Prior to the infraorbital nerve exiting the infraorbital foramen, the superior alveolar nerve branches off; this can occur anywhere from at the level of the foramen to 20 mm prior to the foramen.7 Depending on a patient’s anatomy and the proximity of the needle to the actual foramen, a patient may describe the feeling of anesthesia to the anterior gingiva and maxillary teeth from the central incisor to, potentially, the ipsilateral bicuspids.8

Technique The infraorbital nerve can be blocked through a direct transcutaneous path, an intraoral path from the gingival buccal sulcus, or in the author’s preferred method, through an indirect transcutaneous approach from the isthmus, which is an area between the alar base and start of the nasolabial fold. This preference stems from the fact that, in most patients, the foramen is not completely perpendicular to the face but rather runs in a caudal/medial trajectory from deep to superficial (see Fig. 5.2). Through the isthmus approach, the injector can potentially enter the foramen and most precisely block the region of interest and potentially the aforementioned superior alveolar nerve (Fig. 5.3). To safely block this nerve, the author places the nondominant index finger on the infraorbital rim as a way to protect the globe. With the dominant hand, the author then holds the syringe with an ergonomic pen grip and a small area just

34

SECTION I

CHAPTER 5  • Anatomic blocks of the face and neck

lateral to the alar rim is entered and the needle is directed ­cranial/lateral towards the foramen (see Fig. 5.3). Less than 1 cc of the local anesthesia is sufficient if performed successfully. The onset of the block typically takes 3–8 min; during this time, the surgeon can prepare for the treatment. Table 5.1  Commonly performed nerve blocks of the face

Anatomic nerve block

Section in this chapter

Infraorbital nerve

1

Mental nerve Nerve from the mylohyoid (mental plus)

2

Supraorbital nerve(s) Deep branch of the supraorbital nerve Supratrochlear nerve Infratrochlear nerve

3

Zygomaticotemporal nerve Zygomaticofacial nerve Lacrimal nerve

4

Dorsal nasal nerve

5

Great auricular nerve Lobular nerve

6

Transverse cervical nerves Lesser occipital nerve

7

Mandibular branch of cranial nerve V (V3) Buccal nerve

8

Area of anesthesia Using this technique, the area anesthetized is the medial cheek, portions of the nasal sidewall and nasal alar rim, the entire hemi-upper lip from the base of the columella to approximately 1–1.5 cm lateral to the lateral commissure. If the commissure is required, a small infiltrate of local anesthesia in the area will be necessary or a buccal nerve block can be performed (see Section 8 of this chapter). This block is especially valuable for cosmetic injections of the upper lip or cosmetic resurfacing of the upper perioral region as well as skin cancer resection and reconstruction of the medial cheek, upper perioral region, and upper lips.

Section 2: mental and mental plus nerve blocks Anatomy The mental nerve is also important when performing procedures around the mouth. The mental nerve usually exits from a foramen below the second bicuspid. There is some variability as this nerve can exit up to 1 cm anterior and 1 cm posterior to this point.9 Fortunately, the nerve can usually be visualized or even palpated by everting the lower lip and directly injected using a small amount of local anesthesia.7 In addition, the chin pad can partially be innervated from the nerve to the mylohyoid.10,11 This nerve branches from the inferior alveolar nerve prior to entering the mandible and can be blocked at the medial mandibular ramus – a strategy commonly employed

Infraorbital nerve

Mental nerve

Greater auricular nerve and lobular nerve

Lacrimal nerve

Nerve from the mylohyoid

Transverse cervical nerve

Lesser occipital nerve

Zygomaticofacial/zygomaticotemporal nerves

Supraorbital/supratrochlear nerves

Buccal nerve

Dorsal nasal nerve

Infratrochlear nerve

Figure 5.1  General regions for commonly performed nerve blocks of the face.

V3

Anatomic blocks of the face

B

A

C

35

D

Figure 5.2  The infraorbital nerve block and optimal access. (A) The entry point of the isthmus to best enter the skin. (B) The general direction of the foramen, which has a caudal/medial trajectory from deep to superficial. (C) Infraorbital nerve, which lies in a line drawn down directly below the medial limbus. (D) Needle entering at the isthmus and in close proximity to the foramen.

by dentists and oral surgeons. For most plastic surgeons, the chin can be blocked using the mental nerve plus addition to the mental nerve block, or, by pushing the needle 1 cm further from inside the mouth and blocking any nerve branches that would otherwise pass over the inferior mandibular border in this region.7

may also be infiltrated. If blocking the chin pad is required, a mental plus block should be performed at the same time. Specifically, the needle is placed anterior as the sulcus to infiltrate preperiosteal from the midline and just lateral to midline.7 A total of 2 cc of local anesthesia is generally sufficient for this block.

Technique

Area of anesthesia

Depending on the side and the dominant hand of the injector, the mental nerve block can be performed more comfortably by standing above the head of the patient.7 The mental nerve, or at least the upper fascicles, can be can be both seen and palpated (Fig. 5.4). Thus, the nerve can be blocked at this level or closer to where the nerve exits the mental foramen. Using an intraoral approach, a needle can be inserted several millimeters lateral to the lower canine tooth. Less than 1 cc of local anesthesia can be placed in this region. To account for early fascicle separation, an area 1 cm posterior and 1 cm anterior

The mental nerve block can reliably anesthetize the entire lower lip down to the labiomental fold. With the addition of the mental plus block described, the chin pad can be reliably added in a straightforward way regardless of whether the mental nerve or the nerve to the mylohyoid innervates part of the chin pad (see Fig. 5.4). This block is valuable for cosmetic injections of the lower lip and chin as well as cosmetic resurfacing of the lower perioral region. This block is also valuable for skin cancer resection and reconstruction of the lower lip, lower perioral region, and chin.

SECTION I

36

CHAPTER 5  • Anatomic blocks of the face and neck

B

A

Figure 5.3  The author’s access for both the infraorbital and supraorbital, supratrochlear, and infratrochlear nerve blocks. (A) The ergonomic drip of the syringe, with the needle entering at the isthmus and positioned toward the infraorbital foramen. (B) The author’s finger protecting the globe and entering the medial third of the brow to block the supraorbital, supratrochlear, and infratrochlear nerves.

A

B

Mental nerve

Nerve from mylohyoid

C

Figure 5.4  The pertinent anatomy and mental nerve and mental nerve plus block (nerve to the mylohyoid). (A) The generally palpable and sometimes visible mental nerve. (B) Mental nerve exiting the foramen and the nerve to the mylohyoid entering from the neck to innervate a portion of the chin pad. (C) The preferred method for the mental and mental plus nerve blocks.

Anatomic blocks of the face

Section 3: Supraorbital/supratrochlear, infratrochlear nerve blocks Anatomy There a several key nerves to know when working around the orbit and forehead. The supraorbital nerve exits either through a notch or a true foramen.12 Similar to the infraorbital foramen, this exit point is in line with the medial limbus, but instead of being below the globe, is above. After the nerve exits, it splits to become the deep and superficial branches of the supraorbital nerve. The deep branch remains on the undersurface of the aponeurosis of the corrugator and the superficial branch traverses the lower corrugator muscle prior to running on the undersurface of the frontalis.13,14 The medial branches become superficial on the surface of the frontalis and supply the medial forehead. The lateral branches remain deep and follow the lateral brow until the temporal fusion line, where they run superior into the lateral frontal scalp. This nerve is often encountered with brow lifts that traverse the lateral fusion line and are deep to the frontalis. There is a small area medial to the supraorbital nerve that is supplied by the supratrochlear nerve. This nerve is found under the medial-most portion of the brow. The supratrochlear nerve is accompanied by vessels with the same name. Inferomedial to the supratrochlear nerve is supplied by the infratrochlear nerve, a branch of the nasociliary nerve that runs along the medial orbit. This nerve supplies the medial eyelids, medial canthus, and a small amount of the adjacent skin.15

Technique With the index finger just inside the superomedial brow, the trochlea can be felt. Medial to this, the infratrochlear nerve exits. The majority of this block can be performed with a single entry site in the middle one-third of the eyebrow. In a lateral to medial fashion, generally along the superior orbital rim with the nondominant hand protecting the globe (see Fig. 5.3) Once beyond the notch, 2 cc of local can be injected. The needle is then advanced medially and an additional 1 cc of local anesthesia is injected to target the supratrochlear nerve. The needle is then advanced to the nasal bone and a small amount of local anesthesia is deposited at this point.7 The supraorbital nerve is often accompanied by a large vein, so ecchymosis may occur in some cases.

Area of anesthesia This block targets the middle half of the upper eyelid skin, the forehead skin from the midline to the temporal fusion line, as well as the frontal and portions of the frontoparietal scalp. This block is valuable for resurfacing procedures of the forehead and potentially for hair restoration procedures. In addition, this block with valuable for skin cancer resection and reconstruction medial to the temporal fusion line.

Section 4: zygomaticotemporal nerve, zygomaticofacial nerve, and lacrimal nerve Anatomy The zygomaticotemporal nerve is an important nerve to understand, especially as we gain a better understanding of migraine trigger points and migraine surgery. The zygomaticotemporal

37

nerve is the terminal branch of the maxillary trigeminal nerve, V2. After exiting through the inferior orbital fissure, it forms two branches, the zygomaticotemporal and the zygomaticofacial. The zygomaticotemporal nerve passes through a foramen into the anterior part of the temporal fossa and exits a foramen on the posterior concave surface of the lateral orbital rim, about at the level of the lateral canthal level with some variability. The zygomaticofacial nerves emerge through foramina on the anterior surface of the zygoma just lateral to the infraorbital rim.16,17 The exit point of these nerves can be found approximately 2 cm inferolateral to the junction of the lateral orbital rim and inferior orbital rim.7 Despite an otherwise successful block of the skin lateral to the orbit, patients can have sensation of the skin above the lateral canthus. This is generally supplied by the lacrimal nerve. A small amount of anesthetic can be added just above the lateral canthus to successfully block this skin.18

Technique These nerves can be blocked relatively efficiently, again from above the head of the patient. The zygomaticotemporal nerve is blocked behind the lateral orbital wall, 10–12 mm lateral and inferior to the zygomaticofrontal suture, which is palpable.7 The zygomaticofacial block is performed through a perpendicular block of this nerve. Specifically, 1–2 cc of local anesthetic is placed 2 cm inferolateral to the junction of the lateral orbital rim and the inferior orbital rim. Alternatively, the zygomaticotemporal nerve may be blocked 15–20 mm lateral and 6–12  mm cephalad to the lateral canthus17 (Fig. 5.5).

Area of anesthesia The zygomaticotemporal nerve gives sensation to a temporal fan-shaped area from the lateral orbital wall to the temporal skin, lateral to the temporal fusion line and into the hair-bearing scalp in this region. The zygomaticofacial nerve block will give anesthesia to an inverted triangle distribution from over the entire zygoma and down the cheek in a small distribution to the anterior ramus of the mandible7 (see Fig. 5.5). If the lacrimal gland is successfully blocked, the skin lateral to the orbit and the outer third of the superior orbit will be anesthetized. If more scalp blockade is required, the auriculotemporal nerve runs parallel to the superficial temporal artery and just above the junction of the helix and the preauricular cheek skin. This block is valuable for cosmetic injections of the temple including hairline platelet-rich plasma injections. In addition, this block can be used as in skin cancer resection and reconstruction or for migraine trigger point injections.

Section 5: dorsal nasal nerve Anatomy The dorsal nasal nerve is an important nerve to be aware of, given the prevalence of skin cancers and lesions of the nose.19 It is also important, given the rise of non-surgical rhinoplasty. The dorsal nasal nerve is a branch of the anterior ethmoidal nerve and exits at the distal end of the nasal bone at the bone-cartilage junction, approximately 6–10 mm off the midline.20 It continues distally and supplies the tip of the nose. It is important to remember the contribution of the nasal ala and columella from the intraorbital nerve distribution (see Section 1 of this chapter).

SECTION I

38

CHAPTER 5  • Anatomic blocks of the face and neck

nasal tip causes great discomfort, this block is much better tolerated7 (Algorithm 5.1). This block is especially valuable for cosmetic injections of the nose or for skin cancer resection and reconstruction of the nasal dorsum and tip.

Section 6: great auricular nerve and lobular nerve Anatomy

A

Zygomaticotemporal nerve

Zygomaticofacial nerve

The great auricular ascends from the cervical plexus and gives sensation to the lobule. Attention has been paid to this nerve as it is the most frequently injured nerve during rhytidectomy.21 The nerve comes around the posterior border of the sternocleidomastoid (SCM), generally at the midpoint of the muscle classically described as Erb’s point. The nerve then follows the fascial surface in a cephalad trajectory toward the ear. This nerve becomes more superficial, on middle of the SCM muscle, approximately 6.5 cm below the external auditory canal. The lobular nerve is consistently found 3.32 cm from the external auditory canal. This is found directly inferior to the antitragus 85% of the time and directly inferior to the tragus the remaining 15% of the time.

Technique

B

Figure 5.5  Location and distribution of the zygomaticotemporal nerve and zygomaticofacial nerves. (A) Injection point of the zygomaticotemporal block. The entry point to this block is 15–20 mm lateral and 6–12 mm cephalad to the lateral canthus. An aliquot of local anesthetic can be placed here or the trajectory can be followed more proximally in a direction deep, inferior, and medial toward the lateral orbital rim. To block the zygomaticofacial nerve, local anesthetic should be placed on the outer surface of the lateral orbital rim, just above the periosteum. (B) Relative distribution of the zygomaticofacial nerve (ZF) and infraorbital nerve (IO).

Technique The dorsal nasal block can be performed by palpating the end of the nasal bones. Given the consistent distance from the midline, the dorsal nasal nerve can be injected with less than 1 cc of local anesthetic either as a separate injection with or from the anesthetized area after the infraorbital nerve blockade.

Area of anesthesia This block anesthetizes the mid-vault, or cartilaginous dorsum, the sidewalls distal to the end of the nasal bones, and the nasal tip. Since injecting local anesthetic directly into the

To successfully block the great auricular nerve, the SCM needs to be identified. A reproducible way to do this is by having the patient turn their head toward the ipsilateral shoulder against the resistance of your hand. This will outline the body of the muscle. Then taking a line dropped down from the external auditory canal to the midportion of this muscle and measuring 6.5 cm, the injector will be able to successfully administer 1–2 cc of local anesthetic to block this nerve.22 While every surgeon is different, 6.5 cm is usually the length of the small finger or the distance from the metacarpal phalangeal joint of the thumb to the tip of the thumb (Fig. 5.6). Alternatively, if only the lobule requires anesthesia, a lobular nerve block can be employed. This is particularly useful in earlobe repair or reduction. To effectively perform this block, 1–2 cc of local anesthetic is infiltrated in a square-shaped area 3.3 cm below the external auditory canal between a line dropped down from the tragus and a second line dropped down from the antitragus.

Area of anesthesia The great auricular nerve supplies the skin over the parotid and angle of the mandible, the lower ear including the lobule, and the skin over the mastoid process.23 This block is especially valuable for earlobe repair and for skin cancer resection and reconstruction of the earlobe, mastoid region, anterior lower cheek, and angle of the mandible.

Section 7: transverse cervical nerves and lesser occipital nerve Anatomy In addition to the great auricular nerve, there are other clinically relevant cervical cutaneous nerves: namely, the

Anatomic blocks of the face

39

Algorithm 5.1 Algorithm for nasal blockade Patient prefers general anesthesia

Patient unfit for general anesthesia

Patient prefers local anesthesia

Nasal blockade

General anesthesia

Tip

Sidewall

Dorsum

Dorsal nasal block

Ala

Columella

Infraorbital block

Medial to medial canthus

Infratrochlear block

Algorithm for nasal blockade. If the patient is amenable for local anesthesia for cosmetic or reconstructive nasal procedures, then nasal blockade can be employed. Based on the specific area of concern, the patient may require a dorsal nasal block, infraorbital block infratrochlear block, or some combination of the three.

transverse cervical nerves and the lesser occipital nerve. The transverse cervical nerves innervate the anterior and lateral neck below the mandible and the lesser occipital nerve innervates the skin posterior to the ear and the middle third of the helix and antihelix of the ear. The transverse cervical arises from the ventral rami of spinal nerves C2 and C3. The lesser occipital nerve arises primarily from C2 but can also have a component of C3. Both nerves become more superficial along the posterior border of the SCM. Similar to the great auricular nerve, these nerves are classically depicted also exiting at Erb’s point. We now know that there are at least seven different branching patterns for the cervical cutaneous nerves as they penetrate the fascia of the posterior border of the SCM.24 These authors found that 50% of the time, the lesser occipital nerve, the great auricular nerve, and the transverse cervical nerves exit independent sites at the level of the posterior border of the SCM.24 The average emergence of each nerve as a ratio of the total length of the SCM was lesser occipital 0.63, great auricular 0.54, and transverse cervical 0.47. The authors did note that the order in which they emerge is highly consistent with the lesser occipital being most cranial and the transverse cervical being most caudal.24

Technique To successfully block the transverse cervical nerves, the SCM needs to be identified. This can be done in a similar way to the description in Section 6 earlier. This will help identify the point at which the great auricular nerve becomes more superficial. The branches of the transverse cervical nerves will be caudal to this point, cephalad to Erb’s point, and superficial at the level of the anterior border of the SCM. It is important to note that these branches will still be deep to the platysma. Thus, to block these branches, 3 cc of local anesthetic is infiltrated in a rectangularshaped distribution at the anterior border of the SCM, deep to the platysma between these landmarks (see Fig. 5.6). Using a similar technique, the lesser occipital can be blocked by creating a similar rectangle along the posterior border of

the SCM, with the caudal border being the point at which the great auricular nerve becomes superficial, as described in Section 6 earlier.

Area of anesthesia The transverse cervical nerve block will give anesthesia to the anterior and lateral neck and some of the cheek while the lesser occipital nerve block will give anesthesia to the skin posterior to the ear and a portion of the middle third of the helix and antihelix. This block is valuable for cosmetic procedures and lasers of the neck. Also, this block is valuable for skin cancer resection and reconstruction of the anterior and lateral neck.

Section 7: V3 and buccal nerve Anatomy The mandibular branch of cranial nerve V, or V3, is the most invasive of the described blocks in this chapter. This nerve gives sensation to a large area of the cheek, the upper preauricular region, and the auriculotemporal hair regions. The V3 nerve travels behind the pterygoid muscles, 1 cm posterior to the pterygoid plate. This is the region of the proposed block. Alternatively, if only the mucous membrane of the cheek, or the commissure of the mouth is required, then a buccal nerve block can be performed.25 The buccal nerve is 1 cm superior to the mandibular third molar at the anterior border of the pterygomandibular raphe.

Technique To successfully block V3, first find the sigmoid notch. This is generally palpable 2.5 cm anterior to the tragus, under the arch. Confirm this position by asking your patient to open their mouth widely. Mark this area and, using a 25 G or 27 G needle, inject a small amount of local anesthetic while

SECTION I

40

CHAPTER 5  • Anatomic blocks of the face and neck

Transverse B cervical nerve

A

Figure 5.6  Location of the great auricular nerve and transverse cervical nerves. (A) Reproducible location of great auricular nerve at Erb’s point, which is 6.5 cm below the external ear at the midpoint of the sternocleidomastoid (SCM) muscle. (B) The branches of the transverse cervical nerves. It is important to note that this injection should be placed at the anterior border of the SCM, deep to the platysma.

Algorithm 5.2 Algorithm for V3 distribution blockade Patient prefers general anesthesia

Patient unfit for general anesthesia

General anesthesia

Patient prefers local anesthesia

V3 distribution blockade Comfortable with V3 block V3 block

Uncomfortable with V3 block V3 block substitutes

Preauricular

Cheek

Mandibular

Auriculotemporal nerve block

Buccal nerve block

Tumescent anesthesia

Algorithm for V3 distribution blockade. If the patient is amenable for local anesthesia for cosmetic or reconstructive procedures in the V3 distribution, then consider a V3 block. If you are uncomfortable with the V3 block, you can use an auricular temporal nerve block, a buccal nerve block, or tumescent anesthesia in the area as an alternative.

hubbing the needle. Next, change to a 22G spinal needle on a 5-cc syringe. Now you must advance the needle straight back until you hit the pterygoid plate. At this point, mark the depth of the needle (usually 4.5 cm). Next, retract the needle almost to the skin and redirect the needle posterior by approximately 1 cm. Stop at the same depth that you had previously marked when hitting the pterygoid plate. Next, aspirate and inject 3–4 cc of local anesthetic. This is an important step; the maxillary vessels are located in this region. Please note, if you do not feel

comfortable with the anatomy or this specific technique, the cheek is amenable to dilute infiltration to offer a similar, albeit superficial, block (Algorithm 5.2). If the commissure requires anesthesia or if the entire lips require anesthesia, then a buccal nerve block performed either alone or in conjunction with an infraorbital and mental nerve block can be performed. The buccal nerve can be blocked with 1–2 cc of local anesthetic just superior to the third molar just anterior to the pterygomandibular raphe.

Conclusion

Area of anesthesia The V3 block will anesthetize the bulk of the cheek and upper preauricular and auricular temporal hair regions. A buccal nerve block will block the mucosal surface of the inside of the cheek as well as the commissure of the mouth and, sometimes, a small area of adjacent skin.25 The buccal block is especially valuable performing intraoral surgery or excising buccal fat pads. In addition, this block will anesthetize the commissure, which can be helpful for skin cancer resection and reconstruction.

Access the reference list online at   Elsevier eBooks+

41

Conclusion Regional blocking techniques help keep patients safe and comfortable during both cosmetic and reconstructive procedures. This is especially important when trying to avoid unnecessary costs for aesthetic procedures or if a patient is considered moderate or high risk to undergo general anesthesia. This chapter should serve as both a guide and a reference when blocking the face and, at minimum, make you question whether all cases that you perform in the operating room truly require general anesthesia.

References

References 1. Wilson SC, et al. Trends and drivers of the aesthetic market during a turbulent economy. Plast Reconstr Surg. 2014;133(6):783e–789e. 2. Connelly N, Leonard R. Discomfort associated with regional anesthetic placement in obstetrics: does alkalinization help? Int J Obstet Anesth. 1996;5(2):89–91. 3. Fialkov J, McDougall E. Warmed local anesthetic reduces pain of infiltration. Ann Plast Surg. 1996;36(1):11–13. 4. Shaefer JR, Lee SJ, Anderson NK. A vibration device to control injection discomfort. Compend Contin Educ Dent. 2017;38(6):e5–e8. 5. Clark LE, Mellette JR. Jr. The use of hyaluronidase as an adjunct to surgical procedures. J Dermatol Surg Oncol. 1994;20(12):842–844. 6. McMinn R, Hutchings R, Logan B. Color Atlas of Head and Neck Anatomy. Chicago: Year Book Medical Publishers; 1981:10. 7. Zide BM, Swift R. How to block and tackle the face. Plast Reconstr Surg. 1998;101(3):840–851. 8. Zide BM, Jelks GW, Polack FM. Surgical Anatomy of the Orbit. Philadelphia: Lippincott, Willims and Wilkins, 1986. 9. Haribhakti VV. The dentate adult human mandible: an anatomic basis for surgical decision making. Plast Reconstr Surg. 1996;97(3):536–541. discussion 542. 10. Roberts G, Harris M. Neurapraxia of the mylohyoid nerve and submental analgesia. Br J Oral Surg. 1973;11(2):110–113. 11. Marinho RM, Tennant CJ. Paresthesia of the cutaneous branch of the mylohyoid nerve after removal of a submandibular salivary gland. J Oral Maxillofac Surg. 1997;55(2):170–171. 12. Xie K, et al. Effects of supraorbital foramen variations on the treatment efficacy of radiofrequency therapy for V1 trigeminal neuralgia: a retrospective study. Pain Res Manag. 2020 Article ID: 8142489. 13. Janis JE, et al. The anatomy of the corrugator supercilii muscle: part II. Supraorbital nerve branching patterns. Plast Reconstr Surg. 2008;121(1):233–240.

41.e1

14. Christensen KN, et al. Cutaneous depth of the supraorbital nerve: a cadaveric anatomic study with clinical applications to dermatology. Dermatol Surg. 2014;40(12):1342–1348. 15. Kaçar CK, et al. Effects of adding a combined infraorbital and infratrochlear nerve block to general anaesthesia in septorhinoplasty. J Pain Res. 2020;13:2599–2607. 16. Jeong SM, et al. Anatomical consideration of the anterior and lateral cutaneous nerves in the scal. J Korean Med Sci. 2010;25(4):517–522. 17. Totonchi AN, Pashmini Guyuron B. The zygomaticotemporal branch of the trigeminal nerve: an anatomical study. Plast Reconstr Surg. 2005;115(1):273–277. 18. Zide BM, Swift R. Addendum to “How to block and tackle the face”. Plast Reconstr Surg. 1998;101(7):2018. 19. de Freitas CAF, et al. Nonmelanoma skin cancer at critical facial sites: results and strategies of the surgical treatment of 102 patients. J Skin Cancer. 2019:4798510–4798510. 20. Zide BM. Nasal anatomy: the muscles and tip sensation. Aesthetic Plast Surg. 1985;9(3):193–196. 21. Lefkowitz T, et al. Anatomical landmarks to avoid injury to the great auricular nerve during rhytidectomy. Aesthet Surg J. 2013;33(1):19–23. 22. Sharma VS, et al. What is the lobular branch of the great auricular nerve? Anatomical description and significance in rhytidectomy. Plast Reconstr Surg. 2017;139(2):371e–378e. 23. McKinney P, Katrana DJ. Prevention of injury to the great auricular nerve during rhytidectomy. Plast Reconstr Surg. 1980;66(5):675–679. 24. Kim HJ, et al. Emerging patterns of the cervical cutaneous nerves in Asians. Int J Oral Maxillofac Surg. 2002;31(1):53–56. 25. Takezawa KM, Ghabriel M, Townsend G. The course and distribution of the buccal nerve: clinical relevance in dentistry. Aust Dent J. 2018;63(1):66–71.

SECTION I  •  Aesthetic Anesthesia Techniques

6 Local anesthesia Malcolm D. Paul

Introduction The first local anesthetic agent was cocaine, discovered and utilized in the nineteenth century. In 1885 Halsted at Johns Hopkins University first introduced cocaine for nerve blocks. He later became addicted to cocaine through self-experimentation. Either by blocking conduction in peripheral nerves or by preventing excitation of nerve endings, local anesthetics effectively block the receptors for pain. This is achieved by anesthetics reversibly binding to, and inactivating, sodium channels. The depolarization of nerve cell membranes and the propagation of impulses along the course of the nerve occurs by the influx of sodium channels. When depolarization does not occur as well as the loss of the capacity to propagate an impulse, there is a loss of sensation in the area supplied by the nerve.1 The two classes of local anesthetics are amino esters and amino amides (Table 6.1, Fig. 6.1). In plastic surgical procedures, the amide esters, principally lidocaine and bupivacaine, are the most common local anesthetic agents used. The following considerations are important in deciding the dose of local anesthetic to be administered: 1. Patient weight. 2. Was epinephrine added to the local anesthetic agent? 3. Modality of administration: a. Will the local anesthetic agent be administered by a syringe or by an infusion pump utilized in the tumescent technique? b. What volume of tumescent anesthesia is administered? 4. The acidity of the environment that you are injecting into. 5. Whether or not the patient is taking medications (or supplements) that compete with the metabolism of the local anesthetic.

6.

An unintentionally high blood level of local anesthetic results in an excessive concentration at the central nervous and cardiovascular systems. This may lead to a clinical spectrum of toxicity ranging from mild symptoms to cardiac arrest and death. 7. Rate of absorption of local anesthetic into the bloodstream is a primary determinant of systemic toxicity and is influenced by local vascularity and extent of local tissue binding. 8. Presentation and rapidity of onset of local anesthetic toxicity is variable and is dependent on the local anesthetic used and whether the patient is sedated/ anesthetized. 9. Intralipid emulsion is effective at reversing local anesthetic toxicity, although the underlying mechanism is poorly understood. 10. CPR, ACLS, and low-dose epinephrine are the focus of treatment for local anesthetic toxicity-induced cardiovascular collapse. 1 1. Preventative measures (safety checklists, monitoring, appropriate dosing) can help reduce the incidence of local anesthetic toxicity. It follows that one should administer the smallest dose of local anesthetic, administered over the longest time period, achieving maximum anesthesia, and, when desired, maximum vasoconstriction. It has been argued that the maximum dose of lidocaine per kilogram patient weight can be increased when utilizing the “tumescent technique”. However, care must be taken to avoid large volumes of fluid injected at the start of the procedure with a recommended dose of 30 cc of 1% lidocaine plain per 1 L of lactated Ringer’s solution and 1  mg epinephrine/L. Certainly, adding epinephrine to the tumescent formula will decrease the rate of absorption of the lidocaine and, significantly, tumescent fluid is aspirated with the lipoaspirate (Box 6.1, Algorithm 6.1).

Combining local anesthetic agents with oral analgesics and anxiolytic agents (benzodiazepines)

43

Table 6.1  Dosages of local anesthetics

Drug

Onset

Maximum dose (with epinephrine)

Duration (with epinephrine)

Lidocaine

Rapid

4.5 mg/kg (7 mg/kg)

120 min (240 min)

Mepivacaine

Rapid

5 mg/kg (7 mg/kg)

180 min (360 min)

Bupivacaine Ropivacaine Levobupivacaine

Slow Medium Medium

2.5 mg/kg (3 mg/kg) 2–3 mg/kg 2.0 mg/kg or 400 mg in 24 h

4 h (8 h) 3 h (6 h) 4–6 h (8–12 h)

Procaine

Slow

8 mg/kg (10 mg/kg)

45 min (90 min)

Chloroprocaine

Rapid

10 mg/kg (15 mg/kg)

30 min (90 min)

Etidocaine

Rapid

2.5 mg/kg (4 mg/kg)

4 h (8 h)

Prilocaine

Medium

5 mg/kg (7.5 mg/kg)

90 min (360 min)

Tetracaine

Slow

1.5 mg/kg (2.5 mg/kg)

3 h (10 h)

Aromatic lipophilic portion

N

–

Amine – hydrophilic portion

Intermediate chain

O C O C C N

AMINO ESTERS

H O N C C N

AMINO AMIDES

Figure 6.1  Chemical structure of local anesthetics.

Combining local anesthetic agents with oral analgesics and anxiolytic agents (benzodiazepines) The level of anesthesia includes criteria that are designed to insure patient safety. The four levels of anesthesia are: Level 1: Local anesthesia with minimal sedation/anxiolysis: the patient is fully conscious and can respond to verbal commands. Level 2: Moderate sedation: consciousness is reduced, but the patient can respond to verbal commands. Level 3: Deep sedation: the patient can respond to repeated painful stimuli, but he cannot be aroused easily. Level 4: General anesthesia: the patient loses consciousness and cannot be aroused even with painful stimuli. The patient needs assistance with breathing. The muscle function is depressed and heart function may be impaired. The evolution of techniques in performing facial aesthetic procedures under local anesthesia alone (wide-awake approach) or under Level 1 anesthesia followed the sequence below:

BOX 6.1  Signs of lidocaine toxicity 1. Early neurological symptoms: a. Circumoral and/or tongue numbness b. Metallic taste c. Lightheadedness d. Dizziness e. Visual and auditory disturbances (difficulty focusing and tinnitus) f. Disorientation g. Drowsiness 2. Severe respiratory and cardiovascular symptoms: a. Hypotension b. Arrhythmia c. Bradycardia d. Cardiac arrest e. Respiratory arrest 3. Treatment of patients with suspected local anesthetic toxicity: a. The initial step is to stabilize any potential threats to life. b. If one notices the onset of signs and symptoms of local anesthetic toxicity, one should immediately stop the injections and prepare to treat the signs and the symptoms of local anesthetic toxicity. c. The treating physician must ensure adequate oxygenation by mask or by intubation. d. One must pay attention to impending respiratory arrest, significant hypotension, dysrhythmias, and seizures, as these are crucial in the management of a patient who is showing signs and symptoms of lidocaine toxicity. Once other possible causes of these signs and symptoms have been ruled out, management of the specific symptoms can begin.

1.

Lalonde2,3 pioneered the concept of completely anesthetizing skin and soft tissue without the use of any medications other than the careful injection of local anesthetic agents. His technique includes the following recommendations: a. Buffer local anesthetic with sodium bicarbonate. b. Use smaller 27- or 30-gauge needles. c. Immobilize the syringe with two hands and have your thumb ready on the plunger before inserting the needle.

44

CHAPTER 6  • Local anesthesia

SECTION I

Algorithm 6.1 Initial management Mild cardiac suppression Cardiac arrest

Emergency call Stop LA injection Secure airway Establish iv line

Antihypotension (ephedrine, adrenaline, etc.) Anti-arrhythmia (atropine, etc.)

Anticonvulsant (benzodiazepine) Lipid emulsion

Lipid emulsion

CPR ACLS (adrenaline)

After circulatory stabilization

Lipid emulsion

Close monitoring until completely awake

Cardiopulmonary bypass

Consider stay in ICU

A

Initial management Mild cardiac suppression Cardiac arrest Lipid emulsion

Lipid emulsion Bolus 1.5 mL/kg iv over 1 min

After circulatory stabilization

Continuous infusion 0.25–0.5 mL/kg/min (~18mL/min) Repeat bolus once or twice for persistent cardiovascular collapse

Continue infusion for at least 10 min after attaining circulatory stability. (Recommended upper limit: approximately 10 mL/kg lipid emulsion over the first 30 min) B

Management of acute local anesthetic toxicity. ACLS, Advanced cardiovascular life support; CPR, cardiopulmo­nary resuscitation; ICU, intensive care unit; iv, intravenous; LA, local anesthetic. ACLS, Advanced cardiovascular life support; CPR, cardiopulmo­nary resuscitation; ICU, intensive care unit; iv, intravenous; LA, local anesthetic. From Sekimoto K, Tobe M, Saito S. Local anesthetic toxicity: acute and chronic management. Acute Med Surg. 2017 Mar 6;4(2):152-160. doi: 10.1002/ams2.265. PMID: 29123854; PMCID: PMC5667269.

d. Use more than one type of sensory noise when inserting needles into the skin. e. Try to insert the needle at 90 degrees. f. Do not inject in the dermis, but in the fat just below it. g. Inject at least 2 mL slowly just under the dermis before moving the needle at all and inject all local anesthetic slowly when you start to advance the needle. h. Never advance sharp needle tips anywhere that is not yet numb. i. Always inject from proximal to distal relative to the nerves. j. Use blunt-tipped cannulas when tumescing large areas. k. Only reinsert needles into skin that is already numb when injecting large areas. l. Always ask patients to tell you every time they feel pain during the whole injection process so that you can score yourself and improve with each injection. m. Always inject too much volume instead of not enough volume to eliminate surgery pain and the need for “top-ups”.

2. 3. 4. 5.

The volume of local anesthetic administered should be within the safe dosage range, regardless of the method of injection. Using a small-diameter cannula in place of a sharp needle can improve the patient experience and decrease the risk of intravascular injections and small hematoma formation. Most facial aesthetic surgeons performing surgery under Level 1 anesthesia embrace a combination of local anesthesia with analgesics and anxiolytic agents. A combination of pre- and intraoperative meds that worked for decades in providing analgesia and anxiolytic effects included an opioid along with a benzodiazepine. This combination was within the guidelines for Level 1 anesthesia. However, dosing a patient with larger and/ or more frequent amounts of these medications can move the case to Level 2 anesthesia, which (depending upon the state) may require that the facility be accredited and there may be the requirement of additional equipment, etc. While adhering to the guidelines in Level 1 anesthesia, the dosage and amount of each of these components was determined by: a. BMI. b. Level of anxiety.

Current practice

6.

7.

c. Tolerance to the individual medications selected, including a history of taking these medications prior to the surgical procedure. d. Allergies including a history of allergic reaction to local anesthetics. Recently, surgeons have switched to non-opioid medications (NSAIDs, GABA analog, and COX-2 inhibitors) to avoid the possibility of creating opioid dependency. However, this is unlikely when opioid medications are only administered for a short period of time unless the patient has a history of prior addiction. Most recently, this author has begun utilizing sublingual sufentanil (DSUVIA, AcelRX Pharmaceuticals, Inc.) in the place of the combination of acetaminophen and oxycodone. DSUVIA (an opioid) produces profound analgesia in 20–30 min, is slowly absorbed by the oral mucosa lasting 3–4 h, does not produce respiratory depression when used as directed, and still permits the anesthesia to be classified as Level 1. This medication is a “game-changer” in allowing the surgeon to perform a variety of facial aesthetic procedures with a single sublingual medication and half the dose of the benzodiazepine selected. In this author’s experience, patients have had no pain sensation for their entire procedure(s) beginning with the injection of the local anesthetic agent and throughout the surgical procedure. If the procedure(s) takes longer than 3-4 h, the medications can be given a second time. As in the use of opioids, the facility where the procedure is performed should have the necessary equipment to support respiratory function as well as a “crash cart”.

Current practice Regardless of the level of anesthesia that is selected, it is important to check off the items listed in the guidelines developed by the American Society of Plastic Surgeons (Box 6.2). Clearly, a majority of patients are good or excellent candidates to have their facial aesthetic procedures performed in a well-equipped outpatient surgery center or office-based facility. Basic equipment includes, but is not limited to: intravenous (IV) sets and IV fluids, a “crash cart”, oxygen tank and mask equipment for supporting respiration, continuous monitoring of pulse oximetry, pulse and blood pressure monitoring, and an electrocardiogram (ECG) on demand or running continuously with the ability to print the readings. Even though the patient will be treated under Level 1 anesthesia, cardiopulmonary problems and local anesthetic toxicity can occur due to the following conditions: 1. Pre-existing cardiovascular disease including arrythmias, which may present as tachycardia and/or premature atrial contractions and premature ventricular contractions. Ischemia may be pre-existing and can become symptomatic during stress and/or the absorption of epinephrine. This occurrence may be related to the rapid absorption of epinephrine from injected soft tissues or from direct intravascular injections. It is important to slowly administer the local anesthetic agent and monitor the pulse. If the pulse becomes rapid or the blood pressure rises quickly, it is important to stop injecting local with epinephrine.

45

BOX 6.2  American Society of Plastic Surgeons Task Force guidelines for Safety in office-based surgery* Patient selection guidelines 1. Perform thorough history and physical examination 2. Order appropriate preoperative testing: a. Age >45 years old: electrocardiogram b. History of cardiac disease: electrocardiogram, possible cardiology referral for clearance c. Complete blood count, metabolic panel as indicated by comorbidities 3. Determine ASA physical status classification: a. ASA physical status 1: normal healthy patient – Ideal candidate for office-based surgery b. ASA physical status 2: patient with mild systemic disease that is well controlled without functional limitations – Ideal candidate for office-based surgery c. ASA physical status 3: patient with severe single-system disease and some functional limitations – Reasonable candidate for office-based surgery, recommend local and sedation techniques . ASA physical status 4: patient with severe systemic disease d that is a constant threat to life – Only with local and sedation techniques

Procedural guidelines 1. Hypothermia: a. Facility should be equipped to adequately monitor and adjust temperature b. Equipment should be available to warm patient c. Intraoperative blood loss: d. If predicted blood loss >500 mL, procedure should only be performed in facility with access to blood and blood components 2. Liposuction: a. Limit lipoaspirate to 6 h. If so, in-hospital observation should be considered 4. Thromboprophylaxis: a. Low risk, (no risk factors, 40 years old, procedure >30 min, general anesthesia) – Pneumatic compression devices c. High risk (>40 years old, >1 risk factor, long procedure, general anesthesia) – Pneumatic compression, consider medical prophylaxis ASA, American Society of Anesthesiologists. *Adapted from the following sources: Iverson RE. Patient safety in office-based surgery facilities: I. Procedures in the office-based surgery setting. Plast Reconstr Surg. 2002; 110:1337; discussion 1343; Iverson RE, Lynch DJ. Patient safety in office-based surgery facilities: II. Patient selection. Plast Reconstr Surg. 2002; 110:1785; discussion 1791; and Iverson RE, Lynch DJ. Practice advisory on liposuction. Plast Reconstr Surg. 2004; 113:1478; discussion 1491.

46

2. 3.

SECTION I

CHAPTER 6  • Local anesthesia

Respiratory depression can occur from the oral ingestion of opioids combined with benzodiazepines. Narcotic reversal medication such as naloxone should be available. Injecting large volumes of local anesthetic during a short period of time may cause lidocaine toxicity, which can be reversed with lipid emulsion therapy. It appears that diazepam can reverse lidocaine toxicity. Doses of bupivacaine above the recommended dose may cause cardiac toxicity, which may be reversed with lipid emulsion therapy or with the administration of glucose, insulin, and potassium.

Suitable candidates for office-based aesthetic plastic surgical procedures performed under local anesthesia/Level 1 undergo the following protocol: 1. Medical clearance if indicated by the information provided in a complete history and physical examination. 2. Hypertensive patients must be cleared by their primary care MD, internist, or cardiologist. 3. An ECG is required within 6 months of the procedure for any patient with a history of cardiac disease. 4. Patients above age 59 have a screening ECG. 5. Patients are asked to stop smoking at least 2 weeks before their scheduled procedure. 6. Informed consent is obtained. 7. Appropriate skin markings and discussion with the surgeon before the procedure to answer any remaining questions or concerns.

1.

2.

3.

4.

The following protocol is used routinely. Patients bring all meds with them to the surgery center including: • Lorazepam 2 mg • Diazepam 5 mg • Oxycodone with acetaminophen 5:325 for postoperative pain control • Cephalosporin if not allergic (ciprofloxacin or clindamycin can be substituted) • Ondansetron 4 mg oral dissolving tablet (ODT) to prevent nausea • Medrol Dosepak to be initiated before or immediately after surgery. DSUVIA (sufentanil) sublingual tablet, 30 mcg is administered along with 1 mg lorazepam, ondansetron 4 mg ODT, and one antibiotic dose. The Medrol Dosepak may be started as well or delayed until immediately after the procedure. Patients are placed in a comfortable position on the operating table and the following are added: a. Pneumatic compression devices. b. Pulse oximetry fingertip sensor applied. c. ECG/blood pressure and pulse monitors applied. Some patients will still be awake although pain free and may need a second milligram of lorazepam to allow them to relax during the injections and the procedure(s).

Access the reference list online at   Elsevier eBooks+

5.

Prior to the incorporation of DSUVIA in the author’s practice, patients would often be uncomfortable with some injections and often would require frequent redosing. DSUVIA will provide profound analgesia for 3–4 h (obese patients metabolize the medication faster and may require a second dose after 3 h). If the procedure will take longer than 3–4 h, a second dose can be given sublingually as indicated. 6. Within 20–30 min of having received DSUVIA and lorazepam, patients are ready for the first injections of local anesthesia. 7. Utilizing three 10-cc syringes containing lidocaine 1% with epinephrine and 1 cc sodium bicarbonate on 27-gauge needles, the planned incision lines are injected along with a block of the greater auricular nerves. 8. Tumescent anesthesia, developed and published by Klein,4 has significantly improved the dissection of facial soft tissues while reducing blood loss and is administered via a liposuction infusion pump (available from several manufacturers). The tumescent fluid is mixed as follows: a. 500 cc of lactated Ringer’s ( if 250-cc bags of lactated Ringer’s are used, divide the doses of the following by half) b. 30 cc of 1% lidocaine plain c. 1 cc epinephrine (for a dilution of 1:500,000) d. 1 g of Tratnexamic acid to improve hemostasis due to its’ antifibrinolytic property. 9. The tumescent fluid is injected before prepping and draping occurs through a 22-gauge spinal needle attached to the infusion tubing. By injecting the tumescent fluid before the patient is prepped and draped, there is adequate time to achieve the full effect of epinephrine, which takes about 26 min (not 7 min, as we always thought). Care is taken to observe the monitors for tachycardia, and/or hypertension related to the absorption of epinephrine. If this occurs, stop the injection and wait for the readings to return to normal. It is rare for the increase in heart rate and blood pressure to not return to normal within a few minutes. Delaying further injections of tumescent fluid is the correct decision. 10. The procedures are performed as planned. It is unusual to have to reinject areas of the face and neck because of the prolonged effect of sublingual sufentanil.

Summary The evolution of the use of local anesthesia along with the availability of impressive analgesics and anxiolytic medications has allowed the safe performance of facial aesthetic procedures in an equipped free-standing surgery center or office-based surgery center while adhering to Level 1 anesthesia criteria. As always, safety is our primary concern and, with the proper training, education, and equipment, the majority of our patients can have their facial aesthetic procedures performed safely while avoiding the risks and the sequelae of general anesthesia.

References

References 1. McLeod I.K., Meyers, A.D. Local anesthetics. Medscape; March 2021. Available: https://emedicine.medscape.com/otolaryngology. 2. Lalonde DH. Wide-awake flexor tendon repair. Plast Reconstr Surg. 2009;123:623–626.

46.e1

3. Strazar AR, Leynes PG, Lalonde DH. Minimizing the pain of local anesthesia injection. Plast Reconstr Surg. 2013;132(3):675–684. 4. Klein JA. The tumescent technique for liposuction surgery. Am J Cosmetic Surg. 1987;4:263.

 

 

SECTION II • Aesthetic Surgery of the Face

7 Non-surgical skin care and rejuvenation Zoe Diana Draelos

Access video lecture content for this chapter online at Elsevier eBooks+

Introduction Skin care involves several basic hygiene activities that include cleansing and moisturizing. With advancements in the understanding of skin physiology, more effective moisturizers have been developed that contain ingredients designed to improve the appearance and functioning of the skin. These products are known as cosmeceuticals; however, from a regulatory standpoint, there is no such category. Cosmeceuticals are simply cosmetics, usually with a moisturizer base and some added “hero” ingredient that may be called “active” because it imparts some added benefit to the skin. These specialty ingredients are usually vitamins, botanicals, or proteins that are generally recognized as safe and therefore do not require any regulatory oversight. Basic to skin care is an understanding of the different skin types, each with unique skin care cares. There are many classifications for skin type based on the degree of wrinkling, skin color, amount of sebum production, etc. The classification that seems most helpful is the Fitzpatrick skin type classification system based on erythema and tanning reactions to the first sun exposure in early summer (Table 7.1). Based on this skin typing system, recommendations can made for sun protection and appropriate formulations can be selected for cleansing and moisturization. It is interesting to note that there are physiologic differences between the various Fitzpatrick skin types. The differences are summarized in Table 7.2. While the corneocyte surface is the same, there are 20 stratum corneum cell layers in African-American skin as compared with 16 cell layers in Caucasian skin. The desquamation rate for African American skin is 2.5 times that of Caucasian skin, perhaps accounting for the increase in skin ashiness, accompanied by the pigmentation of the desquamating skin scale. However, the stratum corneum lipid content is higher in African Americans than Caucasians, but the ceramide level is lower. As expected, melanophage and mast cell granule size is larger in African-American skin. These unique differences may account for some of the dermatologic issues

observed and can be addressed in customized skin care for the unique needs of all skin types. Despite all of these differences, it is important to note that the number of melanocytes per unit area of skin does not vary across ethnicities. Instead, it is the relative amount of melanin packaged into melanocytes that accounts for the physiologic differences between Caucasian skin and ethnic skin.1 There are pronounced differences in photoaging between the various Fitzpatrick skin types based on the ability to withstand reactive oxygen species generation by photoradiation. Ten percent of the UVB radiation penetrates to the dermis, accounting for sunburn; however, the mean transmission into the dermis by Fitzpatrick type VI skin is 5.7%, compared with 29.4% for Fitzpatrick type I and II skin. Similarly, 50% of the UVA radiation penetrates to the papillary dermis; however, the mean transmission for Fitzpatrick type VI skin is 17.5%, as compared with 55% for Fitzpatrick skin type I and II.2 This difference is due to the basal cell layer functioning as the main site for UV filtration in Fitzpatrick type VI skin while the stratum corneum functions as the site for UV filtration in Fitzpatrick skin types I and II. The basal cell layer removes twice as much UV radiation as the stratum corneum.3 Based on these unique skin needs, we can then better understand how to address cleansing, moisturizing, retinoids, and sun protection for persons of all skin types.

Cleansers Cleansing is perhaps the most profound of all activities undertaken for skin hygiene and beautification. Cleansing is necessary after all surgical procedures to prevent infection and optimize wound healing, but cleansing of the face and other body areas is also undertaken on daily basis by most individuals. Cleansing requires a delicate balance between skin hygiene and stratum corneum barrier damage. The act of cleansing is a complex physical and chemical interaction between water, detergent, and the skin. During cleansing,

48

SECTION II

CHAPTER 7  • Non-surgical skin care and rejuvenation

Table 7.1  Fitzpatrick skin type classification system

Skin type

Erythema and tanning reactions to first sun exposure in early summer

I

Always burn, never tan

II

Usually burn, tan less than average (with difficulty)

III

Sometimes mild burn, tan about average

IV

Rarely burn, tan more than average (with ease)

V

Brown-skinned persons

VI

Black-skinned persons

Table 7.2  Skin characteristic comparison

African American

Caucasian

Corneocyte surface area

Same, 900 μm

Same, 900 μm

Stratum corneum cell layers

20 cell layers

16 cell layers

Spontaneous desquamation rate

2.5 times Caucasian

Transepidermal water loss

Same

Stratum corneum lipid content

Higher than Caucasian

Ceramides

Lower than Caucasian

Mast cell granules

Larger than Caucasian

Melanophage size

Larger than Caucasian

Same

micelles are created with external hydrophilic groups surrounding an internal lipophilic pocket. These micelles can surround oily substances, such as sebum, dispersing the oil in water for removal and rinsing.4 Cleansers are based on surfactants and are the primary cause of dry skin. This arises because surfactants cannot distinguish between lipophilic skin soils requiring removal and the lipophilic intercellular lipids required for barrier maintenance. The bipolar structure of skin soils is similar to the fatty acids, cholesterol, and ceramides comprising the lipid bilayers of the stratum corneum.5 Cleanser barrier damage leads to alterations in stratum corneum function and desquamatory failure with increased corneocyte retention. This is the mechanism by which cleansers induce the rough, scaly appearance characteristic of dry skin.6 The cleanser component that causes dry skin is the highcharge density of the carboxyl head group, which promotes strong protein binding. This characteristic insures excellent cleansing and removal of protein soils, but damages the stratum corneum proteins, denatures enzymes, and alters corneocyte water holding of the capability.7 Barrier damage is also influenced by cleanser pH. Soap typically has an alkaline pH of 10–11, producing skin protein swelling and ionization of the lipid bilayers. Thus, synthetic detergents with more

neutral pH of 5–7 minimize barrier damage and are the preferred cleanser.8 There are many different types of cleansers available for purchase with unique compositions and specific skin benefits. The term soap is used loosely to refer to any cleanser; however, this is not correct, as soap denotes a specific chemical entity. Soap is created when a fat interacts with an alkali, resulting in a fatty acid salt with detergent properties.9 Modern commercial soaps are a blend of tallow and nut oil, or the fatty acids derived from these products, in a ratio of 4:1. Altering the ratio modifies the cleansing ability of the formulation. For example, increasing this ratio results in “superfatted” soaps touted for their cleansing “mildness.” It is the excess fatty acid that reduces the ability of the cleanser to remove lipids, thus these products are marketed as “sensitive skin” cleansers. These soaps can be packaged as bars or liquids. The most common cleanser formulations marketed today are composed of synthetic detergents, known as syndets, and possess a lower alkaline pH, resulting in less removal of intercellular lipids. Soaps typically have a pH of 9–10 while syndets are formulated at a pH of 5.5–7, closer to the natural neutral skin pH (Dove Soap, Unilever).10 It is possible to combine both soap and syndet cleansers into a formulation known as a combar, providing better cleansing with less lipid disruption (Dial Bar, Henkel).11 Bar cleansers are the most widely used form of cleanser, with many different types of bar cleansers available, as summarized in Table 7.3. The typical bar cleanser composition is a combination of two surfactants: the soap alkyl carboxylate and the syndet acyl isethionate. Alkyl carboxylate and acyl isethionate are both anionic surfactants, but the carboxylate group is most damaging, binding and denaturing stratum corneum proteins. Liquid cleansers have a composition similar to bar cleansers, except they are poured from a bottle. There are a variety of different cosmeceutical cleansers that are currently available and will be briefly discussed by type.

Cold cream cleansers Cold cream, composed of water, beeswax and mineral oil, uses fats to solubilize lipophilic skin soils.12 Beeswax and mineral oil function as lipid solvents that combine with the detergent action of borax, also known as decahydrate of sodium tetraborate, to cleanse the face.13 The formulation also contains ceresin and carbomer to thicken the cream and fragrance. The cold cream is wiped on with the fingers, wiped off with a tissue, and may be rinsed or left on the face. Cold cream is an excellent facial cleanser and cosmetic remover for patients with dry skin.

Cleansing milks A thinner variant of cleansing cream is cleansing milk, without the more viscous waxes, designed for normal to combination skin. Cleansing milk contains water and lightweight oils, such as olive oil, sunflower oil, jojoba oil, or sesame seed oil, and emollients, such as glycerin, making it less likely to leave a facial residue. The oils are emulsified into the water, making cleansing milks an oil-in-water emulsion providing cleansing by dissolving, as opposed to emulsifying, skin soils. The liquid is dispensed from a bottled and wiped over the face with a cotton pad.14 The cleanser can be wiped off or wiped first,

Moisturizers

Table 7.3  Bar soap formulations

Bar soap type

Formulation details

Superfatted

Increased fat, up to 10%

Castile

Olive oil added as fat

Deodorant/antibacterial

Antibacterial agent added to kill odor causing bacteria, OTC drug, composition regulated by monograph

French milled

Milder formulation with lower pH

Floating

Air introduced into soap by whipping

Oatmeal

Ground oatmeal added, whole oats create a more exfoliating bar while oat powder creates a bar with less exfoliation

Acne

OTC drug, composition regulated by monograph, may contain sulfur, salicylic acid, or benzoyl peroxide

Facial

Smaller bar size

Bath

Larger bar size

Botanical ingredients:aloe vera/chamomile/lavender

Botanical ingredient added to soap, no special skin benefit in a rinse-off product, no special claims possible

Vitamin E

Vitamin E added for marketing purposes, no special skin benefit in a rinse-off product

Cocoa butter

Cocoa butter used as fat

Nut oil/fruit oil

Nut oil or fruit oil used as fat

Transparent/glycerin

Glycerin added, does not reduce barrier damage

Heavy-duty abrasive

Ground pumice used as grit to exfoliate stained skin

Exfoliating

Plant material (nut kernels, dried herbs, fruit pits, etc.) added to physically exfoliate the skin

Soap-free

Contains syndets (synthetic detergents)

Natural

No formulation meaning, consumer marketing appeal

Organic

No formulation meaning, consumer marketing appeal

Handcrafted

Bar molded by hand instead of poured or machine molded, offers no cleansing benefit

49

pad, rubbed, and rinsed away with water. The clear oil will turn milky when water rinsed. Mineral oil, castor oil, jojoba oil, and olive oil are commonly used. Olive oil can be comedogenic; thus the cleansing oil should be thoroughly water rinsed and might require the addition of a detergent for complete removal.

Micellar water cleansers Micellar water cleansers, also known as cleansing waters, contain water and a very mild surfactant representing a dilute cleansing solution. A micelle is a molecular cluster with a hydrophilic and a hydrophobic end, in this case dissolved in a water solution. The hydrophobic end attaches to the skin soils, dissolving the soil in water through the hydrophilic end, and allowing water rinsing to cleanse the face. Several different surfactants can be used, such as cetrimonium bromide, a ­cationic quaternary surfactant also known as a “quat”. Quats are mild surfactants commonly found in hair conditioners that allow the excess conditioner to water rinse down the drain, preventing the hair from appearing greasy. Polysorbate 20 is also used because it is a non-foaming surfactant. Amphoteric surfactants of the type found in baby shampoo can also be used, such as disodium cocoamphodiacetate. The product is stroked on the face with a cotton pad, rubbed to remove skin soils, and rinsed with water. Micellar water is excellent at removing water-soluble cosmetics or facial cleansing in patients with dry, sensitive skin.

Cleansing scrubs Cleansing scrubs are particulate-containing cleansers designed to mechanically exfoliate either the face or body. The cleanser is based on previously discussed detergents in cream form with the addition of aluminum oxide, ground fruit pits, polyethylene beads, or sodium tetraborate decahydrate granules.15 The particles are manually massaged into the skin, dislodging desquamating corneocytes and improving skin visual smoothness and tactile softness. Typically, the scrub is used once weekly; more frequent or aggressive use can cause skin barrier damage and skin sensitivity. Aluminum oxide and ground fruit pits produce the most aggressive exfoliation due to their rough surface contour; however, recently, apricot pit powder has been introduced, producing less skin trauma.

Moisturizers

followed by water rinsing. Cleansing milks are commonly used for the removal of eye cosmetics, since they are non-irritating and do not readily blur vision with an oily residue.

The excellent efficacy of cleansers has led to the need for moisturizers. Moisturizers must fulfill four basic needs in order of consumer importance: make the skin smooth and soft; increase skin hydration; improve appearance; and possibly deliver a cosmeceutical ingredient to the skin surface. A moisturizer that does not deliver on these four attributes cannot be a success in the marketplace.

Cleansing oils

Improved skin smoothness and softness

Cleansing oils are a water-in-oil emulsion primarily used for the removal of facial or eyelid waterproof cosmetics and waterproof sunscreens that cannot be easily removed with soap and water. The oil is spread over the face with a cotton

The most basic consumer need achieved by moisturizer application is smooth and soft skin. All moisturizers in the current marketplace make the skin smooth and soft; however, better formulations are longer lasting. Skin that is smooth and soft

50

SECTION II

CHAPTER 7  • Non-surgical skin care and rejuvenation

is an assessment of the organization of the corneocytes on the skin surface. As the intercellular lipids are removed, the edges of the corneocytes fold, thus creating friction when the hand is rubbed across the skin surface. Creating smooth and soft skin utilizes emollients, such as propylene glycol, dimethicone and cetyl alcohol, which are thin oily substances capable of depositing between the desquamating corneocytes temporarily until the next cleansing, at which time they must be reapplied.

Increased skin hydration Moisturizers that are medically relevant must increase skin hydration by retarding water loss from the skin surface, known as transepidermal water loss (TEWL).16 This is accomplished by placing a water-impermeable film over the skin to retard evaporation and by applying substances to the skin surface to attract water. Moisturizers are a misnomer, as they do not moisturize the skin.17 Only through skin barrier repair can TEWL be permanently returned to normal levels. Increased skin hydration is the mechanism by which most cosmeceuticals decrease fine lines of dehydration, especially those around the eye where the skin is thinnest. Retarding TEWL will hydrate this skin temporarily until the moisturizer is removed with cleansing. While wrinkle reduction may appear to be a functional benefit, it is a result of increased skin hydration that will be temporary unless skin barrier repair occurs.

Improved optical appearance A lesser moisturizer goal is to improve skin appearance, a characteristic known as radiance or luminosity. These attributes are the appreciation of the amount of light reflected by the skin surface back into the eye of the observer, which is directly related to the smoothness of the skin surface. With advancing age, skin melanin, hemoglobin, and collagen distribution become more irregular. Cosmeceutical moisturizers capable of delivering a lightly pigmented film to the skin surface or enhancing light reflection from the skin surface may improve the optical appearance of the skin. Pigments, such as iron oxide, and optically reflective materials, such as mica or fish scale, can be added to moisturizers to create anti-aging appearance benefits. All cosmeceutical moisturizers work through two basic mechanisms of restoring skin water content: occlusion and humectancy.18 Occlusive moisturizers function by placing a water-impermeable barrier over the skin surface, creating an environment conducive to barrier repair. The most occlusive and most physiologic moisturizer is said to be petrolatum; however, its aesthetics are undesirable, accounting for the myriad cosmeceutical moisturizers on the market.19 It reduces TEWL by 99%, allowing enough water vapor to leave the skin for initiation of barrier repair.20,21 Humectants are substances that attract water, acting like sponges on and in the skin. All liquid and cream moisturizers contain humectants to prevent product desiccation, but the humectant may be present in insufficient concentration to have a physiologic function. The dermis possesses glycosaminoglycans, including hyaluronic acid, to function as humectants; however, other cosmeceutical humectants include glycerin, honey, sodium lactate, urea, propylene glycol, sorbitol, pyrrolidone carboxylic acid, gelatin, vitamins, and some proteins.22,23

These topically applied ingredients can draw water from the air, although the moisturizer becomes sticky and unaesthetic when this occurs. Most humectants, of which glycerin is the most effective, draw water from the deeper epidermis and dermis, allowing the skin to feel smoother by filling holes in the stratum corneum through swelling.24 An unopposed humectant will draw water from the skin to the lower-humidity atmosphere; thus a cosmeceutical moisturizer must contain both occlusives and humectants for optimal efficacy.25

Moisturizer ingredients Many ingredients are used to formulate moisturizers. The most commonly used moisturizer constituents are presented next.

Petrolatum Petrolatum is a semisolid mixture of hydrocarbons obtained through the dewaxing of heavy mineral oils. Pure cosmeticgrade petrolatum is practically odorless and tasteless, but has not been synthetically duplicated. Petrolatum is the most effective moisturizing ingredient on the market today, reducing TEWL by 99%. It functions as an occlusive to create an oily barrier through which water cannot pass. Thus, it maintains cutaneous water content until barrier repair can occur. Petrolatum is able to penetrate into the upper layers of the stratum corneum and aid in the restoration of the stratum corneum barrier. Petrolatum impacts all four phases of skin remoisturization: initiation of barrier repair, alteration of surface cutaneous moisture partition coefficient, onset of dermal–epidermal moisture diffusion, and synthesis of intercellular lipids.

Silicone After petrolatum, the most significant cosmetic ingredient to be discovered is silicone. Topical silicone is hypoallergenic, noncomedogenic, and non-acnegenic. It is a remarkable nongreasy moisturizer and skin conditioning agent providing the basis for “oil-free” moisturizers. Silicone acts as a nongreasy, occlusive agent that can have an astringent effect on other oily substances, such as petrolatum. Silicone can also function as an emollient, filling in spaces between desquamating corneocytes, to create the smooth skin surface that patients desire, until the product is removed with rubbing or washing, creating a smooth surface. Dimethicone and cyclomethicone are the two most common derivatives utilized in moisturizer formulations.

Ceramides Endogenous ceramide synthesis is the first step in barrier repair. Nine different ceramides have been identified and synthetically duplicated for inclusion in moisturizer formulations distinguished by their polar head group architecture, as well as by their hydrocarbon chain properties.26 Many cosmeceutical moisturizers use a ceramide cocktail to improve the skin barrier.

Natural moisturizing factor There are a group of substances reported to regulate the moisture content of the stratum corneum, known as natural

Sunscreens

moisturizing factor (NMF). NMF has been synthetically formulated consisting of a mixture of amino acids, derivatives of amino acids, and salts. Cosmeceutical NMF contains amino acids, pyrrolidone carboxylic acid, lactate, urea, ammonia, uric acid, glucosamine, creatinine, citrate, sodium, potassium, calcium, magnesium, phosphate, chlorine, sugar, organic acids and peptides.27 Ten percent of the dry weight of the stratum corneum cells is composed of NMF broken down from filaggrin; however, cosmeceutical formulations attempt to remoisturize the skin through synthetic NMF combinations.

Sodium PCA One ingredient of synthetic NMF is sodium PCA, which is a sodium salt of 2-pyrrolidone-5-carboxylic acid. Synthetic sodium PCA has been shown to be a better moisturizer than glycerol and is found in several cosmeceutical products functioning as a humectant when used in concentrations of 2% or higher.28

Urea and lactic acid Urea and lactic acid are also components of synthetic NMF and can diffuse into the outer stratum corneum, disrupting hydrogen bonding, exposing water-binding sites on the corneocytes, and facilitating increased hydration. This is especially important in callouses, which can be improved by cosmeceutical foot products containing these ingredients to increase stratum corneum pliability in direct proportion to the amount of lactic acid or urea absorbed.29

Retinoids Retinoids are some of the most efficacious anti-aging ingredients in the marketplace today. Topical cosmeceutical retinoids are synthetic vitamin A derivatives, which include retinol (vitamin A alcohol), retinyl esters, retinoic acid (tretinoin), and retinyl palmitate. Retinoids are biologic modifiers producing receptor-specific effects, including regulating growth of epidermal cells and promoting differentiation of cell lines.30,31 They are difficult to topically formulate due to their inherent photo instability and degradation upon exposure to oxygen. Retinol can be oxidized into retinaldehyde, and then into retinoic acid, the biologically active form of vitamin A. Retinol may be also esterified with fatty acids to form retinyl esters. Retinoic acid is oxidized to a less-active metabolite, 4-oxoretinoic acid, or converted to retinoyl glucuronide, whereas retinol is converted to retinyl glucuronide. Retinyl palmitate is the most stable of the vitamin A esters and can be easily incorporated into the oil phase of creams and lotions, due to its lipophilic nature; however, it is not very biologically active.32 Topical activity of retinyl palmitate is thought to occur following cutaneous enzymatic cleavage of the ester bond and subsequent conversion of retinol to retinoic acid. It is this cutaneous conversion of retinol to retinoic acid that is responsible for the biologic activity of some of the new stabilized over-the-counter (OTC) retinol preparations. Unfortunately, only small amounts of retinol can be converted by the skin, accounting for the increased efficacy seen with prescription preparations containing retinoic acid.33

51

Sunscreens Sunscreens are important for skin health and the prevention of cutaneous aging.34 Both UVB (290–320 nm) and UVA (320–400 nm) radiation are damaging to the skin, with UVB inducing sunburn and skin cancer while UVA rays penetrate deeper within the dermis, producing reactive oxygen species, which are damaging to DNA, collagen, and blood vessels.35 UVA radiation induces immunosuppression, also contributing to the formation of skin cancer.36 Thus, sunscreens must protect against both UVA and UVB radiation by including filters to prevent the energy from destroying the skin.37 These filters can be inorganic or organic, depending on their chemical and physical properties, and function by absorbing, reflecting, or diffusing UV radiation. Table 7.4 lists all the sunscreen filters that are approved for use in the US. The US has far fewer approved filters than the rest of the world. Sunscreens are considered over-the-counter drugs and are regulated by the US Food and Drug Administration (FDA). Inorganic filters are so named because they do not undergo a chemical reaction to diffuse UV radiation. They are powders formed from metal oxides, such as titanium dioxide and zinc oxide. They reflect and diffuse UV radiation, but leave a gritty white film on the skin surface, which may not be acceptable to persons with higher Fitzpatrick skin types. This white film is minimized by decreasing the particle size of the metal oxides through grinding. However, the decrease in particle size changes the protective properties of titanium dioxide, shifting the protection range from the longer UVA wavelengths to the UVB wavelengths. The larger particles can also scatter and absorb visible light, which has more recently been associated with photoaging. Zinc oxide

Table 7.4  US-approved sunscreens

Sunscreen filter

Maximum concentration (%)

p-Aminobenzoic acid (PABA)

15

Avobenzone

3

Cinoxate

3

Dioxybenzone

3

Ensulizole (phenylbenzimidazole sulfonic acid)

4

Homosalate

15

Meradimate (menthyl anthranilate)

5

Octinoxate (octyl methoxycinnamate)

7.5

Octisalate (octyl salicylate)

5

Octocrylene

10

Octyl dimethyl PABA

8

Oxybenzone (benzophenone-3)

6

Sulisobenzone

10

Titanium dioxide

25

Trolamine salicylate

12

Zinc oxide

25

52

SECTION II

CHAPTER 7  • Non-surgical skin care and rejuvenation

has better absorption in the UVA wavelengths but is not very good at both UVB and UVA absorption when used alone. The combination of zinc oxide and titanium oxide is best. The inorganic sunscreens are frequently coated with dimethicone to decrease the formation of secondary oxygen radicals, which are formed when radiation bounces off the particulate filter. They are considered safe, as they do not penetrate the skin to any significant degree. Organic filters are sunscreen ingredients that absorb UV radiation at wavelengths according to their chemical structure, which is called a chromophore.38 The chromophore consists of electrons in conjugated double bond sequences. A photon of UV energy causes electron transfer to a higherenergy orbit in the molecule. The sunscreen filter that was in a low-energy state is converted into a higher-energy state with the excess energy released as heat.39 Table 7.5 presents the protective wavelength for each of the FDA-approved sunscreen ingredients. Controversy has recently arisen regarding the safety of organic filters, which can be absorbed through the skin and appear in the plasma and urine.40,41 Oxybenzone, a commonly used UVB and UVA filter, can be absorbed transdermally and may be an endocrine disruptor.42 Therefore, sunscreens should only be used when necessary and washed off the skin when no longer outdoors.

Summary This chapter has presented basic skin care concepts in terms of cleansing, moisturizing, retinoid use, and sunscreens. These items are widely available and used multiple times daily by most individuals. Their impact on the skin and skin health is significant.

Access the reference list online at   Elsevier eBooks+

Table 7.5  US-approved sunscreen filters based on UV protection wavelength

Sunscreen ingredient

UV protection wavelength UVB (290– 320 nm)

UVA2 (320– 340 nm)

UVA1 (340– 400 nm)

Titanium dioxide

*

*

Zinc oxide

*

*

*

*

*

Inorganic

Organic p-Aminobenzoic acid

*

Avobenzone Cinoxate

*

Dioxybenzone

*

Ensulizole

*

Homosalate

*

Meradimate

*

*

Octinoxate

*

Octisalate

*

Octocrylene

*

Oxybenzone

*

Padimate O

*

Sulisobenzone

*

Trolamine salicylate

*

* *

References

References 1. Szabo G, Gerald AB, Pathak MA, Fitzpatrick TB. Racial differences in the fate of melanosomes in human epidermis. Nature. 1969;222:1081–1082. 2. Kaidbey KH, Agin PP, Sayre RM, Kligman AM. Photoprotection by melanin: a comparison of black and Caucasian skin. J Am Acad Dermatol. 1979;1:249–260. 3. Munavalli GS, Weiss RA, Halder RM. Photoaging and nonablative photorejuvenation in ethnic skin. Dermatol Surg. 2005;31:1250–1260. discussion 1261. 4. Fowler JF, Eichenfield LF, Elias PM, Horowitz P, McLeod RP. The chemistry of skin cleansers: an overview for clinicians. Semin Cutan Med Surg. 2013;32(2 Suppl 2):S25–S27. 5. Slotosch CM, Kampf G, Loffler H. Effects of disinfectants and detergents on skin irritation. Contact Derm. 2007;57(4):235–241. 6. Dykes P. Surfactants and the skin. Int J Cosmet Sci. 1998;20(1):53–61. 7. Slotosch CM, Kampf G, Loffler H. Effects of disinfectants and detergents on skin irritation. Contact Derm. 2007;57(4):235–241. 8. Ananthapadmanabhan KP, Moore DJ, Subramanyan K, Misra M, Meyer F. Cleansing without compromise: the impact of cleansers on the skin barrier and the technology of mild cleansing. Dermatol Ther. 2004;17(Suppl 1):16–25. 9. Willcox MJ, Crichton WP. The soap market. Cosmet Toilet. 1989;104:61–63. 10. Wortzman MS. Evaluation of mild skin cleansers. Dermatol Clin. 1991;9(1):35–44. 11. Johnson AW. Overview: Fundamental skin care – protecting the barrier. Dermatol Ther. 2004;17:1–6. 12. deNavarre MG. Cleansing creams. 2nd edn. In: deNavarre MG, ed. The Chemistry and Manufacture of Cosmetics. Vol III. Wheaton, IL: Allured Publishing Corporation; 1975:251–264. 13. Jass HE. Cold creams. 2nd edn. In: deNaarre MG, ed. The Chemistry and Manufacture of Cosmetics. Vol III. Wheaton, IL: Allured Publishing Corporation; 1975:237–249. 14. Barlage T, Griffiths-Brophy Hasenoehrl EJ. Facial cleansers and cleansing cloths. In: Draelos ZD, ed. Cosmetic Dermatology: Products and Procedures. Chichester: Wiley Blackwell; 2016:103–109. 15. Mills OH, Kligman AM. Evaluation of abrasives in acne therapy. Cutis. 1979;23:704–705. 16. Anderson PC, Dinulos JG. Are the new moisturizers more effective? Curr Opin Pediatr. 2009;21(4):486–490. 17. Draelos ZD. Concepts in skin care maintenance. Cutis. 2005;76(6 Suppl):19–25. 18. Goldner R. Moisturizers: a dermatologist’s perspective. J ToxicolCut & Ocular Toxicol. 1992;11(3):193–197. 19. Friberg SE, Ma Z. Stratum corneum lipids, petrolatum and white oils. Cosmet Toilet. 1993;108:55–59. 20. Grubauer G, Feingold KR, Elias PM. Relationship of epidermal lipogenesis to cutaneous barrier function. J Lip Res. 1987;28:746–752. 21. Ghadially R, Halkier-Sorensen L, Elias PM. Effects of petrolatum on stratum corneum structure and function. J Am Acad Dermatol. 1992;26:387–396. 22. De Groot AC, Weyland JW, Nater JP. Unwanted Effects of Cosmetics and Drugs Used in Dermatology. 3rd edn. Amsterdam: Elsevier; 1994:498–500.

52.e1

23. Spencer TS. Dry skin and skin moisturizers. Clinics Dermatol. 1988;6:24–28. 24. Robbins CR, Fernee KM. Some observations on the swelling of human epidermal membrane. J Soc Cosmet Chem. 1983;37:21–34. 25. Idson B. Dry skin: moisturizing and emolliency. Cosmet Toilet. 1992;107:69–78. 26. Garidel P, Fölting B, Schaller I, Kerth A. The microstructure of the stratum corneum lipid barrier: mid-infrared spectroscopic studies of hydrated ceramide: palmitic acid: cholesterol model systems. Biophys Chem. 2010;150(1–3):144–156. 27. Wehr RF, Krochmal L. Considerations in selecting a moisturizer. Cutis. 1987;39:512–515. 28. Wilkinson JB, Moore RJ. Harry’s Cosmeticology. 7th edn. New York: Chemical Publishing;; 1982:62–64. 29. Idson B. Dry skin: moisturizing and emolliency. Cosmet Toilet. 1992;107:69–78. 30. Goodman DS. Vitamin A and retinoids in health and disease. N Engl J Med. 1984;310(16):1023–1031. 31. Noy N. Interactions of retinoids with lipid bilayers and with membranes. In: Livrea MA, Packer L, eds. Retinoids: Progress in Research and Cinical Applications. New York: Marcel Dekker; 1993:17–27. 32. Idson B. Vitamins and the skin. Cosmet Toilet. 1993;108:79–92. 33. Babamiri K, Nassab R. Cosmeceuticals: the evidence behind the retinoids. Aesthetic Surg J. 2010;30(1):74–77. 34. Moyal D, Fourtanier A. Acute and chronic effects of UV on skin. In: Rigel DS, Weiss RA, Lim HW, Dover JS, eds. Photoaging. New York: Marcel Dekker; 2004:15–32. 35. Moyal D, Fourtanier A. Effects of UVA radiation on an established immune response in humans and sunscreen efficacy. Exp Dermatol. 2002;11(Suppl 1):28–32. 36. Peak MJ, Peak JG. Molecular photobiology of UVA. In: Urbach F, Gange RW, eds. The Biological Effects of UVA Radiation. New York: Praeger Publishers; 1986:42–52. 37. Agar NS, Halliday GM, Barnetson RS, et al. The basal layer in human squamous tumors harbors more UVA than UVB fingerprint mutations: a role for UVA in human skin carcinogenesis. Proc Natl Acad Sci USA. 2004;101:4954–4959. 38. Fourtanier A, Moyal D, Seité S. UVA filters in sun-protection products: regulatory and biological aspects. Photochem Photobiol Sci. 2012;11(1):81–89. 39. Fourtanier A, Bernerd F, Bouillon C, Marrot L, Moyal D, Seité S. Protection of skin biological targets by different types of sunscreens. Photodermatol Photoimmunol Photomed. 2006;22:22–32. 40. Matta MK, Florian J, Zusterzeel R, et al. Effect of sunscreen application on plasma concentration of sunscreen active ingredients: a randomized clinical trial. JAMA. 2020;323(3):256–267. 41. Matta MK, Zusterzeel R, Pilli NR, et al. Effect of sunscreen application under maximal use conditions on plasma concentration of sunscreen active ingredients: a randomized clinical trial. JAMA. 2019;321(21):2082–2091. 42. Arya S, Dwivedi AK, Alvarado L, Kupesic-Plavsic S. Exposure of U.S. population to endocrine disruptive chemicals (Parabens, Benzophenone-3, Bisphenol-A and Triclosan) and their associations with female infertility. Environ Pollut. 2020;265(Pt A):114763.

SECTION II  •  Aesthetic Surgery of the Face

8.1

Editors’ perspective: injectables and nonsurgical resurfacing techniques J. Peter Rubin

Our growing armamentarium of non-surgical techniques serves as a useful and important complement to our surgical facial rejuvenation strategies. Notably, non-surgical strategies are often the “gateway” procedure to entering the practice of a plastic surgeon. Moreover, many non-surgical facial rejuvenation methods will be repeated by patients on a regular and recurring basis, thus creating a long-term relationship with the practice. The chapter on facial fillers by Kavita Mariwalla covers state-of-the-art knowledge of characteristics and applications of injectable agents to add volume to the face. While small in volume, the strategic and focused use of fillers can make a dramatic difference in not only treating signs of facial aging but also in improving facial shape. The chapter on injectable botulinum toxin by Rawaa Almukhtar and Sabrina Fabi discusses the pharmacology, pharmacokinetics, and applications of agents to reduce the activity of muscles of facial expression in an artistic manner. Our concepts of the application of neurotoxins are evolving over time, moving from a more basic approach of simply mitigating dynamic or active facial rhytides to making artistic changes in facial shape and expression. Of all the non-surgical rejuvenation methods, the use of neurotoxins is most likely to result in a long-term regular treatment regimen selected by your patients. The reputational benefits to your practice through those long-term recurrent visits are obvious, providing the patient experience is maximized. The use of lasers in aesthetic surgery has grown, along with the evolution and refinement of the technology. The precise control of

wavelength and energy delivery has expanded the applications dramatically and enables the effective treatment of pigmentary changes, skin texture, and hair growth. The chapter by Jonathan Cook, David Turer, Barry DiBernardo, and Jason Pozner skillfully covers the physics and practical applications of lasers in facial rejuvenation. As anticipated, these different non-surgical modalities for non-surgical facial rejuvenation present the opportunity for combination therapy. Chemical peels have become a vital tool in facial rejuvenation, either as an alternative to lasers or as an adjunct. The use of chemical agents for skin resurfacing involves a number of different compounds that can effectively improve skin texture. The chapter on chemical peels by Richard Bensimon and Peter Rullan discusses the indications and applications for these methods. The chapter on multimodal non-surgical facial rejuvenation by Luiz Toledo discusses strategies for combining these different methodologies into an integrated and effective approach that can be individualized for each patient. In the modern area of facial rejuvenation, the understanding of the non-surgical treatment modalities is essential for the aesthetic surgeon. Although non-surgical, the different strategies discussed in this section of the textbook are not without significant risk. The aesthetic surgeon must have a keen awareness of the potential complications of non-surgical strategies and a thorough knowledge of the methods for identifying and managing complications that may occur.

SECTION II  •  Aesthetic Surgery of the Face

8.2 Injectables and resurfacing techniques: Soft-tissue fillers Kavita Mariwalla

Access video lecture content for this chapter online at Elsevier eBooks+

SYNOPSIS

ƒ Soft-tissue fillers provide versatile tools in the correction of facial wrinkles and facial contouring, as well as in the restoration of the volumetric loss associated with aging. ƒ Reversibility is an advantageous property of fillers, allowing adjustments that may be needed due to technical errors or changes in the tissues that occur with aging. ƒ Inexperienced injectors should always opt for rapidly resorbable fillers such as hyaluronic acid (HA). This allows for faster resolution of any technical errors or overinjection. Hyaluronidase can be used to dissolve the filler. ƒ With respect to the treatment of deep folds and tear troughs, it is important to undercorrect these deformities. This results in a more natural appearance and leaves room for further correction in the future if that is desirable. Overcorrection of these areas can result in visible abnormalities. ƒ “Off-label” use of synthetic materials is technically possible but does carry risk, and discretion should be exercised when using products in this manner. Additionally, the patient must be informed. ƒ Patients often forget their preoperative appearance; pre- and post-treatment photography as well as highlighting asymmetries prior to injection are essential. ƒ Complications of dermal fillers can be avoided by the use of proper technique (small aliquots, appropriate depth and quantity of injection, undercorrection, etc.).

Introduction Facial beauty is in the eye of the beholder; however, facial volume gives the face a characteristic youthful shape and can modify the appearance of what is perceived as beautiful. Indeed it is volume that can connote indicators of youth, symmetry, and even gender differentiation by modulating light and shadows as they fall across the face. Unfortunately, with

time soft-tissue descent, ligament laxity, and bone resorption lead to changes in proportion and placement of volume on the face. As a result, there has been historical interest in the use of injected material to modify the contour of skin, underlying soft tissue, and bone. However, effective and safe tools to accomplish such a goal have become available only in recent decades. The plastic surgeon now has access to numerous fillers to soften the stigmata of aging or correct the contour deficits that occur with many disease processes. In order to use these fillers optimally, one must understand the nature of each product. The goal of this chapter is to present the different classes of fillers and the indications and techniques for their use. Particular attention is paid to the correction of the aging face and techniques for specific areas for enhancement.

The pathophysiology of wrinkles Prior to augmenting facial skin, it is important to understand the factors that create the aging face. Aging is a complex process, which is the result of both intrinsic (soft-tissue maturation, skeletal change/atrophy, genetics, and muscular hyperactivity) and extrinsic factors (gravity, solar damage, smoking and weight fluctuation). As a result, the smooth curvy appearance of the face is slowly replaced by sharp angles, fine and deep wrinkles, and abrupt hollows and bulges. The anatomy of facial aging is thoroughly reviewed in other chapters in this volume. With aging, bony changes give rise to a decrease in height and a moderate widening of the facial skeleton. An increased orbital volume, caused in part by an expanding lower orbital rim, results in sunken eyes. This, when combined with an age-related reduction in maxillary height, and nasal resorption leads to a reduced area for the attachment of midfacial soft tissues. The cheeks descend and consequently the nasolabial folds become deeper. The upper lip complex descends (window shade effect), while tear troughs and perioral rhytides appear. If teeth are lost,

Classification of fillers

alveolar height decreases and the chin atrophies. Additionally, the ligamentous attachments of the soft tissues become lax, which further contributes to the appearance of furrows and creases. In the midface, for example, there are seven distinct fat compartments which all change in shape leading to varying aging features. Similarly, we now understand that most major retaining ligaments induce deep facial grooves as the face ages in an inward and downward fashion. Thus, injecting along the line of ligaments can produce projection while injection behind the line of ligaments can create lift. With age, cell division slows. The epidermis thins out, and the epidermal–dermal junction becomes flatter. The integrity of the stratum corneum decreases and the basal cells acquire more atypia. As a result of these changes, water loss through the skin is increased, leading to drier, more fragile skin. The comparative shrinkage of the more rigid stratum corneum over the deeper and less rigid dermis leads to the classical appearance of wrinkles. These skin depressions are more pronounced in sun-exposed regions and areas that are subject to repeated movements such as face, neck, and hands. Subcutaneous fat atrophy leads to easy bruising and less light reflection which optically also ages the face. The dermis becomes thinner and contains fewer elastic and collagen fibers. Sebaceous glands are less numerous and less active, which also contributes to skin dryness. All the above changes lead to a drier, less elastic, more fragile skin that is more susceptible to gravity and thus wrinkling. It is important to discuss with patients that fillers alone may not achieve their desired aesthetic result and combination treatment with lasers and energy-based devices may also be required. In all cases, topical skincare should not be ignored as skin barrier integrity, hydration and maintenance are key to the end result of soft-tissue filling. Of course it is also important to realistically set goals of volumization with fillers. For many patients, filler use will not be enough and they are actually facelift candidates. Similarly, many facelift patients over time may need filler as tissue descent is a chronic, lifelong process. Chronic sun exposure is the most significant environmental factor impacting skin aging. It is responsible for dyschromia, lentigines, telangiectasias, and the loss of the youthful pink hue. Skin texture becomes coarser because the epidermis is thicker in photoaged skin than in normal skin. Overall collagen amount decreases, except in the superficial dermis where there is an area of increased collagen production (grenz zone) representing a chronic inflammatory process known as heliodermatitis. Solar elastosis is pathognomonic of photoaged skin with abundant, degraded, thickened elastic fibers. Lastly, sun exposure contributes to a reduction in ground substance, contributing to deeper folds and wrinkles. Microscopically, all wrinkles appear like thinned breaks in the dermis. Even though the terms wrinkles, folds, creases, furrows, and rhytides are often used interchangeably, specific features can be used to distinguish between different types of rhytides. Fine wrinkles refer to changes in the texture of the skin that involve the superficial aspect of the dermis. Mimetic wrinkles can extend down to the middle level of the dermis (lines) or down to its full thickness (furrows). These are due to the repeated folding of the skin secondary to the contraction of the facial muscles. As a result, they are perpendicular to the direction of these muscles and occur in locations such as the glabella, periorbita, forehead, and lips. Dynamic wrinkles eventually become static, remaining visible even when the underlying muscle is relaxed.

55

Folds refer to larger grooves with some level of skin overlap. These are the result of soft-tissue descent secondary to gravity, decreased support, and loss of skin elasticity. Examples include upper eyelid dermatochalasis, nasolabial folds, marionette lines, jowls, and horizontal neck lines. The tear trough is an infraorbital groove that results from soft-tissue tethering along the arcus marginalis between bulging orbital fat above and descending deflated soft tissue below. The importance of being able to classify wrinkles is central to being able to direct treatment.1 Superficial lines that course at the upper level of the dermis are amenable to dermabrasion, chemical peels, and lasers. Mimetic wrinkles respond to muscle inactivation with neuromodulators (Botox, Dysport, Xeomin, Jeuveau, and Daxxify) or myotomy/myectomy but can also be improved with the concomitant use of fillers. Finally, fillers are most useful in the treatment of folds, during their early stages, or as an adjuvant modality to surgery, during their more advanced stages. To help guide the physician’s treatment and their assessment of improvement, several classification systems have appeared over the years. One of these, the Lemperle classification (see Table 8.2.4) is based on wrinkle depth and can be very helpful.

Access the Historical Perspective section online at Elsevier eBooks+

Classification of fillers Soft-tissue fillers are an ideal option for patients seeking facial rejuvenation with minimal downtime. For the young patient not requiring surgery, these materials offer a viable option, while for older patients, surgery can be combined with fillers and other surface treatments to create an optimal result.8,9 Although the number and variety of products available are impressive, the ideal filler has not yet been found.10–12 The definition of an ideal filler may be debatable, but there are certain basic qualities that are agreed upon (Box 8.2.1). Ultimately, even though it is important that worldwide research and development for the ideal soft-tissue filler continues, a balance is needed between embracing new products and ensuring patient safety. In fact, in May 2015, the FDA released a safety communication entitled “Unintentional Injection of Soft Tissue Filler into Blood Vessels in the Face”, which states that: Unintentional injection of soft-tissue fillers into blood vessels in the face can result in rare, but serious side effects … This can cause vision impairment, blindness, stroke and damage and/or death of the skin (necrosis) and underlying facial structures. … certain injection locations where blood vessel blockage have been reported more often. These sites include the skin between the eyebrows and nose (glabella), in and around the nose, forehead, and around the eyes (periorbital region).13 In October 2021 the FDA convened a multidisciplinary panel reviewing the type and incidence of filler complications. They have not issued a final recommendation. The statement also goes on to recommend avoiding the injection of fillers if the level of training and experience is insufficient.13 In order to better understand the properties of each product that is either already available or in the pipeline, fillers can be classified into the following categories:

Historical perspective

Historical perspective The use of an exogenous material to augment soft tissue can be traced back to Neuber in 1893 who used fat transplanted from the arms to correct facial defects.2 Later, with the invention of the syringe, Brunning first injected fat in 1911, but significant resorption and fat necrosis depopularized this technique. It was not until liposuction and the concept of micro fat grafting that the use of lipoaspirate for soft-tissue augmentation successfully resurfaced. Concurrent with the initial efforts to graft fat came attempts to inject other synthetic materials in order to volumize soft tissue.2,3 In 1899, Robert Gersuny first injected Vaseline, while later, Eckstein used paraffin to correct fistulas and hernias and to attain aesthetic soft-tissue augmentation. Serious complications such as granulomatous inflammatory reactions (paraffinomas) and nodule formation, embolization, and migration were reported early on, yet paraffin kept being used for over two decades before it was abandoned. The first reports of the use of silicone date from the end of World War II in Japan when numerous women had their breasts injected with non-medical grade silicone.4 Shortly after, in 1947, Dr. James Barrett Brown first used silicone for the correction of soft-tissue deficits in the US. Concurrently, hard and rubber silicone found use in creating alloplastic implants. Early flawed animal experiments suggested that injectable silicone was safe, and physicians relied heavily on this improper information. The popularity of the technique led to numerous complications such as lump formation, migration, ulceration,

55.e1

and extrusion.5 The illicit injection of non-medical grade silicone continues to this day, even though the US Food and Drug Administration (FDA) took a more active role in criminalizing its use in the 1990s. Today, highly purified medical grade silicone oil (AdatoSil 5000, Silikon 1000) is FDA approved for the treatment of retinal detachment and can be used cautiously off-label for volume augmentation. In 1981, bovine collagen was the first filler approved by the FDA for soft-tissue augmentation; it soon became the gold standard against which all fillers were compared. Its rapid resorption and allergenic nature led to a series of efforts to develop a compound that would not cause allergic reactions and that would last longer. It was not until two decades later that hyaluronic acid (HA) became available for clinical use. HA found multiple medical uses before it was approved in the US as a soft-tissue filler. HA dermal fillers rapidly replaced collagen as the gold standard in cosmetic soft-tissue augmentation. The high demand and success of HA products led to an intense search for products that are similar to HA, which did not cause hypersensitivity reactions, but are longer lasting.7 This in turn led to a number of newer and longer-­lasting products such as poly-l-lactic acid (PLLA: Sculptra, FDA approval in 2004 for HIV-related facial lipoatrophy; Galderma Laboratories, FDA approval in 2009), calcium hydroxylapatite (Radiesse, FDA approval in 2006), and polymethylmethacrylate (PMMA)/polyacrylamide products such as Bellafill (previously Artefill, FDA approval in 2006).6 Today, plastic surgeons have in their armamentarium numerous safe fillers that can produce unprecedented aesthetic results, provided that they are used in an educated/safe manner.

56

SECTION II

CHAPTER 8.2  • Injectables and resurfacing techniques: Soft-tissue fillers

BOX 8.2.1  Ideal filler characteristics • • • • • • • • • • •

Non-toxic Biocompatible Long-lasting (if not permanent) Reversible Off-the-shelf Autologous Easy to use Safe Produces positive, natural, discernible change Minimal downtime Level of placement (could be placed through dermis at subcutaneous, intramuscular, or periosteal levels) • Predictable (permanence, bulk, and behavior) • Performs well as a person ages • Not discernible by touch/appearance

  autologous

materials materials   synthetic materials.   biologic

Autologous fillers Autologous materials are derived from the patient’s own tissue.14–17 They therefore come closest to matching the description of the ideal soft-tissue filler in terms of safety. However, they are not as convenient to use since they require a two-step procedure – harvesting of tissue and injection. Toxicity, allergenicity, immunogenicity, carcinogenicity, and teratogenicity are not issues, but there can be problems with donor site scar, infection, migration, inflammatory reactions, loss of persistence, and unreliable reproducibility. Autologous fillers include:   dermis, fascia, cartilage, superficial musculoaponeurotic system (SMAS), breast implant capsule   fat grafts   platelet-rich fibrin matrix (PRFM)   platelet-rich plasma (PRP)   cultured fibroblasts   bone marrow-derived and adipose-derived stem cells. Dermis and cartilage grafts have a long history of use in plastic surgery, and with careful handling and placement, these grafts may have good, long-lasting results. Similarly, fascial grafts from the fascia lata of the thigh, the temporalis, sternocleidomastoid, and the SMAS can be used. In a good recipient bed, fascia is permanent and persists through a combination of creeping replacement by host fibroblasts and continued viability of fascial fibroblasts. Fat grafts as free en bloc transfers of tissue lose at least onehalf of their bulk after transplantation, and frequently develop cysts, calcifications, and necrotic lumps. However, this is not the case with micro fat grafting in which small intact packets of fatty tissue are harvested as atraumatically as possible and injected in tiny amounts along multiple tracts. This keeps the injected fat cells near a blood supply for increased survival and integration. The great advantage of this technique is that the fat that survives is permanent. The disadvantage is the

unpredictability of the survival, the need for a donor site, and the time required to process the fat.14–16,18 Selphyl (Aesthetic Factors, Princeton, NJ) is a patented system that allows the extraction of platelet-rich fibrin matrix (PRFM) from the patient’s own blood.19,20 This novel technology allows processing of blood in the office in a three-step process that takes approximately 20 minutes. The collected PRFM is then injected into the patient’s wrinkles. The collection of a 9 mL blood sample allows the collection of 4 cc of PRFM. The development of collagen and dermal matrix increases over a period of 3 weeks and there is early evidence to suggest long-lasting wrinkle correction (up to 20 months).19-22 Possible applications include correction of nasolabial folds, glabellar lines, and panfacial rejuvenation, as well as acne and other scar treatments. Selphyl has been cleared for use in the US (FDA) and Europe (CE mark). In recent years several companies have come forward with cost- and time-efficient in-office PRP extraction methods. Typically once blood is drawn, the process of spinning and collecting the platelet-rich plasma takes only 10–15 minutes. The quality of the PRP and the quantification of platelet-derived growth factors has not been compared between different systems but what is clear is that the differences between systems lie in the separating gel. Whether specific separating gels present in the blood collection tubes produce a higher grade of PRP has not been studied across brands. LAVIV or Azficel-T (Fibrocell Science, Exton, PA; FDA approval 2011) is approved for the correction of moderate to deep nasolabial folds. LAVIV is an autologous cellular product composed of fibroblasts harvested from postauricular skin.23 The fibroblasts obtained from the skin biopsy are aseptically cultured and expanded until sufficient cells for three consecutive injections are obtained. The treatment sessions are spaced 3–6 weeks apart. Although the mechanism of action of LAVIV is unclear, a two-point improvement in the Lemperle classification scale was achieved in up to 57% of subjects treated. The longevity of this correction beyond 6 months remains to be shown.24

Biologic fillers Biologic materials derived from organic sources (humans, animals, or bacteria) offer the benefits of ready, “off-the-shelf” availability, but can introduce issues of allergenicity, immunogenicity, and transmission of disease.25–29 Biologics provide only a temporary effect and typically do not correct the wrinkles or creases completely. The three major types of biologic tissue fillers are acellular soft-tissue matrix, collagen, and hyaluronic acid (HA) products. Although there are a few classes of materials that fall under the category of biologic fillers, hyaluronic acid filler use is by far the most common globally. Examples of different types that have FDA approval include those listed in Box 8.2.2. AlloDerm (LifeCell, Branchburg, NJ) is an acellular, structurally intact sheet of human dermal graft that was first used clinically in the treatment of full-thickness burns. Processed from prescreened human cadaver skin, the cells responsible for immunogenicity are removed while the matrix structure and biochemical components are left intact. The grafted material then acts as a template for recipient cell repopulation, resulting in soft-tissue regeneration. Some of its cosmetic-related applications include lip augmentation, nasolabial fold correction, glabellar wrinkle softening, and rhinoplasty

Classification of fillers

(dorsum and tip), as well as septal perforation, Frey syndrome, liposuction defect, and scar treatments. Complications include infection, persistent palpability or lumpiness, and variable “take” of the grafted material. Cymetra (LifeCell, Branchburg, NJ) is also a lyophilized acellular collagen matrix derived from human cadaver dermis, but in a particulate form. It is FDA-approved for subcutaneous injection and is used for lips, nasolabial folds, and deep wrinkles. Bovine collagen, marketed as Zyderm and Zyplast (Allergan, Irvine, CA), became available in 1981 and was the first commercially marketed injectable approved by the FDA for soft-tissue augmentation; at the time, it was the standard

against which all other fillers were compared. CosmoDerm and CosmoPlast (Allergan, Irvine, CA) contained human collagen and did not require a pretreatment skin test.30–32 They are no longer available. Hyaluronic acid or HA is an anionic, hydrophilic, nonsulfated glycosaminoglycan common to most living organisms and is a component of synovial fluid and of connective tissues of the skin, cartilage, and bone. In human skin, HA adds bulk and acts as a shock absorber and lubricant. HA, in its unprocessed molecular configuration, has a half-life of two days as it is rapidly degraded and metabolized by the liver.33 The solution to this problem has been to cross-link HAs into more stable compounds with significantly longer degradation times.34 HA, being extremely hydrophilic, maintains its volume by binding water from the interstitial fluids around it. In fact, 1 g of HA can bind an impressive 6 L of water.33 As the HA is progressively degraded by the surrounding tissues, underlying molecules of HA bind more water and therefore maintain the initial filling volume. This process is called “isovolumetric degradation” and it is the reason that HA fillers can maintain a virtually constant fill volume until the product is almost completely degraded.33,35 The significant differences between the HA fillers on the market today include the source of HA, concentration, type and degree of cross-linking, amount of free unmodified HA present, and whether the product is monophasic (cohesive gel) or biphasic (particulate). Another crucial characteristic is the elastic modulus or G′ (pronounced G prime) of a gel, which is a measure of its firmness and resistance to deformation.36 In general, the HA family of dermal fillers is a good choice for novice injectors, treatment-naïve patients, and for patients with moderate aging changes. The rheology of HA fillers is critical to understand as it allows for better selection of a particular HA brand based on the need for flexibility, volume, and support of a particular area of the face. A comparison of commercially available fillers in the US is presented in Fig. 8.2.1.

BOX 8.2.2 FDA-Approved soft-tissue fillers Cymetra

SKINVIVE by Juvederm

AlloDerm

Juvederm Ultra

Dermalogen

Juvederm Ultra Plus

Surgisis

Juvederm Voluma XC

Renuva

Juvederm Volbella XC

Bellafill

Juvederm Vollure

Sculptra

Juvederm Volux

Restylane

Juvederm Volite

Restylane Lyft

Belotero Balance

Restylane Refyne

Radiesse

Restylane Defyne

RHA Redensity

Restylane Kysse

RHA 2

Restylane Contour

RHA 3

Restylane Silk

RHA 4 Revanesse Versa

Restylane Eyelight

57

Source: https://www.fda.gov/medical-devices/aesthetic-cosmetic-devices/dermalfillers-soft-tissue-fillers. Accessed June 1, 2023.

600 Restylane Lyft Restylane-L

Firmness/support (G’)

450

Restylane Silk Juvéderm Voluma

300

Teosyal RHA 4

Juvéderm Vollure

Juvéderm Vollux Restylane Defyne Teosyal RHA 3

Teosyal RHA 1

150

Juvéderm Volbella Revanesse Versa

Restylane Kysse Juvéderm Ultra plus XC

Teosyal RHA 2

Juvéderm Ultra XC Belotero Balance

0

0

150

300

450

600

750

900

1050

1200

Flexibility (x strain) (%)

Figure 8.2.1 US FDA-approved commercially available hyaluronic acid fillers in comparison to each other based on strength (G′) and flexibility.  

Restylane Refyne

1350

1500

58

SECTION II

CHAPTER 8.2  • Injectables and resurfacing techniques: Soft-tissue fillers

Restylane (Galderma Laboratories, Lausanne, Switzerland) is a NASHA (non-animal stabilized hyaluronic acid) soft-tissue filler that originally received FDA approval in 2003 for use in the correction of facial wrinkles.7,37–45 It is now marketed as a family of products differing in the size of the constituent particles. Brands within this group that differ by viscosity include Restylane Silk, Restylane Kysse, Restylane-L, Restylane Lyft, Restylane Defyne, Restylane Refyne and Restylane Contour. In 2006, Allergan’s Juvéderm series of HA fillers received FDA clearance. Similar to Restylane, Juvéderm also comes in various concentrations and viscosities and its cross-linking technology is termed Hylacross and Vycross. The Vycross range of fillers are homogeneous smooth gels that are used for both lift and lines. The patented Vycross technology incorporates short- and long-chain HA leading to more efficient cross-linking than Juvéderm Ultra, which only has long-chain HA. Addition of the short chains of HA permits more cross-links, more stability, and consequently, a longer lasting filler than the previous generation. This increased cross-linking also produces a more viscose gel, and therefore a greater lift capacity as well.46 Brands in this portfolio include Juvéderm Voluma, Juvéderm Vollure, Juvéderm Volbella, Juvéderm Volux XC, Juvéderm Volite, Juvéderm Ultra Plus XC and Juvéderm Ultra XC (Allergan, Irvine, CA). New to the US market but used globally for many years is Teosyal RHA 4, Teosyal RHA 3, Teosyal RHA 2 and Teosyal Redensity. Produced by Swiss HA product manufacturer Teoxane, all are marketed in the US by Revance Therapeutics Inc. (Nashville, TN) as RHA 4, RHA 3, RHA 2 and RHA Redensity (FDA approval 2019). Belotero Balance (Merz Aesthetics, Greensboro, NC; FDA approval 2011) is another HA filler available in the US. It has unique properties that make it softer (lower G′), longer lasting, and particularly useful for superficial injections of fine lines. Its low viscosity allows it to spread evenly throughout the soft tissues, which makes for a soft, smooth fill.47

Revanesse Versa (Prollenium Medical Technologies Inc., Aurora, ON; FDA approval December 2017) is new to the market and similar to the other HA fillers can be used for lift as well as lines. As discussed above, many of the recent fillers already contain lidocaine, but alternatively, lidocaine (usually 2%) can be mixed with most fillers to obtain analgesia during injection. However, doing this will most probably change the viscosity of the product, as well as certain of its properties. There are still a large number of non-FDA-approved biological fillers, which are available in the rest of the world.48 These are mainly HA-based products, with various sources, processing, and cross-linking (Table 8.2.1).

Synthetic fillers Synthetic materials can offer permanence. Many injectable and surgically implantable synthetic products have been used over the years, and many have been condemned for complications, including granulomas, acute and delayed infections, migration or displacement, and deformities that can result

Table 8.2.2  Synthetic fillers approved by the Food and Drug Administration (FDA) in the United States

FDA-approved synthetic fillers

Type

AdatoSil 5000

Silicone

Silikon 1000

Silicone

Bellafill (Artecoll)

Polymethylmethacrylate (PMMA)

Radiesse

Calcium hydroxyapatite

Sculptra (New-Fill)

Poly-l-lactic acid (PLLA)

Table 8.2.1  Biological fillers not approved by the Food and Drug Administration (FDA) in the United States, but approved elsewhere

Non-FDA-approved biological fillers

Type

Country (approval)

R-fine

Hyaluronic acid

Canada, Europe, Asia

Hyaluderm

Hyaluronic acid

Europe

Revanesse/ReDexis

Hyaluronic acid (cross-linked)

Canada

MacDermol S/MacDermol R

Hyaluronic acid (avian, cross-linked)

Europe

Varioderm

NASHA

Europe

Amalian

NASHA

Europe

Macrolane

NASHA

Europe

Zetaderm/Zetavisc

NASHA

Europe, Canada, Russia

HydraFill

NASHA (cross-linked)

Europe

Esthelis/Fortelis

NASHA (CMP technology cross-linked)

Europe, Canada, Asia

Puragen

NASHA (DXL technology cross-linked)

Europe, Canada

Rolifan/Philoderm/Beautygel/Esthirase/Coilingel

NASHA (cross-linked)

Europe, Canada, Brazil

HyalSkin

NASHA (BDDE cross-linked)

Europe

BDDE, 1,4-Butanediol diglycidyl ether; CMP, cohesive polydensified matrix; DXL, double cross-linked; NASHA, non-animal-stabilized hyaluronic acid.

Injection technique

from complications or removal of the material. It is with these products that the difference between the regulatory process in the US and that in the rest of the world is highlighted. The FDA controls access to the US market and enforces strict “labeling” practices, which means that the manufacturer must spell out the exact applications for which the material has been approved. Synthetic fillers approved by the FDA appear in Table 8.2.2. AdatoSil 5000 (Bausch & Lomb Incorporated, Rochester, NY) and Silikon 1000 (Alcon Research, LLC, Fort Worth, TX) are silicone gels with improved viscosity that have been approved by the FDA for use in treating detached retina. Both can be legally injected off-label for skin augmentation according to the 1997 FDA Modernization Act. However, only FDAapproved highly purified liquid silicone should be considered and injected using a microdroplet technique. Historically, injectable silicone products have tended to harden, migrate, and cause inflammation and skin necrosis.4,49 Those who have achieved success with silicone do so by injecting limited amounts at monthly intervals or longer. While side effects can be difficult to treat, liquid injectable silicone is particularly effective for human immunodeficient virus-associated lipoatrophy. Bellafill (Suneva Medical, San Diego, CA) is a permanent injectable implant consisting of smooth and round microspheres of nonresorbable polymethylmethacrylate (PMMA) which are 30–50 micrometers (20% by volume) suspended in a water-based gel containing 3.5% bovine collagen gel (80% by volume) and 0.3% lidocaine.50–52 After injection, the collagen is resorbed and the round, smooth microspheres are encapsulated by host collagen where they are stabilized and become permanent. Used in Europe for the past decade as Artecoll (Canderm Pharma Inc., Canada), Bellafill was approved by the FDA in October of 2006. Radiesse (Merz Aesthetics, Greensboro, NC) is a mixture of calcium hydroxyapatite (30%) and polysaccharide gel (70%).52–58 The polysaccharide gel is very white, which makes Radiesse inappropriate for use in the dermis. Radiesse is FDAapproved (December 2006) for nasolabial and labiomental crease correction, and since mid-2015 it is also FDA approved as a cosmetic filler for the dorsum of the hand.59 It is reported to last anywhere between 1 and 2 years. Recent use of hyperdilute Radiesse has shown neocollagenesis and is frequently used as a biostimulatory filler. Areas such as the decolleté and neck are now being augmented in this way. Sculptra (Galderma Laboratories, Forth Worth, TX) is a biocompatible, biodegradable material that is composed of PLLA (poly-l-lactic acid), sodium carboxymethylcellulose, and non-pyrogenic mannitol. It must be reconstituted with 5–10 mL of sterile water at least 2 hours prior to injection and does not require a skin test.60,61 Sculptra is hypothesized to induce the production of fibroblasts leading to collagen production. Over time (6–24 months), Sculptra is degraded in the skin to carbon dioxide and water.62,63 Sculptra has been used in surgical products for more than 20 years as a component of dissolvable sutures. It has also been safely used outside the US since 1999 in over 30 countries under the trade name of “New-Fill” for a variety of facial volume and contour deformities. It was approved by the FDA in August of 2004 as the only product for the correction of human immunodeficiency virus (HIV)-associated facial lipoatrophy

59

Table 8.2.3  Synthetic fillers not approved by the Food and Drug Administration (FDA) in the United States, but approved elsewhere

Non-FDA-approved synthetic fillers

Type

Country (approval)

Bioplastique

Silicone

Europe

Aquamid

Polyacrylamide

Europe, 40 other countries

Beautical

Polyacrylamide

Europe

Bio-Alcamid

Polyacrylamide

Europe

Outline

Polyacrylamide

Europe

Evolution

Polyacrylamide

Europe

Formacryl

Polyacrylamide

Russia

Argiform

Polyacrylamide

Russia

Bioformacryl

Polyacrylamide

Ukraine

Amazing Gel

Polyacrylamide

Asia

DermaLive/DermaDeep

Polyacrylamide

France

Metacril

Methylmethacrylate

Brazil

ArteSense

Methylmethacrylate

Europe, Canada, Asia

Rhegecoll

Methylmethacrylate

Pending worldwide

Laresse Dermal Filler

Carboxymethyl cellulose/ polyethylene

Europe

Atléan BTCP

Tricalcium phosphate

Europe

Bioinblue

Polyvinyl alcohol

Europe

Reviderm

DEAE Sephadex

Europe, Canada, Asia

Matridex

DEAE Sephadex

Europe

DEAE, diethylaminoethyl.

and is also approved for cosmetic use in the US (Galderma Laboratories; FDA approval 2009). It is injected subcutaneously in the area of fat loss/volume loss and provides a gradual and significant increase in volume. It is reported to last up to 2 years after three consecutive treatment sessions, approximately 1 month apart. A large number of other synthetic fillers are available in various parts of the world and a few are listed in this chapter48,64 and in Table 8.2.3. It is difficult to comment on the effectiveness and safety of these products because very little evidence to support these products is found in the literature.

Injection technique Before using injectable fillers, anesthesia of the areas to be treated should be considered. Nerve blocks, such as mental,

60

SECTION II

CHAPTER 8.2  • Injectables and resurfacing techniques: Soft-tissue fillers

infraorbital, and supraorbital/supratrochlear, work well and provide analgesia to large areas of the face. Direct infiltration of the area with lidocaine is another option, but this could lead to distortion of the anatomic structure to be corrected, and thus potentially to over- or undercorrection. The inclusion of epinephrine in the infiltration can potentially decrease bruising.65 Currently almost all fillers contain lidocaine so it is important to ensure that patients do not have a lidocaine allergy prior to use. Additional lidocaine with epinephrine can be admixed with fillers as a way to dilute them, but keep in mind that epinephrine can blanch areas of injection which can mask vascular compromise. The needle used for injection largely depends on the viscosity of the product injected. Less viscous HA products are injected with 30–31 G needles. More viscous HA products can be slowly injected through either a small needle such as a 30 G or a larger 28 G needle with more ease. Radiesse usually requires a 28 G needle, as does Voluma, while Sculptra and Bellafill, which are among the most viscous products injected, require at least a 26 G needle. Injection is usually in an anterograde or retrograde fashion, as the needle is advanced or withdrawn, respectively. Anterograde technique can be helpful in areas where soft fluid filler product ballottes the subcutaneous tissues away to decrease the risk of vascular injection.

The injection technique can vary from simple linear threading and the deposition of a small aliquot to more complex methods such as serial linear threading, radial fanning, cross-hatching, and serial puncture deposition.66 These techniques are used in combination depending on the location to be treated. The linear threading or tunneling technique involves injection either intradermally or into the subcutaneous level (Fig. 8.2.2A). Once the needle is inserted, the product is injected in a retrograde or anterograde fashion. Linear threading is most commonly used to correct wrinkles and furrows. However, when deeper creases are treated, multiple parallel linear threads at different levels have to be used to accomplish the desired volumetric augmentation (Fig. 8.2.2C). Examples of where this technique is commonly used include the glabellar lines, the nasolabial folds, the lips, and the tear trough, among others. Radial fanning is a variation of the linear threading technique (Fig. 8.2.3A). Just before the needle is completely withdrawn from the skin, it is reinserted in a different direction and the product is again injected in a retrograde fashion. This process is repeated multiple times in different directions until adequate correction is accomplished. This approach is particularly useful in malar augmentation, but it is also used

Epidermis

Dermis

Epidermis

Dermis

Subcutaneous tissue A

Subcutaneous tissue Epidermis Muscle Periosteum

Dermis B

C

Subcutaneous tissue

Figure 8.2.2 The (A) linear threading or tunneling, (B) droplet or depot, and (C) parallel linear threading techniques for dermal filler injection.  

Bone

Indications and applications

61

B

A

Figure 8.2.3  (A) Radial fanning and (B) cross-hatching techniques of dermal filler injection.

in the correction of the prejowl sulcus and the nasolabial fold. Cross-hatching is often used in the correction of large surface areas such as the marionette lines/prejowl sulcus or the hollowing of the lower cheek (Fig. 8.2.3B). Two independent radial fanning injections oriented perpendicular to each other constitute also a form of cross-hatching and are commonly used in cheek augmentation. Frequently the needle is inserted deep into the tissue and an aliquot of product is laid down; this is known as the depot or droplet technique (Fig. 8.2.2B). Large volumes deposited in this fashion can lead to palpable nodules and irregularities. Usually small droplets are deposited in a serial fashion; this is known as the serial puncture technique. These aliquots have to be close together to prevent irregularities. If any irregularities appear they can be managed by massaging. This technique is frequently used for tear trough correction and in lip augmentation, but also in the treatment of all other wrinkles and creases. Experienced injectors often use combinations of all of these techniques. Some practitioners recommend the use of blunt-tipped microcannulas. Many authors describe their experience of decreased bruising, especially when using a fanning injection technique.67–69 Microcannulas have gained tremendous popularity in recent years due to a perceived decrease in risk of vascular occlusion. This author cautions against relying on the blunt tip as cannula gauges even at 25 G can pop an inflated balloon.

Knowledge of anatomy is central to injecting anything in the face, whether with a needle or a cannula. It is not clear if cannula use more precisely deposits product and prevents its migration compared to a needle. Use of the instrument to place fillers is ultimately a personal preference of the injector though cannulas are becoming more common as one needs only to introduce the cannula through a single puncture hole to be able to reach several areas for filler.

Indications and applications There are multiple indications for the use of dermal fillers. Below is a list of the most common areas of the aging face usually addressed with injectables. The appropriate types of fillers for each area, as well as some technical nuances for their optimal application, are also described.

Glabellar lines Commonly, the glabellar furrow is successfully treated with neuromodulators. However, for toxin-naïve patients in their sixth decade or in patients with heavy solar damage, these lines are static – typically requiring a combination approach with lasers or with fillers. In addition to static lines, it is important to take note of brow descent that can be seen with the aging process but also with consistent neuromodulator treatment of the frontalis. The “chronic toxin” look appears as

62

SECTION II

CHAPTER 8.2  • Injectables and resurfacing techniques: Soft-tissue fillers

a flat forehead expression with descent of the brows over time. Thus, the glabellar lines should always be evaluated in combination with assessment of periocular bone and fat loss. This is where filler not only in the glabellar area is important but also the adjacent forehead. Key to the placement of fillers in the glabella is an understanding of the inherent risk. Informed consent for the use of fillers in this area should include the risk of arterial occlusion and its consequences, including blindness and a discussion of the potential for both superficial and deep vascular occlusion. Hyaluronidase should always be on hand in any practice injecting fillers but especially so in this area and a plan should be known to staff in case an event occurs. Prior to injection, photographs are necessary, as is marking of the supratrochlear and supraorbital arteries. Position the patient with their head at a 45° angle for optimal approach. Use of a needle in this area is preferrable to a cannula, as placement is superficial and filler choice should likewise reflect the depth of placement. The exception to this is if the glabellar area is to be volumetrically reflated with dilute low-molecular-weight hyaluronic acid, as detailed by Carruthers and Carruthers.8 This technique employs a depot of filler in the subgaleal vascular safe zone and then massage over the subgaleal glide plane. With the needle in the bevel-up position, the deeper etched component of the glabellar furrow can be treated with hyaluronic acid placed at the dermal–epidermal junction using a serial linear threading fashion in an retrograde motion. Often

filler will appear to extrude from a pore which is normal and if the appropriate filler is chosen, will not create a Tyndall effect. It is not advisable to use a fanning injection technique in this area. Depending on the product used, serial droplets can also be employed. This author prefers Belotero Balance or Redensity for this area in particular. It is important to let patients know that the lidocaine present in the filler may cause transient brow drop for up to an hour after the procedure. When combined with neuromodulators, the effect can last more than 6 months. With a combination technique of filler and toxin, patients will notice an improved more open palpebral aperture and a more relaxed appearance of the glabellar area. A follow-up is always offered at 1 month as some patients may require additional filler for ideal correction. In this author’s practice toxin and filler are not placed in this area on the same day and toxin is used first followed by filler 2 weeks later if indicated.

Forehead lines Changes of the forehead skin texture are usually sun-related whereas age-related changes cause volume loss, descent of the brow and muscular atrophy. Together these can give the near permanent appearance of horizontal forehead lines. While direct injection into the lines delivers a satisfactory result, on occasion a bolus of filler is needed in the forehead concavity to give support. Similar to unintended consequences of chronic

Epidermis

Epidermis

Dermis

Dermis

B

Subcutaneous tissue

Subcutaneous tissue Epidermis

Muscle Dermis

Periosteum A

Bone

C

Subcutaneous tissue

Figure 8.2.4 Injection of dermal filler into the deep tissue/periosteal level (A), more superficial into the subcutaneous tissue (B), and into the most superficial epidermal– dermal junction (C).  

Indications and applications

toxin in the glabella, chronic toxin in the forehead, especially in mature women beyond the sixth decade, can give a plasticized appearance to the forehead skin, which may make the skin appear thin. This requires forehead recontouring rather than injection into superficial lines themselves. For full reflation, PLLA or CaHa is preferred with placement by a cannula in the suprabrow concavity. As with glabellar lines, a combination of neuromodulator (done first) and filler can be ideal. The injection technique in this area is similar to that used for the glabellar lines. If the patient has a very dynamic forehead, then neuromodulators will be very helpful in achieving a better result and increase longevity of the filler. More commonly, low-viscosity fillers are used, and these are placed at the dermal–epidermal junction using a serial droplet or linear threading technique (Fig. 8.2.4C). Reflation should begin at the central forehead and progress laterally. In general, injections into forehead creases are placed superficially and because of this, are painful. Topical numbing preparations cause hyperemia and given the vascularity of the forehead, often create significant bruising. For patients on blood thinners this bruising can leave some hemosiderin deposition on the forehead. To avoid this, numb the forehead in sections using ice packs. Because several injection points are used, needles should be changed every 6 to 7 injections. Fanning technique is discouraged. Caution should be used above the brow area as a heavy hand with fillers can lead to some brow descent. Edema is common for up to 48 hours and patients are encouraged to sleep with their head elevated and to avoid exercise for 48 hours. Bruising can be delayed when injecting in this area but given the vascularity of the forehead, patients are encouraged to call with any bruises that seem out of the ordinary following treatment.

Eyebrows With age, the brow position drops more laterally than medially leading to a flat appearance and loss of projection. It is important to assess the eyebrows according to their three-dimensional shape rather than the shape imparted by the eyebrow hair. The most important part of treating eyebrows with fillers is to remember that not all brows look better with filler. Patients will often inquire about ways to lift the brows non-surgically and while it is possible to gain a 1–2 mm elevation with fillers in this area, it is far from a work around for surgery. Those with brows that have even descent or brows in which the medial supraorbital crease peaks medially are ideal candidates for brow filler. For some patients, the look of “nursing home eyes” has occurred not due to age but rather as a result of aggressive removal of upper eyelid fat resulting in a skeletonized orbital rim. For these patients, filler in the temple for correction is needed, in addition to the brow. This author prefers hyaluronic acid fillers for the eyebrows as HAs provide better structural support and projection. The goal of eyebrow filler is to achieve a larger look in the vertical dimension to the upper lid. However, it is important to define where in the eyebrow area filler is being placed. The smooth contour over the superior orbital room is created by the ROOF (retro-orbicularis oculus fat) pad. Filler above the lateral eyebrow line will worsen the appearance of an orbital hollow. Ideally, filler is placed at the line of the brow at the lateral tail. This also gives the illusion of raising the eyebrows

63

while restoring a more youthful appearance to the upper lid and eyebrow region. Injection in this area must be slow and a bolus technique is not advised. Sandwich the brow between the thumb and first finger and using a 30 G ½-inch needle, begin laterally and plan three longitudinal fills across the brow in a linear fashion moving the needle slowly but constantly with low-pressure flow. Care must be taken to inject small volumes with each pass to prevent emboli and injury to the sensory nerves. The filler is placed at a level that is not mobile. Caution is necessary in the eyebrow region as the supraorbital and supratrochlear nerves/vessels emerge here. It is important to keep the needle in the area where the brow is sandwiched between the fingers. Point the needle tip superior to avoid any tracking to an area like the globe which is adjacent to the orbital rim. For this reason, a canula is not recommended by this author as they are long and can easily track subcutaneously and inadvertently end up in an unintended space. Rarely does one need more than 0.5 cc of filler in the brow itself. Bruising is possible though not common and neither is edema. The goal is not necessarily the appearance of a lid lift but a repositioning of tissue such that light reflection gives the illusion of a wider eye and more projected and contoured eyebrow. When placed in the right plane, filler in this area can last up to 2 years. If planning to use any energy-based devices to create lift, proceed with those first before placing fillers.

Tear troughs The tear trough, or the infraorbital hollow, is a common area for correction. It is important to assess patients properly as many who present with the complaint of looking tired and wanting undereye filler actually require a lower lid blepharoplasty for a prominent and herniated infraorbital fat pad. The tear trough is one component of the infraorbital hollow with the nasojugal fold and the palpebromalar groove comprising the other components. Patients with thick smooth skin,

A

B

Figure 8.2.5  Tear troughs. (A) This 48-year-old woman presented with significant tear troughs that made her appear tired. Perlane was placed at the depth of the periorbital hollow on the bone and on the malar bone to augment cheek projection and minimize the negative vector. A total volume of 1.1 cc was placed per side; it was placed mainly in the periorbital hollow, but a smaller amount was placed on the malar bone to increase cheek projection relative to the globe. (B) The patient is seen 6 months after treatment.

64

SECTION II

CHAPTER 8.2  • Injectables and resurfacing techniques: Soft-tissue fillers

minimal laxity and moderate tear troughs are the ideal candidates for HA fillers in this area. It is important not to be singularly focused when volumizing this area as there is significant interplay with the medial cheek. Often reflation of the midface medially is required in addition to correction of the trough. Patients should be photographed with standardized lighting which can highlight the tear trough deformity and lower lid fat prolapse. Like the glabella, injection of the infraorbital hollow is a high-risk injection and informed consent discussions should detail this. Pre-injection icing is key and likely to reduce bruising compared to topical analgesia. Patients are injected in the upright position and planning should include marking the areas of injection while the patient is looking upward. One approach to filling this area is to place hyaluronic acid filler product deep on the bone and periosteum (Fig. 8.2.5). This ensures that the product is not palpable or visible, especially with animation. Various fillers have been used for this purpose, but the most commonly applied are Restylane, Juvéderm, or Belotero. Other long-term fillers such as Radiesse, Sculptra, and Bellafill can have a devastating outcome in the case of visible nodular/granulomatous formation, and should be avoided for this use.53,70–72 Another technique involves using a cannula at one insertion point lateral to the lateral canthus and using a serial linear threading technique to rejuvenate not only the trough but also the lateral orbital rim. Discontinuous aliquots of 0.1 mL are deposited along the length of the infraorbital hollow. This author uses a ½-inch 30 G needle with an insertion point at the upper medial cheek. The needle is pointed toward the medial canthus and using a slow flow injection technique, filler is placed in the SOOF. A bolus of no more than 0.1 cc is placed and milked upwards toward the trough and medially. Similar boluses are placed inferior to the orbital rim and massaged into place. With this technique rarely is more than 0.5 cc of filler needed per side. When compared to a cannula, a needle produces the same results. It is important to note that while many believe a cannula can prevent vascular injection, in this area the prominent infratrochlear vessels adjacent to the nasal bone and the infraorbital nerve in the midpupillary line make this area one that is high risk regardless of tool used. Usually 0.5 cc of filler is used per side, depending on the severity of the tear trough and the desired projection of the malar prominence. Regardless of technique used, the product can be massaged to smoothen its distribution over the bone and the hollow. If swelling and bruising are noticed immediately after filler injection, pressure and cold compresses should be applied. In the case of overcorrection, the product can be massaged down for up to 2–3 weeks. If the overcorrection persists, the HA filler can be partially dissolved with hyaluronidase. If placed in the SOOF (suborbicularis oculi fat), filler does not need to be repeated more than once a year. Indeed patients who return for repeat infraorbital hollow correction at the 6 or 8 month mark usually need to have product dissolved by year 4 or 5 as persistent edema begins to predominate as the filler ages. Post-procedure edema is common and can last up to 3 weeks. Keep in mind that the tear trough is very unforgiving and the Tyndall effect can happen easily, as can bruising. The most severe complications in this area include retrograde embolus into the periorbital vasculature as the filler inadvertently slips behind the orbital septum. Less is more in the tear trough and persistent edema laterally is a sign that too much

Table 8.2.4  The Lemperle nasolabial fold classification

Class

Description

0

No wrinkles

1

Just-perceptible wrinkles

2

Shallow wrinkles

3

Moderately deep wrinkles

4

Deep wrinkles, well-defined edges

5

Very deep wrinkles, redundant folds

filler has been placed and needs to be dissolved. For the tear trough, meticulous injection technique and planning are key to avoiding creation of a “sausage roll” underneath the eye at the conclusion of correction which is why it is also always important to check filler placement with the patient animating at the end of the treatment.

Nasolabial folds The nasolabial folds may be of different shapes, lengths, and depths. In addition, some patients have pre-existing telangiectasia in this area that can be made worse with injections. The gradation system, as described by Dr. Lemperle (Table 8.2.4), is useful in evaluating and discussing goals of correction with patients. For the nasolabial folds in general, it is paramount to assess whether the fold is being contributed to by midface descent. If it is, than filler directly into the folds is a mistake without concomitant correction of the cheek area. The amount of change in the average case should be approximately 50% correction of the depth of the fold (Fig. 8.2.6). Care must be taken not to overfill the fold because this will give patients an odd appearance when they animate or smile. Fillers can be used to soften the broader portion of the fold, which is usually the upper two-thirds down to the lateral oral commissure. Choices here include all types of fillers.39 Keep in mind that anatomy of the vasculature here can vary so it is important to know the depth of placement of product. Most HA fillers can be placed at the level of the mid to deep dermis. With semipermanent or permanent fillers (Radiesse, Sculptra, Bellafill), the product should be placed in the deep subcutaneous tissue (see Fig. 8.2.4C).43,70,73,74 The filler is placed at angles to the fold in order to decrease the risk of intra-arterial facial artery injection. Layering may be performed to enhance longevity (see Fig. 8.2.5B). Also, for very deep folds, more viscous products (Voluma, Vollure, Restylane Lyft, Juvéderm Ultra Plus, RHA 4, Defyne) or permanent/semipermanent products (Radiesse, Sculptra, Bellafill) may be placed deep under less viscous fillers such as Restylane and Juvéderm. This may increase longevity of the correction and give a more polished appearance. If the nasolabial fold has a superficial line etched into it, this can be softened with Restylane Silk or Belotero or RHA 2. As with all repeated injections of HA, the product lasts longer and less volume of product is needed to achieve the same volume and contour change. Taping of the fold after the injection for a few days may help the product bind into place with scar tissue and can prevent the lateral displacement of the product to the nasolabial fold when the patient smiles.

Indications and applications

A

65

B

Figure 8.2.6  Nasolabial folds and marionette lines. (A) This 64-year-old woman presented with perioral lines and significant jowls. However, she was not interested in surgical rejuvenation and wanted just to soften the appearance of her perioral wrinkles and folds. Approximately 0.4 cc of Restylane was used for each nasolabial fold and 0.3 cc to address the marionette lines on each side. (B) The patient is shown 1 month post treatment.

Typically the technique of injecting directly into the nasolabial folds has been retired in favor of harmonious volumization of the midface and lower face together. At the lateral oral commissure, nasolabial folds can be mimicked by natural dimples. It is important not to chase this line and to assess where it is being created from as filler into a perceived fold that dimples with smiling will look fine at rest and unusual in animation if corrected. While the presence of laugh lines are a common patient complaint it is critical to assess the entire midface when attempting correction of this area.

Malar augmentation Malar augmentation can be achieved with most fillers available.75 In the case of semipermanent and permanent fillers, care must be taken for the product to be injected deep in the tissue (see Fig. 8.2.4A). With HA fillers, the product can be applied from the deepest layers to the most superficial (see Fig. 8.2.4A–C). Medium-viscosity (MV) HAs such as Juvéderm and Restylane can be used in this manner applying the product over bone, into deep tissue, and in the dermis. Alternatively, more durable fillers such as high-viscosity (HV) HAs, Radiesse, Sculptra, or Bellafill, can be used deep, with MVHAs placed more superficial to obtain further refinement if necessary. This approach leads to a more durable result. The most appropriate technique for malar augmentation is the radial fanning technique, with entry points first lateral and then inferior to the malar prominence (see Fig. 8.2.5A). Nevertheless, any other technique can probably yield adequate results. Pressure over the augmented area should be avoided over the first week post-treatment. When used appropriately, dermal fillers can replace the use of an implant for malar augmentation. The goal in this area is to reposition light reflection rather than to create the same apple cheek for each patient.

Marionette lines Marionette lines extend from the oral commissure in a downward oblique fashion, giving a sad appearance. Usually there is a volume deficit medially extending to the level of

the jawline, creating what is known as the prejowl sulcus. Therefore, correction of the marionette lines is often combined with correction of the prejowl sulcus. Most fillers available today can be used for correction of the marionette lines. The principles mentioned earlier for other sites apply here too. More permanent viscous fillers are used for deeper correction, with less viscous, finer products for more superficial correction.76 The area to be filled is actually triangular, extending from the marionette line to the lower lateral lip vermilion to the superolateral aspect of the chin (Fig. 8.2.7). Usually a radial fanning technique from two independent injection sites, superior and inferior, can lead to a smooth correction of the area. A layering technique with more viscous hyaluronic acids like RHA 4 leads to excellent results though it is important to massage these aliquots carefully so the patient does not feel as though they have nodules. Because of the location, some filler technology can produce nodules if exposed to transient bacteremia as is the case after dental procedures. For this reason it is important to take a careful history and to tell patients to avoid the dentist for at least 1 month post filler. In this dynamic area, partial to complete correction is possible, but overcorrection can lead to lumps that are visible or felt intraorally under the oral mucosa, as well as a strange appearance upon animation. Semipermanent filler like Radiesse into the prejowl sulcus can achieve excellent results especially when molded over the jawline. This definition can set not only the melolabial lines but also the lips and chin. Bruising is very common in this area. Almost all HA fillers are acceptable to use in this area but depending on the amount of correction needed, the choice should be made based on the product’s ability for anterior projection as the marionette lines often appear as topographic depressions of the lower face.

Jawline augmentation In the areas along the jawline (filling the hollow anterior to the jowl), filler is best placed on the very deep plane on the bone or subcutaneously to allow augmentation of the soft tissues similar to a solid implant (see Fig. 8.2.4A). HVHAs or MVHAs

66

SECTION II

CHAPTER 8.2  • Injectables and resurfacing techniques: Soft-tissue fillers

2nd needle insertion point

2nd

1st 1st needle insertion point

B

A

1st (0.5” needle)

1st (0.25” needle)

2nd 2nd

3rd

C

Figure 8.2.7  Technique used (A) for malar augmentation, (B) for marionette lines, and (C) for nasolabial folds.

A

B

Figure 8.2.8 Sculptra. (A) Preoperative and (B) 1-year postoperative results after augmentation to the brow, cheeks, and jawline with three sessions of Sculptra (two vials per session) in a 51-year-old female. The dilution of each vial of Sculptra consisted of 7 mL of sterile water and 3 mL of 1% lidocaine with epinephrine.  

Indications and applications

A

Figure 8.2.9  Fat grafts. (A) Preoperative and (B) 1-year postoperative results after micro fat grafting to the temples, cheeks, and jawline, and bilateral upper blepharoplasty in a 50-year-old male.

B

may be used but, of note, only Juvéderm Volux XC has specific FDA clearance for filler in this area (August, 2022). Jawline augmentation is usually combined with marionette/prejowl sulcus correction. HA is placed in the deepest point of the hollow. This will correct most of the deformity. Placement of the material in the deep dermis may be required for complete correction of the jowl deformity. Using the thumb, massaging and molding the filler into place so that it appears congruous with the bony jawline is important.

Panfacial volumetric augmentation With aging, the ovoid soft shape of youth gives way to sharper angles, hollows, and creases. It is not enough to augment one area of the face but rather a need develops to improve overall facial volume in order to achieve harmonious balance of the upper and lower face. Correction of the temporal hollowing, lifting of the brow, filling of the periorbital hollowing, and malar, jawline, and perioral enhancement, can result in a markedly rejuvenated appearance (Figs. 8.2.8 & 8.2.9). This non-surgical facelift can be achieved with HA, Sculptra, or Radiesse injected in the deep tissues, in combination with superficial HA injections to obtain more refinement. Because both Radiesse and Sculptra show a delay in the appearance of the final result and because multiple injections may be required, more viscous HA fillers in the deep tissues may be used instead for an immediate effect and more predictable results. The advantage of using Radiesse and Sculptra is that they last for 1 and 2–3 years, respectively. Alternatively, fat can be used for panfacial volumetric augmentation, with “finer” fillers used to obtain a more superficial correction.

Facial lipoatrophy HVHAs or MVHAs are ideal fillers to soften the appearance of lipoatrophy associated with antiretroviral therapy for HIV. Other options include Sculptra, Radiesse, Bellafill, and fat.77,78

67

The areas that are best treated are the concavities adjacent to the zygomatic–temporal bone and the zygomatic arch (less so the inframalar hollow). In the temple and adjacent to the arch, it is important to place the filler deep within or under the periosteum and take care to inject slowly to be sure of even placement and to minimize bruising. The product is easily massaged, but if the massage is too aggressive the entire effect will be minimized. The idea is not to fill the entire area of atrophy completely but to soften the contours so that the wasting does not appear too severe. In the inframalar hollow, the goal should be to correct one-third to one-half of the hollow. Linear threading or a fanning technique may be used, and a gradual and consistent result can be achieved. Volumes of 0.5–1.5 cc per area may be used, on average. This will vary among individuals, depending on their requested goals. Repeated injections on a 2–4-week basis may help to contour areas that have a large volume deficiency.

Lips Contouring of the lips may be accomplished with several kinds of fillers (Fig. 8.2.10A,B).79,80 When approaching the lips it is important to distinguish lip volume from lip structure but in both scenarios one must keep in mind ethnic variation of lip size and width as well as aesthetic preferences. Hyaluronic acids are ideal for lip rejuvenation as they can be reversed and while it is common to use one filler for both the vermilion border and the body of the lip some practitioners will choose a more structural filler for the lip border and a softer product for the body (e.g., Restylane for the border and Juvéderm Ultra for the tubercles). Most patients have baseline asymmetry to their lips between the sides which should be marked and demonstrated to them prior to injection. If using an intraoral block for anesthesia of the lips it is important to work quickly as analgesia often causes a natural and temporary drop of the upper lip. While it is always encouraged that one use the syringe and needle the

68

SECTION II

CHAPTER 8.2  • Injectables and resurfacing techniques: Soft-tissue fillers

A

B

Figure 8.2.10  Lips. (A) This 51-year-old woman requested lip augmentation. Restylane was injected into the vermilion border and philtral columns to achieve a narrower appearance. Restylane was injected from the inside of the lip from the vermilion border to the wet–dry junction. (B) She is shown 3 months after injection with good persistence of filler.

filler is FDA approved with, back-filling tuberculin syringes allows for precise placement of filler in this delicate area. Prior to injection, the consultation should focus on whether the patient is seeking restoration of the lip or enhancement and it may be necessary to address the other components of the perioral area at the same time; namely the chin, upper lip lines and skin texture. If the patient has a very active depressor anguli oris muscle the corners of the mouth can become downturned so the addition of low-dose botulinum toxin may be necessary. While it is becoming increasingly popular to use low-dose botulinum toxin for perioral rhytids, this author finds the result in patients beyond the fourth decade to be underwhelming with a greater chance of interruption of phonation compared to enhancement of appearance. Begin injections at the oral commissure and crisp the vermilion lip at the white roll first. Previous teachings focused on retrograde injection but an anterograde pushing forward technique was demonstrated to cause less bruising and pain. A cannula can easily be used in the lip but caution should be exercised when monitoring filler volume as product flows quite readily through a cannula and the back and forth motion in the lip creates significant edema. The philtral columns may also be augmented with filler placed in the mid-dermal level but care must be taken not to lengthen the upper lip. Filler in the philtral column should also always be placed at an angle as the columns are less vertical and more like the Leaning Tower of Pisa. Deposit more filler in the lower two-thirds of the philtral column as to enhance and peak the Glogau–Klein points and create a more natural appearance of the upper lip, especially in mature patients whose philtral columns flatten. Palpation of the tissue as the filler is injected is important. Injection of the lip proper from the wet–dry junction to the vermilion border may also be carried out just deep to the mucosa within the orbicularis oris muscle. If it is placed immediately beneath the mucosa, it will be seen as a blue color. Placement posterior to the wet–dry junction along the wet mucosa may enhance the lip volume as well as the projection. Variation in the placement of the product must be done, depending on the desires of the patient and the starting shape of the lips.

The cupid’s bow becomes wider with age and should be made narrower. The depth of the mental fold increases with age and may require softening. Frequently the upper lip is atrophied above the vermilion border, particularly the lateral aspects, and restoration is done with MVHA placed at the mid-dermal level to improve volume and projection of the upper lip. One should use minimal volume in the upper lip above the vermilion border as any added volume may cause lengthening of the upper lip. Care must also be taken to limit the amount of filler placed in the upper lip skin adjacent to the nasolabial fold because this will result in an awkward animation of the upper lip and nasolabial fold, particularly during smiling, and can give the appearance of a “joker-type” upper lip or create an unusual fold at the lateral edge of the upper lip. Patients with long, thin lips and very broad smiles may get limited results because of tissue tension. Often patients complain that their lips are too thin when they smile. This is a dynamic change and cannot be corrected with fillers or implants. Patients with lips that are tight to the dentition or a class II occlusion should be augmented with conservative volumes, since irregularities of dentition may be reflected in the upper lip appearing too prominent or “duck-like”. Approximate volumes for augmentation of the lips may range from 0.5–1.0 mL per lip. MVHAs should last for a period of 4–6 months; however, when it is repeated, the results may last for 8–12 months. Care must be taken in persons with soft, supple lips that move a lot with animation; these patients may not respond well to HVHAs, and their lips may appear too stiff. When injecting HVHAs, one must avoid the formation of lumps or bumps as they are difficult to massage out of the tissue. If the patient has lip implants, then the filler may be added around the implant. HA fillers can also be combined with other tissue fillers. Less viscous HAs may first be injected along the vermilion border, which provides augmentation of the white roll. Lastly, patients with a history of herpes should be given prophylaxis because the treatment may cause a herpetic outbreak and scarring. Edema can last for up to 72 hours and

Indications and applications

patients should be advised to ice at 10 minute intervals per hour to minimize this. On occasion, touch ups may be needed at 2 weeks after the initial treatment and caution should be exercised to avoid overcorrection. Late-onset nodules have been reported, especially if dental procedures follow lip augmentation in the month prior or following filler placement. There is no evidence of keloid formation in patients of different ethnicities and for patients with autoimmune disorders like scleroderma fillers are not considered a contraindication and can actually diminish disease progression in the oral area.

Perioral and mandibular filling Retrusion of perioral bone and fat and age-related descent of the cutaneous envelope leads to jowl formation, etching, and folding of the marionette lines and a pebbled appearance of the chin. The enlargement of the piriform aperture from recession of the medial edge of the maxilla combined with bony mandible loss contributes to the shortening of the lower face in the older patient. It thus becomes important when addressing the lip that one also assess and augment the framing area around the lips. Fillers that are soft and malleable give the best functional result in the perioral area. Nonpermanent crosslinked fillers are ideal for lip lines while calcium hydroxylapatite works particularly well in the jawline. Lip lines are best injected directly using a superficial filler such as RHA 2 or Belotero. Use of a thin needle (31 G or 32 G) is ideal and massage is critical to avoid beads-on-a-string appearance in this area. Keep in mind that when perioral lines are augmented the vermilion border should be assessed so that the upper lip does not become too full or flattened as to then push down on the lip or create a simian appearance. The contour of the mandibular margin changes over time and prior to filling in this area it is important to understand the neurovascular landmarks at the antigonal notch. Palpate the anterior border of the masseter to understand where the facial artery is so as to avoid it during injection. A high G′ filler is ideal for this injection which is carried out by pinching

A

69

the skin upward and injecting in an anterograde fashion away from the periosteum. The lateral mandibular area is best injected with the physician standing on the side of the correction, however frequent assessment should be done with the patient looking straight ahead to attain symmetry.

Chin As the bony mandible loses definition, so too does the chin fat become atrophic. The pebbled appearance of the chin is easily corrected with low doses of botulinum toxin placed directly into the mentalis whether as a depot into the insertion of the mentalis at the menton or as two injections into the belly of the mentalis which bifurcates. In addition to or in lieu of toxin, filler produces a very nice enhancement for chin retrusion. A high G′ filler or CaHa are successful products to be used in this area. Injections should be placed deep and as a bolus in the center of the mentum between the arches of the mental arteries. Massage is carried about by rocking the chin in the cupped palm of the injector’s hand. Additional amounts of 0.2 to 0.4 mL of HA filler can be injected superior and lateral to the mentum in order to create a continuous arc with filler in the marionette lines.

Nasal reshaping (off-label) Many fillers have been used in the correction of minor nasal deformities (Fig. 8.2.11A,B).56,81 More commonly, HA fillers and calcium hydroxylapatite have been used for non-surgical rhinoplasty. Radiesse, even though it may provide more support than HA fillers, can also become visible if placed in large amounts or too superficially. In general, permanent fillers have a higher risk of becoming visible or palpable. If a permanent filler such as Bellafill is to be used, it is probably preferable to attempt correction with a resorbable filler first. Injection can be by either serial threading or tunneling techniques. The product should be placed in the subcutaneous layer, especially in patients with thin skin, to avoid visibility. Patients with a mild

B

Figure 8.2.11 Nose. (A) This 30-year-old woman had concerns about the irregular appearance of her nasal tip cartilage. Restylane was used to fill in the hollows and shape the tip of her nose. Restylane, 0.4 cc, was used to soften the appearance of the nasal cartilage. The patient had inquired initially about rhinoplasty with tip alteration. She had not had previous surgery, and the nasal tip had not changed other than the irregularity becoming more noticeable with time. The skin at the tip of the nose was very thin, and any slight surgical irregularity may have been noticeable; additionally, the skin may have been compromised by an open rhinoplasty. The new tip contour was achieved under a block with local anesthetic and 0.4 cc of Restylane. (B) She is seen here 5 months after injection.  

70

SECTION II

CHAPTER 8.2  • Injectables and resurfacing techniques: Soft-tissue fillers

hump, short nose, saddle nose and irregularity of the nasal dorsum at lateral view are all candidates for filler rhinoplasty. As with lips, ethnic considerations should be considered for nasal shape and a careful history of prior procedures in the area is necessary. Typical features of leptorrhine, platyrrhine, and meshorrhine can be changed with filler in the nasal tip and radix so it is important to review this with patients as it can significantly change their appearance post procedure. When using an HA filler in the nose, it is important to use one high in viscoelasticity and low in water-absorbing capacity. Cannula use is well tolerated in this region with an entry point at the pronasale. Regardless of tool used to deploy filler, it should be placed in the radix to the nasal tip to improve nasal length and height. On side angle always assess the radix to glabellar angle to make sure that curvilinear arch is preserved. The injector should be positioned in front of the patient during injection and pushing the cannula to the sellion begin injection in a retrograde fashion continuously to build a column in order to achieve the desired height of the nasal bridge. Pinch the skin of the nose while doing this to prevent filler from lateral spread. A double-layer approach is preferable to depositing excessive amounts of filler in the dorsum, which can create the appearance of a thick nose. Begin by first placing filler deep and follow it by superficial injection in the subdermal layer. Once the height of the nose is achieved, lateral sides of the nasal sidewall should be injected using a needle regardless of what was used to create the original column. Correction of the nasal tip is accomplished with filler placement in the interdomal area. Similarly columella retraction is corrected by placement of 0.2 mL of filler into the subcutaneous columella to improve its projection. While filler use cannot sharpen the angle of the nasal tip, creating a narrower nose can give the optical illusion of a sharpened tip. There are reports of alar skin and nasal tip necrosis with injection of fillers, especially post rhinoplasty. Care should be taken to inject small amounts (100°C) less than 1 ms) can induce cell death.1,4

Biostimulation Biostimulation (also called low-level laser therapy) belongs to the group of photochemical interactions. Most biostimulation studies involve low-power lasers, and this field continues to be a subject of controversy. Home-use devices that use LEDs are now available in a wide range of wavelengths. Typical fluences are in the range of 1–10 J/cm2, and normally there is no acute temperature elevation, or any clinical endpoint.1,4

Cooling Before the addition of surface cooling, fluence thresholds for efficacy and epidermal damage were often close. Visible light technologies, (especially green–yellow light sources such as

IPL (420–1400)

Absorption Coefficient (cm -1)

20,000

1470 nm

2940 nm

1987 nm

5,000 1,000

Oxyhemoglobin Deoxyhemoglobin Melanin Water

100 1 0.1 200

400

700

1,000

5,000

10,000

Wavelength Figure 8.4.2 Absorption curves for hemoglobin, melanin, and water. IPL, intense pulsed light. (Image courtesy of Sciton (Palo Alto, CA), based on absorption spectra data courtesy of Scott Prahl, PhD and Steven L. Jacques, PhD, Oregon Medical Laser Center (omlc.org/spectra).)  

Diagnosis and clinical evaluation

A

89

B

Figure 8.4.3  (A) Pre- and (B) post-KTP (potassium titanium oxide phosphate) laser treatment (8 J/cm2, 20 ms).

IPL, potassium titanium oxide phosphate (KTP) laser, and pulsed dye laser (PDL)) are the wavelength ranges where epidermal damage is most likely. The epidermis is an innocent bystander in cutaneous laser applications where the intended targets, such as hair follicles or blood vessels, are located in the dermis (Fig. 8.4.3).1,4 Beyond visible light sources, surface cooling also has been employed in near- and mid-infrared (NIR and MIR) lasers. With NIR lasers, surface cooling is important because of dermal/epidermal junction-derived epidermal heating. In addition, deep beam penetration may cause significant bulk heating to nearby tissues. With MIR lasers, the chromophore is water. Without surface cooling or a fractional design, water’s ubiquitous nature in the skin causes a laser-induced top-tobottom injury. All techniques are susceptible to operator error and device failure. As physicians rely more heavily on cooling devices, any lack of their proper deployment unveils the dark side of cooling. Fractured sapphire windows, disabled cryogen spray apparatus, and crimped forced air chiller tubes have all contributed to unintended epidermal injury.1,4

Ablative skin rejuvenation Fully ablative lasers include carbon dioxide (CO2) and erbium (Er:YAG), both of which target water as a chromophore. Similar to the concept of chemical peels or dermabrasion, these devices can be used for “full-field” ablation, meaning that 100% of the target area from the epidermis down is treated.

Non-ablative skin rejuvenation The original concept of non-ablative rejuvenation was wrinkle reduction by selective dermal heating.24,25 Deeply penetrating non-fractional mid-IR lasers coupled with surface cooling were designed to “bypass” the epidermis, creating a “slablike” dermal injury. Unfortunately, “CO2-like” results were never replicated because dermal heating was either too deep or too mild. Superficial severe dermal heating was almost

always associated with epidermal damage. It followed that all of these devices “bypassed” the solar elastosis ultimately responsible for most static wrinkles of the face.1,4 The “non-ablative” term has now evolved to include any light-based intervention with “relative” epidermal preservation.26 In addition to wrinkle reduction, new outcome measures include acne scar improvement, telangiectasia resolution, homogenization of pigment, pore size reduction, skin tightening (jowls, neck, and some extrafacial sites), and improved skin tone (Fig. 8.4.4).24–26

Fractional resurfacing Resurfacing with fractional photothermolysis represents a newer class of therapy (see Fig. 8.4.1). Fractional ablative resurfacing creates a column of ablated tissue, while nonablative fractional resurfacing creates a column of desiccated tissue. In a non-ablative fractional injury, the stratum corneum is left largely intact as thousands of microscopic wounds surrounded by viable tissue are made with a variety of laser wavelengths and delivery systems. In both ablative and non-ablative fractional treatments, the untreated tissue provides growth factors, cytokines, and fibroblasts to the treated areas, assisting in faster wound healing when compared to non-fractionated lasers. These islands of viable untreated epidermis and dermis also maintain the skin’s barrier function while speeding re-epithelialization (Fig. 8.4.5).1,27

Diagnosis and clinical evaluation Adequate evaluation and photographic documentation of the patient prior to laser treatment is essential.27–28 This assessment includes consideration of age, medical issues and medications, skin type, the severity of actinic damage, degree of redness, depth and number of rhytides, and the presence of scars. The patient with deep rhytides and excessive facial skin laxity is likely a better candidate for traditional rhytidectomy with or without resurfacing. The patient with moderate

SECTION II

90

CHAPTER 8.4  • Injectables and resurfacing techniques: Lasers in aesthetic surgery

A

B

Figure 8.4.4  Acne scar treatment with 1550-nm erbium:glass fractional laser: (A) before; and (B) 6 months after three treatments.

A

B

C

Figure 8.4.5  Fractional resurfacing (2940 nm):(A) immediately before laser treatment; (B) immediately after treatment; and (C) 3 months after laser treatment.

photodamage and medium rhytides may be a more optimal candidate for one of the many types of resurfacing procedures. Some patients may benefit from both procedures because rhytidectomy typically addresses skin quantity and soft-tissue malposition, whereas resurfacing addresses skin quality. It should be noted, however, that great care should be undertaken when both rhytidectomy and resurfacing are performed concurrently. If rhytidectomy is performed, it is recommended to avoid deep resurfacing of the undermined facial skin, as wound healing issues may ensue. An important tool of the evaluation of the patient for a resurfacing procedure is Fitzpatrick’s scale of sun-reactive skin types. This scale describes patients’ reactions to ultraviolet radiation and existing degree of pigmentation. Type I patients always burn and never tan. Type II patients tan only with difficulty and usually burn. Type III patients tan but sometimes burn. Type IV patients rarely burn and tan with ease.

Type V patients tan very easily and very rarely burn. Type VI patients tan very easily and never burn.29 Patients with lighter skin types can expect to undergo laser treatments with minimal concern for abnormal pigment changes, whereas individuals with darker skin are at higher risk for unwanted hyperpigmentation or hypopigmentation.29 An often-ignored rule is that patients tend to revert to their constitutive color after resurfacing (unless it is carried out very deeply). So, although there is a concern that constitutively dark patients might be at risk for temporary dyspigmentation, on a practical level it is the severely photodamaged type II and III patients that present the greatest challenges in moderate-depth resurfacing. This group of patients, once their superficial melanin is removed by the procedure, tend to remain “less tan” after the photodamage is reduced. This can result in conspicuous lines of demarcation between treated and untreated areas. Another helpful classification system is the Glogau30 photodamage

Patient selection and treatment

scale. Type 1 patients have little wrinkling, no keratoses, no scarring, and require no make-up. Type 2 patients have early wrinkling, early actinic changes, minimal scarring, and require a small amount of make-up. Type 3 patients have wrinkles present at rest, moderate actinic keratoses, moderate scarring, and always require make-up. Type 4 patients have severe wrinkling, actinic keratoses, and scarring that even large amounts of make-up does not cover. A thorough medical history and review of systems should be completed in concert with the physical examination, as part of a thorough patient workup. Pre-existing cardiac, hepatic, or renal disease may influence the treatment decision and choice of chemical peel or alternative resurfacing method. The use of exogenous estrogens, oral contraceptives, and other photosensitizing medications has been shown to predispose patients to unpredictable pigment changes.28 Therefore, such agents should be avoided several weeks before and after treatment. For any procedure that includes epidermal compromise, the physician should provide antiviral prophylaxis several days before and after the treatment for those patients with a history of herpes simplex infection. Prophylaxis will help minimize chances of unwanted viral reactivation as the re-epithelialization process occurs. It is also advisable to allow any existing viral-type lesion to heal completely before proceeding with a resurfacing procedure.28 Patient cooperation and compliance with the post-treatment regimen is required to ensure normal wound healing and to avoid complications.28 It is ill-advised to treat patients likely to be noncompliant or unable to avoid sun exposure because of occupation. Men may be less willing to use camouflage make-up in the event of pigmentary disturbances. Patients with a decreased number of epithelial appendages from prior radiation treatment or current isotretinoin (Accutane) use are also poor candidates because healing will proceed more slowly and scarring is more likely. One should wait at least 6 months after stopping isotretinoin to allow sufficient regeneration of epithelial appendages prior to deep full-field ablative resurfacing. For non-ablative treatments, the role of isotretinoin in wound healing is unclear. Most likely, healing will proceed unimpeded, and no special precautions are necessary. Still, treatments during an actual course of isotretinoin should only be undertaken if the benefits outweigh the potential risks.

Patient selection and treatment The optimal approach to the treatment of the aging face depends on selecting the appropriate treatment for the patient’s pathology.

Facial rejuvenation Careful patient selection and a clear understanding of potential complications are important to achieving consistent results. The most common indications for both full-field and fractional laser resurfacing are superficial dyschromias, textural anomalies, superficial-to-deep rhytids, acne scars, and surgical scars. There are several approaches that can be used to achieve a rejuvenated facial appearance, and we review each technology in terms of indications, applications, pre- and post-procedure preparation, and complications.

91

These options are “full-field” ablative laser resurfacing, fractional non-ablative laser resurfacing, fractional ablative resurfacing, IPL, and, finally, combination therapies. It should be emphasized again that the term “full field” refers to the delivery of laser energy across the entire surface of the skin within the treatment area, covering the “full field,” rather than a smaller, “fractional” treatment zone.

Full-field ablative lasers Full-field ablative resurfacing is reserved for patients with the deepest rhytids and is especially well suited to the treatment of deep rhytids in the cheeks and perioral areas. The distinction must be made between wrinkles resulting from skin excess, and deeper furrows within the skin itself. Visible lines caused by relative skin excess (and skin laxity) can only be effectively treated by excising the additional skin, such as during rhytidectomy. In contrast, “etched-in” lines, which arise within the skin itself (most commonly around the mouth and eyes), and mild laxity can be effectively treated with deep full-field ablative laser resurfacing. Options for full-field laser ablation include erbium (Er:YAG) with a wavelength of 2940 nm, and carbon dioxide (CO2) with a wavelength of 10,600 nm. Our preference is to use Er:YAG for full-field ablative resurfacing, as it has an absorption coefficient 10 times greater than the CO2 laser and thereby ablates tissue more efficiently with less residual thermal damage (5–10 μm) (Fig. 8.4.2). There is a linear relationship between fluence (energy density), and the amount of tissue ablated, with 3–4 μm of tissue removed per J/cm2. Multiple passes of Er:YAG can be used to produce deeper tissue removal without additive residual thermal injury. This results in recovery times following deep full-field Er:YAG laser resurfacing of only 7–10 days to full epithelialization, followed by 3–6 weeks of erythema. Superficial and deep resurfacing can be performed with these devices with increasing results and increasing recovery times with deeper treatments. Complications such as hypopigmentation occur less often than with CO2 laser full-field resurfacing. Variable-pulse Er:YAG systems allow for shorter ablative pulses followed by longer subablative pulses to create increasing thermal damage, with a coagulative effect. These devices are typically used to emulate CO2 laser-like results but without the long healing times and tendency for complications such as hypopigmentation.

Fractional ablative lasers The same ablative laser technologies utilized for full-field resurfacing, CO2, and erbium are also available in fractional ablative systems produced by various manufacturers. The fractional application of ablative wavelengths results in fully vaporized channels through the skin, creating holes of various depths depending on fluence (the amount of energy applied per unit surface area). The various devices available differ in terms of system power, spot size, speed, and the amount of peripheral thermal damage created deep to and around the ablated hole. The advantage of all fractional ablative lasers, in comparison to full-field ablation, is shorter healing times and fewer complications. Fractional ablative lasers are capable of delivering

SECTION II

92

CHAPTER 8.4  • Injectables and resurfacing techniques: Lasers in aesthetic surgery

more significant results than fractional non-ablative lasers, with particular efficacy in creating textural improvement, and mild-to-moderate skin tightening. In our practices, we use fractional ablative erbium primarily for treating postsurgical and acne scars. We find significant improvement in the appearance of scars after three to five treatments, spaced 4–6 weeks apart. Direct comparison between devices is difficult because of differences in power output, spot size, density, and degree of thermal damage; however, similar degrees of injury should produce similar clinical results (Figs. 8.4.6 & 8.4.7).

A

Fractional non-ablative lasers Fractional non-ablative lasers apply the same principle of treating a fraction of the total skin surface, only using non-ablative wavelengths. Instead of vaporizing tissues, these devices create columns of thermal damage, without eliminating the epidermal barrier. These thermal injuries can be thought of as similar to a coagulative effect, in which proteins are denatured but not completely vaporized. Healing of these wounds takes place from adjacent and deep structures and involves remodeling of the treated tissue

B

Figure 8.4.6  Treatment of perioral wrinkles with fractional CO2 laser: (A) before and (B) 6 months after a single treatment.

A

B

Figure 8.4.7 Fractional CO2 resurfacing done sequentially– SMAS facelift followed by fractional CO2 3 months later: (A) before and (B) 6 months after treatment.  

Patient selection and treatment

(rather than filling in a vaporized hole). For this reason, fractional non-ablative treatments have shorter recovery times than their ablative counterparts. By avoiding an open ablative wound, these treatments also have less risk of scarring and hypopigmentation. The indications for fractional non-ablative lasers depend to some extent on the wavelengths of each particular device; however, in general they are well suited for treating minor textural abnormalities, including fine lines and visible pores. There are several non-ablative fractional devices from various manufacturers with wavelengths of 1440 nm, 1470 nm, 1540 nm, and 1550 nm. As with fractional ablative devices, non-ablative fractional lasers differ in power output, spot size, density, and degree of thermal injury; this makes comparisons of clinical efficacy difficult between devices. The newest wavelength to be introduced into the fractional arena is thulium (1927 nm), with devices available by several manufacturers. This non-ablative fractional laser is especially effective at removing superficial pigment, due to its ability to target the dermal–epidermal junction where melanin is concentrated within pigmented lesions. Because the chromophore of thulium is water (and not pigment), there is less melanocyte excitation and therefore less risk of PIH. One final application of fractional laser technology is the hybrid fractional laser, with devices made by Sciton, Inc. (Palo Alto, CA) and Alma (Buffalo Grove, IL). The Alma device, called the Alma Hybrid, creates adjacent pulses of fractional ablative CO2 (10,600 nm) and fractional non-ablative 1570-nm injuries. The Sciton device, called Halo, delivers superficial fractional ablative erbium (2940 nm), followed by deeper fractional non-ablative pulses at 1470 nm, stacking both treatments within the same fractional treatment hole. This combination is quite effective at treating textural abnormalities, visible pores, and fine rhytids.31 It allows for a range of treatment depths and densities and can provide significant treatment effects with minimal healing times. This is the authors’ laser of choice for skin rejuvenation when recovery time is limited.

Intense pulsed light In contrast to the ablative and non-ablative laser technologies previously discussed, which generate a single wavelength of light, IPL devices utilize a high-intensity light

A

source to produce a range of noncoherent light wavelengths. Filters placed between the light source and the skin are configured to optimize heating of specific targets, by filtering out all wavelengths below a certain cutoff. Various devices utilize active cooling in their handpieces to prevent injury to the epidermis. Filters in the range of 515 nm are used to treat pigment with a target chromophore of melanin, and filters in the 560–590 nm are used to treat vascular lesions (such as telangiectasias and rosacea) with a target chromophore of hemoglobin. Given the wide range of wavelengths generated from an IPL device, there are many uses for IPL either alone (as a form of “photorejuvenation”) or in combination with other modalities. In our practices we frequently combine IPL with fractional laser treatments, to enhance clearance of pigment and redness. The newest IPL device on the market is the Sciton HERO (high-energy rapid output). This device combines a high repetition rate (up to 4 Hz) and low pulse width to allow for continuous handpiece movement. The technique of “in-motion” IPL avoids some of the common complications, such as “striping” and uneven energy delivery, providing for very effective treatments over large surface areas.

Combination treatments Although a discussion of non-laser technologies is outside the scope of this chapter, it is worth mentioning that lasers can be combined with non-light-based treatments to create a synergistic effect. Some examples of these treatments are high-intensity focused ultrasound (HIFU) and radiofrequency microneedling.

Improving vessels There are several lasers that can improve vascularity within the skin, either by targeting water or hemoglobin as chromophores. In our aesthetic practices, we employ several different modalities. The first option is hybrid fractional erbium, which if set to depths of 400 μm or more, can be used to obliterate superficial visible capillaries and reduce the appearance of redness. Care must be taken with these settings to avoid dyspigmentation in darker skin types (Fig. 8.4.8).

B

Figure 8.4.8 1550-nm fractional erbium:glass laser for perioral wrinkles: (A) before and (B) 6 months after six treatments.  

93

94

SECTION II

CHAPTER 8.4  • Injectables and resurfacing techniques: Lasers in aesthetic surgery

The second device we use for treating vascularity is IPL. In contrast to hybrid fractional erbium, which targets the vessels by their depth relative to the skin surface, IPL works by targeting oxyhemoglobin within vessels through selective photothermolysis. This device works well for treating a background of red skin but may also be used to treat discrete smaller vessels (0.1–0.5 mm). For patients with fair skin types, we use the 560-nm filter, and in darker patients we use the 590-nm filter to decrease “bystander absorption” by melanin (which could result in dyspigmentation). Another option for treating vascular lesions is the flashlamp-pumped PDL. Working on the principle of selective photothermolysis, PDL creates selective damage to vessels by emitting wavelengths of 585 nm, 595 nm, or 600 nm, targeting oxyhemoglobin. The fluence and spot size of PDL can be varied, and lower fluences can be used to treat macular disorders in children and higher fluences are used to treat adult portwine stains, telangiectasias, and other vascular lesions. The disadvantage of PDL is post-treatment purpura, which lasts 1–2 weeks following treatment. As with IPL, PIH may occur in darker skin type patients, because melanin competes with hemoglobin for laser light absorption. For treating telangiectasias, cherry angiomas, larger vessels (0.1 mm and beyond), and in patients with darker skin types, we prefer the Nd:YAG laser (1064 nm). This wavelength is not as readily absorbed by hemoglobin as the previously discussed wavelengths; however, there is almost no melanin absorption at this wavelength. It is also capable of deeper penetration and therefore better absorption by deeper vessels. Care must be taken to apply the smallest fluence and smallest spot size to achieve vessel closure. Surface cooling is necessary to prevent epidermal blistering and it is important to ensure adequate coupling between the skin surface and any active cooling apparatus. The immediate endpoint in these treatments is either “vanishing” of the vessel, or “darkening,” which signifies coagulation. With this clinical response, vessels will disappear in 7–14 days, although repeat treatments may be necessary to eradicate any arborized tributaries that dilate in response. One final option is the Q-switched KTP laser, which uses a KTP crystal to double the frequency of a beam generated by an Nd:YAG laser, to produce a wavelength of 532 nm. This device is useful in the treatment of facial telangiectasias, with less purpura than Nd:YAG alone. It may also be used to treat leg veins with varying degrees of success. As with the other modalities, repeated treatments may be necessary.

Improving pigment Several devices are effective for treating cutaneous pigment, such as light or dark lentigines and early seborrheic keratoses. There is some overlap between the devices which are effective at treating pigment and those effective at treating vascularity, due to the shared mechanism of selective photothermolysis. The first device is hybrid fractional erbium. This device can be used to clear pigmented lesions by delivering fractional energy to the level of the skin that contains the lesion (the dermoepidermal junction or beyond). The denser the fractional energy delivered to a particular lesion, the greater the post-treatment clearance. The device is designed to calculate fluence (energy per surface area) through measurements

of aesthetic subunits, and it is possible to deliver increased treatment densities to specific lesions: either through multiple targeted passes during a treatment, or by performing a second pass over the areas of interest. As with vessels, IPL is also useful for treating pigment. Depending on the size of the lesions, it is often useful to “spot treat” lentigines with 1–3 IPL pulses, using a spot adapter. For fair skin types we use the 515-nm filter since there is little “bystander” cutaneous melanin chromophore. Darker skin types require increasing the filter, as well as potentially decreasing fluence and raising pulse width. For these patients, this may result in more sessions to achieve lesion clearance. For lentigines that are evolving into seborrheic keratoses, especially if they are exophytic, we use pulsed Er:YAG in small spot treatments. Repeated passes of this laser are performed under local anesthesia, and the resulting eschar is “wiped away” using a moistened gauze pad, until the lesion is gone. Occasionally pinpoint bleeding is observed, but this technique is associated with rapid healing. The newest device that we use for treating cutaneous pigment, including light lentigines and melasma, is fractional thulium (1927 nm). This device targets water as a chromophore, and due to its depth of penetration, it is capable of clearing pigment at (or slightly below) the dermoepidermal junction. This versatile laser can behave as a fractional non-ablative device, or by increasing its energy it can also approach the ablative threshold. Because it does not target melanin, the device has a low risk of causing PIH, even in patients with darker skin types. This is especially useful when treating patients in warm climates, where pigment often coincides with some degree of baseline sun damage and “sun tan.” With this device, we are able to demonstrate effective clearing of light and dark lentigines, as well as melasma, in 1–3 treatments spaced 1 month apart. Patients must be cautioned to avoid the sun, as repeated sun exposure will “bring back” the pigment they worked (and paid) to clear. We also recommend that our sun-exposed and darker skin type patients use medicalgrade skin care if they are prone to melasma, in order to maintain their results.

Contraindications Laser and chemical resurfacing have common contraindications. These include active bacterial, viral, fungal, or herpetic infection; open wounds; history of drugs with photosensitizing potential; pre-existing inflammatory dermatoses; uncooperative patients; patients with unrealistic expectations; and history of abnormal or keloid-type scarring.28

Post-procedure care Postoperative care after full-field laser resurfacing is aimed at providing an ideal environment for moist wound healing. Initially, bland ointment (white petrolatum, Aquaphor, or A&D ointment) is applied to the entire treated area. Patients are instructed to reapply the ointment throughout the day, any time the face feels tight or dry. As the outer layers begin to shed, the patient is allowed to shower and gently wash the face with non-residue soap using fingertips only. After

Disclosures

showering, the face should be patted dry, and a new coating of ointment applied. Patients are instructed not to pick at the face during the recovery period.28 Understanding the process of re-epithelialization and the importance of compliance with the prescribed post-treatment regimen is essential information for every patient. This includes awareness of likely facial edema that may contribute to symptoms such as diplopia. If antiviral therapy is instituted, continue therapy until re-epithelialization is complete. In the early stages of wound healing, re-examine the patient within 48 h and again every several days. Instruct patients to refrain from trans-retinoic acid, sunscreen, or make-up, until the face is healed to the satisfaction of the treating physician.28 After fractional lasers, mild moisturizing lotion is used for the first 3 days, then Cetaphil lotion for the duration of the healing process. Healing takes place over the first few days, with re-epithelialization nearly complete by 48 h post-treatment. Redness typically subsides over the next 3–4 days and gradually disappears over the next 3–4 weeks. Early results have been impressive.

Complications Pigmentary change Pigmentary change is not an uncommon complication, especially with deeper laser treatments. Taking proper precautions (as described earlier) can help prevent undesirable pigmentary changes. Usually, patients with lighter complexions have a lower risk of hyperpigmentation than darker-skinned individuals.

Scarring Scarring remains the most feared complication of facial resurfacing. The contributing factors are still not well understood but typically, outside of infection, the depth of the procedure is the primary risk factor in conventional resurfacing. In the case of fractional lasers, the depths and density of the micro injuries should be conservative enough to avoid bulk heating of the skin. By employing the most appropriate resurfacing procedure for any given patient, the risk of scarring can be decreased. In addition, to further decrease the risk of scarring, the patient should be advised to refrain from touching or picking at the healing skin. Patients with a history of keloids should be approached with caution prior to medium or deep treatments because of their risk of scarring. Weaker superficial treatments that only exfoliate the stratum corneum or superficial epidermis can be used for these high-risk patients.28

Access the reference list online at   Elsevier eBooks+

95

Infection Cold sores can be prevented with valganciclovir (1 g PO bid), beginning 1 day prior to treatment, and continuing for 7 days afterwards. Candidiasis can also develop, for which a short course of fluconazole may be used. Cultures may be taken if the diagnosis in in question, and appropriate antibiotics should be administered.28 More recently, atypical mycobacterial infections have been reported after ablative fractional procedures.32 The penetrating nature of fractional approaches may allow these opportunists to thrive. Measures to decrease the risk include thorough cleansing before treatment and avoidance of tap water at the wound site during and immediately after treatment. Physicians should note that the greatest association with infection is pain. If the skin is healing poorly and the patient reports marked pain, an infection is likely. The absence of pain does not remove the possibility of infection but markedly reduces its likelihood.

Prolonged erythema Patients usually do not complain about erythema because it typically subsides within a few weeks, but sometimes erythema can persist for longer than 30–90 days. Prolonged erythema is usually not permanent, and topical hydrocortisone can be used to speed its resolution.28

Acne Some patients develop acne after a facial resurfacing procedure. This usually occurs between days 3 and 9. If it is a true acne occurrence in a patient with a history of acne, then the appropriate oral or topical antibiotic may be started. If severe enough, isotretinoin may be initiated.

Milia Small inclusion cysts, sometimes called milia, can appear in the healing process after a treatment. These usually appear about 2–3 weeks after re-epithelialization and may be aggravated by ointments, owing to occlusion of the sebaceous glands.28

Disclosures Dr. Pozner and Dr. DiBernardo receive discounts from Cynosure, and Dr. DiBernardo is a paid researcher. Dr. Pozner is a paid consultant, speaker, researcher, stockholder, and board member for Scition. Dr. Cook and Dr. Turer do not have a financial interest in any of the products, devices, or drugs mentioned in this manuscript. No funding was received for this chapter.

References

References 1. Alexander JT, Goldman MP, Roberts TL. Facial resurfacing. 2nd edn. In: Mathes J, editor. Plastic Surgery. Vol. 2 Philadelphia: WB Saunders; 2006:339–384. 2. Smith L. Histopathologic characteristics and ultrastructure of aging skin. Cutis. 1989;43:414. 3. Brody HJ. Chemical Peeling and Resurfacing. 2nd edn. St. Louis: Mosby-Yearbooks; 1997:29–38. 4. Anderson RR, Parrish JA. Selective photothermolysis: precise microsurgery by selective absorption of pulsed radiation. Science. 1983;220:524–527. 5. Ross EV, Swann M, Soon S, et al. Full-face treatments with the 2790-nm erbium:YSGG laser system. J Drugs Dermatol. 2009;8:248–252. 6. Goldman L, Wilson RG, Hornby P, et al. Radiation from a Q-switched ruby laser. Effect of repeated impacts of power output of 10 megawatts on a tattoo of man. J Invest Dermatol. 1965;44:69–71. 7. Goldman L, Rockwell RJ. Laser action at the cellular level. JAMA. 1966;198:641–644. 8. Goldman L, Rockwell Jr RJ. Laser systems and their applications in medicine and biology. Adv Biomed Eng Med Phys. 1968;1:317–382. 9. Schenk P, Ehrenberger K. Effect of CO2 laser on skin lymphatics. An ultrastructural study. Langenbecks Arch Chir. 1980;350:145–150. 10. Baker SS, Muenzler WS, Small RG, et al. Carbon dioxide laser blepharoplasty. Ophthalmology. 1984;91:238–244. 11. Fitzpatrick RE, Goldman MP, Satur NM, et al. Pulsed carbon dioxide laser resurfacing of photo-aged facial skin. Arch Dermatol. 1996;132:395–402. This is a blinded assessment of CO2 laser efficacy

for periorbital and perioral rhytids. CO2 laser was found to be useful in this setting.

12. 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. 2004;34:426–438. A novel method for skin resurfacing is presented.

Microscopic treatment zones are targeted for thermal injury.

13. Geronemus RG. Fractional photothermolysis: current and future applications. Lasers Surg Med. 2006;38:169–176. 14. Mezzana P, Valeriani M. Rejuvenation of the aging face using fractional photothermolysis and intense pulsed light: a new technique. Acta Chir Plast. 2007;49:47–50. 15. Gillitzer R, Goebeler M. Chemokines in cutaneous wound healing. J Leukoc Biol. 2001;69:513–521. 16. Glat PM, Longaker MT. Wound healing. In: Aston SJ, Beasley RW, Thorne CH, eds. Grabb and Smith's Plastic Surgery. Philadelphia: Lippincott-Raven; 1997.

95.e1

17. Anderson RR. Dermatologic history of the ruby laser: the long story of short pulses. Arch Dermatol. 2003;139:70–74. 18. Welch AJ, van Gemert MJ. Overview of optical and thermal interaction and nomenclature. In: Welch AJ, van Gemert MJ, eds. Optical Thermal Response of Laser-Irradiated Tissue. New York: Plenum; 1995:1–14. 19. Anderson R, Ross E. Laser–tissue interactions. In: Fitzpatrick R, Goldman M, eds. Cosmetic Laser Surgery. St Louis: Mosby; 2000:1–30. 20. Anderson R. Laser–tissue interactions. In: Goldman M, Fitzparick R, eds. Cutaneous Laser Surgery – The Art and Science of Selective Photothermolysis. St Louis: Mosby; 1994:3–5. 21. Ross EV, Sajben FP, Hsia J, et al. Nonablative skin remodeling: selective dermal heating with a mid-infrared laser and contact cooling combination. Lasers Surg Med. 2000;26:186–195. 22. Ross E, Anderson R. Laser tissue interactions. In: Goldman M, ed. Cutaneous and Cosmetic Laser Surgery. Philadelphia: Elsevier; 2006. 23. DiBernardo BE, Reyes J, Chen B. Evaluation of tissue thermal effects from 1064/1320-nm laser-assisted lipolysis and its clinical implications. J Cosmet Laser Ther. 2009;11(2):62–69. https://doi. org/10.1080/14764170902792181. 24. Kelly KM, Nelson JS, Lask GP, et al. Cryogen spray cooling in combination with nonablative laser treatment of facial rhytides. Arch Dermatol. 1999;135:691–694. 25. Lask G, Lee PK, Seyfzadeh M, et al. Nonablative laser treatment of facial rhytides. In: Anderson RR, ed. Lasers in Surgery: Advanced Characterization, Therapeutics, and Systems VII. Vol. 2970. San Jose: Society of Photo-Instrumentation Engineers; 1997:338–349. 26. Sadick NS. Update on non-ablative light therapy for rejuvenation: a review. Lasers Surg Med. 2003;32:120–128. A review of non-ablative skin resurfacing modalities is presented. 27. Cohen SR, Henssler C, Johnston J. Fractional photothermolysis for skin rejuvenation. Plast Reconstr Surg. 2009;124:281–290. 28. Fabbrocini G. Chemical peels. 2015. Online. Available: http:// emedicine.medscape.com/article/1829120-overview. 29. Fitzpatrick RE, Goldman MP, Satur NM, et al. Pulsed carbon dioxide laser resurfacing of photo-aged facial skin. Arch Dermatol. 1996;132:395–402. 30. Glogau RG, Matarasso SL. Chemical peels. Trichloroacetic acid and phenol. Dermatol Clin. 1995;13:263–276. 31. Cohen JL, Ross EV. Combined fractional ablative and nonablative laser resurfacing treatment: a split-face comparative study. J Drugs Dermatol. 2013;12(2):175–178. 32. Palm MD, Butterwick KJ, Goldman MP. Mycobacterium chelonae infection after fractionated carbon dioxide facial resurfacing (presenting as an atypical acneiform eruption). Case report and literature review. Dermatol Surg. 2010;36:1473–1481.

 

SECTION II •  Aesthetic Surgery of the Face

8.5

Injectables and resurfacing techniques: Chemical peels Richard H. Bensimon and Peter P. Rullan

 

Access video lecture content for this chapter online at Elsevier eBooks+

The process of facial aging can be broken down into three major categories: (1) structural or gravitational changes; (2) correction of deflation or loss of volume; and (3) treatment of wrinkles, texture, and skin quality. The first two categories are very familiar to practitioners and the bulk of clinical and academic activities involve these areas. The treatment of well-established wrinkles and aging textural changes has received much less attention, and since surgeons seem less well equipped to deal with them, it is simply ignored. This is regrettable because even the best performed facelift with “old” skin will still look old. Moreover, we surgeons know that surgery has no effect on perioral rhytids and a facelift can make them more noticeable because of the contrast that is created. Also, aging changes of the skin itself can have greater importance to patients than jowls or loose skin. Why the reluctance to resurfacing? It is our contention that this is mainly due to lack of exposure and especially misconceptions about deep chemical peeling and misinformation that is still seen in professional publications. Our purpose in this chapter is to consider medium-depth trichloroacetic acid (TCA) peels and the deeper, more versatile, croton oil peels. Both authors are experienced deep peelers and PPR, a dermatologist, will share his knowledge with TCA peels. Of note, both authors are in agreement that croton oil peels offer the best solution for deeper, more established wrinkles. Regarding deep chemical peels, the topic will be distilled to its essence and give detailed practical instruction so that practitioners may consider this terrific technique and then be able to provide their patients with a more complete result. The role of facelifting is considered and, especially, the synergy of lipofilling and peeling is discussed as a particularly favorable combination.

Medium-depth trichloroacetic acid (TCA) peels TCA peels are the most commonly used medium-depth chemical peels, and are the most common for dermatology residents

to be trained in. Their popularity over the more effective croton oil is due to three factors. First, it has not been linked to cardiac toxicity and thus does not require cardiac monitoring. Second, it does not require mixing and can be bought in different strengths. Third, it is moderately effective for mild to moderate photoaging, acne scars, skin pre-cancers (actinic keratoses), and other skin conditions. Achieving a medium-depth injury must meet both clinical and histologic criteria, as described below. Some TCA peels are used to treat superficial skin conditions, usually applied as a single agent and in low concentration (%). For example, 10–15% TCA (one coat) is used to treat melasma and acne vulgaris. Many commercial peels with TCA (usually in combination with lactic acid, salicylic acid or even phenol), produced a superficial, or at most, a superficial to medium injury. We will not cover these peels here but focus instead on a true medium-depth TCA peel, where the injury reaches the upper reticular dermis (URD). Medium-depth TCA peels include the augmented 35% TCA peels, where Jessner’s solution (Dr. Gary Monheit1) or carbon dioxide “dry ice” (Dr. Harold Brody2) are used to increase the penetration and depth of TCA. Jessner’s solution (JS) contains 14% salicylic, 14% lactic acid, and 14% resorcinol. Two very similar peels, Obagi’s “Blue Peel” and Z.O.’s “Controlled Depth Peel” (CDP), were both developed by Dr. Zein Obagi.3 In these, a blue/green dye is used to help the peeler find the right depth of injury by using multiple applications of either 20% or 26% TCA, until a desired depth is found. These also contain a propriety emulsifying/surfactant agent to help penetration. Most dermatologists buy TCA from Delasco (Delasco.com, Plano, TX), which uses the weight/volume method to formulate their TCA peels. Brody2 compared the depth of injury from JS or carbon dioxide/dry ice plus 35% TCA (CO2/TCA 35%), using one to three coats, at different times post peels. Three days post peel with JS or CO2 followed by three applications of TCA, the epidermis has full-thickness necrosis, ghost cells with re-epithelization, and mixed dermal infiltrate of neutrophils and lymphocytes. The papillary dermal collagen fibers have been disrupted, and there is edema with increased ground substance extending to

Medium-depth trichloroacetic acid (TCA) peels

the upper reticular dermis. Thirty days post peel with a single application of TCA, there is a hyperplastic epidermis, mean of about 7 cells thick. A thickened papillary dermis is present, and there are increased collagen fibers in the upper reticular dermis. Thirty days post peel by triple application of TCA, there is a very hyperplastic epidermis (about 10 cells thick). A thickened papillary dermis, and many new collagen fibrils and increased ground substance are present in the upper reticular dermis. When compared to the histology of croton oil peels, the biggest difference is the latter’s significant thicker band of neocollagenesis. Recent studies by Dr. Carlos Wambier et al.4 showed the NETosis, or a strong neutrophilic response to phorbol esters, was responsible for this neocollagenesis, rather than simply depth of injury (mid-reticular dermis). The clinical endpoint of these peels varies. With the JS/TCA 35%, the endpoint is an even white frost with some erythema (2+ frost), and without erythema, in the background (3+ frost) (Figs. 8.5.1–8.5.3). With CO2/TCA 35% the endpoint is also an even frost, but it will be accompanied by more edema and erythema afterwards, revealing a deeper injury (Figs. 8.5.4–8.5.6). With the Obagi peels, the endpoint is an even blue edematous color and texture to the skin. The edema is such that when pinching the skin, there is no wrinkling or epidermal sliding. In all of these peels, the skin becomes edematous and red for the first 2 days. The skin dries out, with reddish tones, which then become dark brown. These sheets begin to exfoliate regionally, beginning around day 5 and around the mouth. Healing takes around 7–10 days, revealing a pink re-epithelialized fresh epidermis. Note improvement with CO2/TCA 35%, 30 days later (Fig. 8.5.7).

97

author 8likes to administer 1 mg of alprazolam and 10 mg of zolpidem pre peel as oral sedatives.

Jessner’s solution/TCA 35% Degrease the skin after washing it with a foaming cleanser, using isopropyl alcohol and acetone (pre-mixed or separately). Jessner’s is applied multiple times until a light frost is achieved, ensuring that the stratum corneal layer has been weakened. Using a non-woven 2 × 2 gauze, begin applying 35% TCA (in a metal cup), starting along the perimeter of the face like the mandibular skin and hairlines. This lets you assess the permeability and responsiveness of the skin. Then continue onto the midface, beginning in the periorbital skin and then the upper lip. Step back and let the frost develop (helps refrain from overapplying TCA). Observe. Repeat the TCA where the frost has not become confluent. Step back and observe. When satisfied,

Pre-peel skin preparation Use retinoid creams to increase cell turnover (which reduces the risk of post-inflammatory hyperpigmentation [PIH] and leads to faster healing), and to thin the stratum corneum (which enhances peel evenness and penetration). Prescribe antivirals (valacyclovir) for 10 days starting the day before peel; and instruct the home aide on the use of cold-water compresses and possible analgesics. Hydroquinone is useful in patients with risk of PIH. Stop the retinoids 4–7 days before the peel. Another tip is to remove crusts such as actinic keratoses or seborrheic keratoses before starting the peel. The

Figure 8.5.1 2+ frost from J+35% TCA, one coat. (Courtesy of Dr. Jennifer Rullan.)  

Figure 8.5.2  3+ frost from J+35% TCA, multiple coats. (Courtesy of Dr. Jennifer Rullan.)

Figure 8.5.3 2+ frost from J+35% TCA, two coats.  

98

SECTION II

CHAPTER 8.5  • Injectables and resurfacing techniques: Chemical peels

apply a very cold washcloth immersed in ice-water. Zimmer Cooler or personal electric fans help. Rarely are more than three layers of TCA needed. Beginner peelers can opt to achieve a less-dense white frost as their endpoint.

Dry ice/TCA 35%

Figure 8.5.4  Dry ice being rubbed prior to applying 35% TCA. (Courtesy of Dr. Jennifer Rullan.)

Figure 8.5.5  Dry ice + 35% TCA; note the edema, day 2. Treated actinic keratoses.

Figure 8.5.7 Thirty days after dry ice and 35% TCA. (Courtesy of Dr. Jennifer Rullan.)  

On the day of the peel, purchase an inexpensive block of dry ice (readily available in supermarkets, adjacent to the ice bags). With a small hammer, cut off a handful-size piece of ice and wrap it with a towel. Prepare a bowl with a 1 : 3 ratio of isopropyl alcohol and acetone (used to dip the dry ice right before every time it is rubbed onto the face). After thoroughly degreasing the skin, begin rubbing the dry ice in a quick rotating movement to cosmetic unit (about 10 strokes) followed by the TCA, using 2–3 strokes to achieve a frosting. Rub the dry ice lighter over bone and harder over acne scars. Use same pain control measures as for Jessner’s/ TCA above.

Figure 8.5.6  Day 3 after dry ice + 35% TCA.

Preoperative planning

Obagi Blue Peel/Z.O. CDP These peels must be purchased as kits. You will also need 30% TCA. Pump the Blue Dye 4 times into a cup, followed by either 4 mL or 30% TCA (generates a 20% peel), or 8 mL of 30% (to generate a 26% peel). Once you stir this mixture, begin the peel using the same technique as the Jessner’s/TCA technique. Achieving the “total blue face” endpoint takes longer than with Jessner’s. Beginner peelers can opt to achieve a lessdense blue frost as their endpoint. Patients find it amusing to see their face turn blue. Use the same pain control measures as for Jessner’s/TCA above. Ice-cold water compresses and over-the-counter (OTC) analgesics, like acetaminophen and ibuprofen, are usually adequate to control post-peel burning, which can last 4–8 hours. These are the most important skin care items needed initially. Once burning subsides, topical agents like Alastin Serum Nectar (Alastin Skincare, Inc., Carlsbad, CA) and Aquaphor (Beiersdorf, Inc., Stamford, CT) are the author’s (PPR) favorite agents. Aquaphor is used once the peeling begins. Alastin is used initially and after the peeling occurs, to help reduce the redness faster. Patients can resume the use of retinoids, hydroquinone, and other agents once the skin is not sensitive (around 2–3 weeks after the peel). Sunscreens with zinc oxide and iron oxide can be used as tolerated, usually 2 weeks post peel. Patients should avoid sweating and possible sunbathing for 3–4 weeks.

Deep chemical peels The history of deep chemical peels is a fascinating one, mainly involving lay peelers using “secret” formulas and shrouded in mystery.5 The first instance of a practical formula came from Thomas Baker, a plastic surgeon from Miami in 1961. This formula, presumably obtained from a lay peeler, was simple and could be easily reproduced. It included four ingredients: liquid phenol, three drops of croton oil, water, and a surgical soap Septisol to act as a surfactant to allow miscibility of the aqueous and oily components.6 The presumption was that the phenol was the peeling agent and it was unclear what the croton oil did. In 1962, Dr. Baker halved the volume of the formula, presumably for convenience, while keeping the three drops of the croton oil unchanged. This change appeared inconsequential, but it elevated the concentration of the croton oil to 2.1% and affected the course of chemical peeling. This formula was published nationally and became the standard for decades.7 This peel worked very well in improving severe wrinkles, but it also caused significant and predictable hypopigmentation. The results were certainly there, but patients developed an unnatural porcelain look that necessitated the permanent use of make-up. Due to this, the Baker peel, as it became known, was reserved for older, light-eyed individuals. It was believed that phenol had an “all-or-none” phenomenon that was out of the surgeon’s control. Phenol also had the reputation of being cardiotoxic, requiring careful timing and strict cardiac monitoring. For these reasons, “phenol peels” carry a negative reputation that persists to this day and has limited their acceptance despite more recent improvements. The crucial step in the development of modern chemical peels came about from the work of Gregory Hetter.8 Hetter,

99

a plastic surgeon in Las Vegas, frustrated by his options of resurfacing, took a scientific approach in the hope of better understanding the Baker formula. Hetter experimented by performing a number of peels with different combinations of the ingredients and discovered that phenol alone has little effect. Adding croton oil to the phenol at different concentrations resulted in deeper peels proportional to the concentrations of the croton oil. An analysis of the classic Baker formula showed for the first time that the croton oil concentration was very high at 2.1% – responsible for the results as well as the hypopigmentation. Recognizing that croton oil, not phenol, was the peeling agent, Hetter could now alter the concentration so as to give the clinical result without negatively altering the quality of the skin. An important observation was that the “all-or-none” phenomenon ascribed to phenol was simply that the croton oil concentration was so high that it immediately peeled to the point of hypopigmentation. This may seem a small difference but it is actually a fundamental change that ushered in the modern era of chemical peeling. Being able to choose the croton oil concentration allowed the procedure to be performed superficially or deep and made it applicable to all ages and skin types. An important improvement was that different croton oil concentrations could be used in different areas of the face depending on skin thickness and clinical need. A critical change was that with weaker croton oil concentrations, the application technique became an important factor in determining the depth reached. The entire process is slowed down so that the surgeon can observe the skin changes and stop at the depth deemed appropriate. In this manner, the surgeon is in precise control and the process becomes orderly and predictable.9

Patient evaluation When considering facial rejuvenation, it is important to carefully discuss the patient’s wishes. If correction of jowling and neck deformities are the primary goal, then surgery is indicated. Most patients seeking a facelift have a degree of volume depletion; therefore lipofilling is a consideration. If a patient has pronounced wrinkles, especially around the mouth and eyes, then a facelift would provide incomplete correction, and indeed, a facelift can make their wrinkles look worse by contrast. Keep in mind that a well-performed peel, especially when coupled with lipofilling, may provide greater aesthetic impact than a facelift. If a patient is interested in comprehensive rejuvenation, then all three components can be addressed, usually beginning with a facelift and after about 4 months, proceeding with a peel and lipofilling. The combination of facelift and peeling is not advocated. There are practitioners that peel around the mouth at the time of a facelift. This is certainly feasible, but it may create an imbalance with the rest of the face, and of course, there is always value in treating the entire face.

Preoperative planning On a basic level, a chemical peel is a controlled chemical burn done in the expectation of creating an anatomic change in the dermis via an increased deposition of collagen and elastin. The more advanced the wrinkling and solar damage, the

100

SECTION II

CHAPTER 8.5  • Injectables and resurfacing techniques: Chemical peels

deeper the peel must go, while avoiding hypopigmentation and scarring. As this is a true injury, it is followed by a somewhat peculiar recovery for which the patient must be prepared. It is important to note that any technique, be it peeling or laser, that intends to give a real result has a real recovery period. Any modality that touts an easy recovery will also have little result. The immediate post-peel phase is not long and typically not uncomfortable, but it is unusual; therefore the surgeon must be completely honest with the patient. Detailed photographs of the day-by-day recovery are shown to the patient and possibly to a spouse or caregiver. Meeting with a patient who has had a similar peel is valuable, and today with social media there are many examples available to view. The surgeon must set an upbeat and optimistic, although realistic, tone. Patients do well if they are well informed and bring a good attitude. The reward is a dramatic and remarkably stable improvement in skin texture which is not possible with any other modality. The skin is prepared prior to the peel to prevent pigmentary changes such as hyperpigmentation and to have the skin in optimal condition. The main medications are tretinoin and hydroquinone 4%. The effect is to stabilize the epidermis, stimulate the dermis, to increase collagen content and vascularity, and to suppress melanocytes. The preparation begins 4–6 weeks before peeling with tretinoin 0.05% or 0.1% at night and hydroquinone 4% two times daily. The preparation is stopped about 4 days prior to the procedure to allow the epidermis to normalize. Remember to take clinical photographs prior to the preparation to avoid a possible flaky, irritated appearance. There are differences of opinion whether this skin preparation is necessary, but the author’s experience (RHB) has been that there is more erythema if skipped. In darker-skinned individuals, the preparation is all the more important. In fairskinned, light-eyed individuals, the bleaching aspect (hydroquinone) can be omitted.

Preparation of the solution The preparation of the acid solution is a critical step that should be performed by the operating surgeon. The ingredients are the same as in the classic Baker peel: namely, water, phenol, croton oil, and Septisol (but see below). Phenol is a solid crystalline substance that is soluble in water. Standard solutions found in pharmacies and dermatologic suppliers are 88% or 89% phenol. Phenol has a corrosive effect on skin by denaturing the protein and allowing it to pass into the dermis. Croton oil is a natural oil extracted from the seeds of Croton tiglium, a small tree native to India and Southeast Asia. Croton oil is very caustic and will result in a full-thickness ulcer if applied full strength on the skin. When properly diluted and applied, however, croton oil can bring about dramatic results. Septisol is a surgical soap consisting of liquid hexachlorophene, which serves as a surfactant to allow adequate mixing of the aqueous and oil components. Recently, there has been a problem with Septisol in that it has been banned in the US by the FDA due to issues with triclosan, a preservative. This has nothing to do with its use in peeling, but the end result is that it is no longer available. Thankfully, Young Pharmaceuticals

(youngpharm.com, Wetherfield, CT) has formulated an excellent substitute called Novisol. This is also a surfactant, but its action is different and it results in a stable solution that lasts 45 minutes. A problem with Septisol was that the solution separated immediately, possibly resulting in variable concentrations across the applying sponge. Novisol is used in the same volume as Septisol. Due to the stability of the solution, it may appear that the action using Novisol may be a little weaker. The only repercussion of this is that the highest concentration used may be 1.2% rather than 0.8% on deeper wrinkles such as around the mouth (see below). The water used is regular tap water. Preparation of the solution requires careful attention and a systematic approach. The ingredients are arranged is glass bowls in the order they will be added. Various-sized syringes are available, along with a glass or metal funnel and sterile gloves for protection. Once readied, the acids can be stored in opaque glass containers and sealed with phenolic cone – lined, leak-proof caps. (SKS-bottle.com, bottlesandmore.com) These solutions are stable for an extended period of time. Original formulas involved using drops of croton oil. The problem with this is that the volume of a drop is not uniform, leading to variability, and a drop cannot be subdivided, limiting the options. A very practical solution provided by Hetter was to prepare a standard phenol/croton oil solution using larger volumes that would be then further diluted with the other ingredients. The standard or “stock solution” is made by mixing 24 mL of 88% or 89% phenol with 1 mL of croton oil. By using larger volumes of the ingredients, they are easily measured with accuracy using standard syringes and a multitude of concentrations are possible.10 Standard tables are available showing the specific volumes of each ingredient to arrive at the final croton oil concentration. The final phenol concentration in these formulas is 35% (Table 8.5.1). An examination of the standard formulas shows that the volumes of water and Novisol remain constant at 5.5 mL and 0.5 mL respectively. The values that change are the relative volumes of phenol and stock solution (which contains phenol and croton oil). The sum of the volumes of the 88% phenol and stock solution is 4 mL in each of the formulas. Table 8.5.1  Croton oil formula with 35% phenol concentration

Croton oil 0.2%

0.4%

0.8%

1.2%

Water

5.5 mL

5.5 mL

5.5 mL

5.5 mL

Novisol

0.5 mL

0.5 mL

0.5 mL

0.5 mL

USP phenol 88%

3.5 mL

3.0 mL

2.0 mL

1.0 mL

Stock solution containing phenol

0.5 mL

1.0 mL

2.0 mL

3.0 mL

10 mL

10 mL

10 mL

10 mL

And croton oil (see below) Total

0.1% = 1 mL of 0.4% × 1.2 mL phenol + 1.8 mL water 0.05% = 1 mL of 0.2% + 1.2 phenol + 1.8 mL water Stock solution = 24 mL phenol + 1 mL croton oil (0.4 mL croton oil/1 mL stock solution or 4% croton oil) {1/4}X%: 1 mL X% croton oil solution + 1.2 mL phenol + 1.8 mL water

Intraoperative routine

Analyzing Table 8.5.1 further explains how the variable concentrations are arrived at. The stock solution consists of 24 mL of phenol and 1 mL of croton oil. Each mL of stock solution has 0.04 mL of croton oil, making this a 4% croton oil solution. If we examine the formula for 0.8% croton oil, it is made up of 5.5 mL of water, 0.5 mL of Novisol, 2.0 mL of phenol, and 2.0 mL of stock solution. The 2.0 mL of stock solution has 0.08 mL of croton oil (2 × 0.04 mL). Because the total volume of the solution is 10 mL, the final concentration of croton oil is 0.08 mL in 10 mL total volume, or 0.8%. By knowing the content of croton oil in the stock solution and the volume of stock solution in any of the formulas, the final concentration of croton oil can be easily determined. It is very important to remember that the croton oil concentration of stock solution is very high at 4% and should never be applied directly on the skin without further dilution. For a reference, the Baker formula had a croton oil concentration of 2.1%. To make weaker concentrations, one first mixes 0.4% or 0.2% solutions and these are further diluted using the formulas in Table 8.5.1. The final volume is 4 mL, and the final phenol concentration remains at 35%. This formula is very useful because whatever starting concentration is used will be diluted by one-fourth, i.e., 1 mL of X% croton oil solution + 1.2 mL phenol + 1.8 mL water will yield {1/4} X% solution. Since Hetter’s publications in 2000, 35% phenol concentration has become standard, but useful variations are possible. For example, there are darker-skinned individuals who may have less wrinkling and more pigmentary issues. In this instance, a low croton oil concentration formula is chosen and then the relative volume of water and phenol are changed to elevate the phenol concentration to 50% or 60%. For example, to change the phenol concentration to 60% in the 0.1% croton oil, 4 mL formula, the total volume of phenol needed (X) is determined by X/4 mL = 0.6; then X=2.4 mL. The 1 mL of 0.4% croton oil solution brings 0.35 mL phenol (35% phenol solution), this leaves 2.05 mL of phenol lacking. 0.88X = 2.05 mL represents the volume of 88% phenol needed, or 2.33 mL. In the formula, the volume of phenol and the volume of water add up to 3 mL; substituting 2.33 mL of phenol and 0.67 mL of water in the formula results in a 60% phenol solution. Understanding and manipulating the formulas results in enormous variability. More recently, the dermatological supply company Delasco (Delasco.com, Plano, TX) is preparing and selling ready-made croton oil solutions based on a historically older formula which utilizes glycerin as a surfactant. This formula contains phenol and croton oil and is available on a custom basis in any concentration desired. The phenol concentration in these formulas is 50%, typical of solutions prior to Hetter’s. The author (RHB) has used these solutions in the last 6 months in concentrations of 0.8% and 0.4%. From these, I have diluted multiple solutions resulting in all the standard concentrations commonly used, albeit with a 50% phenol concentration. The dilution formula is as follows: 1 mL X% + 1.7 mL phenol + 1.3 mL water = {1/4}X% These formulas work well and are reminiscent of the original Hetter formulas. With the higher phenol concentration, weaker croton oil concentrations are useful on darker skin with more pigmentary issues. The higher phenol concentration

101

has not caused any issues nor limited the absorption of the solution. These new formulas give the practitioners another option in their peeling armamentarium.

Intraoperative routine Traditionally, deep chemical peels have been performed under general anesthesia or intravenous sedation due to the intense discomfort of the chemical burn. Following induction, standard sensory blocks are performed with bupivacaine with epinephrine and ketorolac tromethamine 30–60 mg is administered as an adjunct to anesthesia. This is a viable approach which I have used for years and is certainly acceptable. There have been recent developments that have led to an alternative technique. Experience treating pigmented spots on my hand with 50% or 60% phenol demonstrated to me that there is an initial period of stinging lasting 10–15 seconds after which the skin is very anesthetic, even when slowly twirling a needle to the point of bleeding. This is explained by phenol causing a neurolytic effect that reversibly prevents the transmission of nerve impulses. This phenol effect is potentially useful; I began peeling by first applying a pass of 50% or 60% phenol. This was initially stimulating, but it quickly subsided, and the peel could proceed. This technique may do away with the need for sensory blocks, but further experience is needed. My experience has been that this use of phenol leads to a relatively pain-free emergence and a comfortable post-peel course.11 The anesthetic use of phenol is very useful in awake segmental peels. To make 50% phenol, one simply dilutes 10 mL of 88% phenol with 7.5 mL water. Ophthalmic ointment and corneal protection are not used because phenol can dissolve in the ointment or become trapped under a protector, preventing complete flushing out if it becomes necessary. Constant vigilance around the eyes is essential. The fear of cardiac toxicity due to phenol requires careful consideration. Reports of arrhythmias and death have been sporadic and anecdotal. It had been the belief that peels performed under general anesthesia but without blocks led to intense stimulation due to the high concentration of croton oil and this led to the cardiac irritability. The general belief was that with proper local blocks and performing a full-face peel in no less than 45 minutes, there was little danger. A recent experience during a live surgery course was very elucidating. An overzealous novice applied peeling solution over a large portion of the face much too quickly and a multitude of worrisome arrhythmias were seen. The decision was to back off, actively hydrate and do nothing. In 10 minutes, the electrocardiogram (ECG) reverted to normal and remained so. This important episode has led me to conclude that (1) phenol is absorbed and can lead to significant arrhythmias and (2) this is an orderly and predictable process that is related to speed of application. If the peel is not hurried and a fullface peel takes 45 minutes to 1 hour, there is no fear of cardiac irritability. A screening ECG is performed in patients over 65 years old or if there is a history of arrhythmias. The first step is to degrease the skin to allow even absorption of the solutions. Ask the patient not to apply anything on the skin on the morning of the peel. Be specific – mention not

102

SECTION II

CHAPTER 8.5  • Injectables and resurfacing techniques: Chemical peels

to apply a moisturizer, as they may not think of it. Acetone is the best agent for degreasing. If regulations in the operating room do not allow acetone, it can be applied in the preoperative area and then degrease again in the operating room with alcohol. The process of peeling is a little stilted, especially for the novice, in the interest of safety. The environment must be quiet and organized, not hectic and hurried. This is especially true around the eyes. Corneal protection and ophthalmic ointments are not used, and extreme care is the sole protection. The head of the bed is elevated to prevent the solution from rolling into the eyes. The applying instrument, be it sponge or cotton-tipped applicator, should never be so wet that it can drip. Never crossing over the eyes with the applying hand is extremely important and should become second nature, not unlike sterile technique. The surgeon’s hand must be dry so as not to apply acid where it is not wanted. The best way to insure this is to clip a surgical towel to the surgeon’s scrub shirt shoulder and draped over the front, always at the ready for wiping the hands. The bottle containing the solution is shaken to evenly mix the ingredients. Both of the formulas discussed will stay well mixed with one shake, but I retain the older habit of shaking the bottle each time I pour out some solution. A small volume of the desired solution is poured into a small glass bowl, and a second bowl is placed over it to prevent escape of the vapors. A small fan held by an assistant helps dissipate these vapors, and the now ubiquitous N-95 masks are useful. A calm, measured demeanor by the surgeon completes the picture. The most common applying material is a 2-inch by 2-inch gauze, preferably synthetic fiber, which is less abrasive. Cotton-tipped applicators are useful for the eyelids and to target individual wrinkles. The splintered wooden end of the applicator or toothpicks are also useful. The gauze is folded twice to decrease the size and have more precision. It is now dipped in the solution and wrung out so that it is moist and not so wet that it could drip. The gauze is set down in a safe place, and the hands are dried with the clipped towel in order to prevent inadvertent application of the acid where it is not wanted. This is particularly important in segmental peels where the error would be obvious. The applying hand should never cross over the eyes. Once the gauze is applied to the skin, the effect is seen in 10–15 seconds depending on how wet the gauze is and the concentration of the croton oil solution. The action of the acid is to coagulate and precipitate the protein of the skin forming a “frost”, which is varying degrees of a white appearance. As more passes are made, the depth of the skin reached is assessed by the degree and quality of the white appearance. With increased depth, the frost becomes progressively more dense, solid, and opaque. On a cellular level, this represents the coagulating action of the acid passing through the epidermis to the papillary dermis (juncture between epidermis and dermis). As the peel passes from the papillary dermis to the upper and mid-reticular dermis, the frosting becomes a dull, flat white. Unlike TCA peels, the action is quick and there is no need to wait a few minutes to see the final effect. Unlike some other peels, this change is irreversible. The only control available to the surgeon is that if the application is too wet, quickly blotting it will diminish the action.

Factors determining the depth of the peel Older peels with a croton oil concentration of 2.1% were problematic because they immediately peeled to a depth resulting in hypopigmentation – there was no control. A key concept of modern peels is that with lower croton oil concentrations, the entire process is slowed down and there is ample opportunity to gauge the depth of peel. In this manner, the application technique, which is wholly under the control of the surgeon, becomes the determining factor of the depth reached. The number of coats applied has a cumulative effect and with a particular concentration, a damp sponge can be rubbed multiple times, variable pressure can be used, or the gauze can be wetter and fewer passes made. The same depth can be reached using different techniques or different concentrations. By the same token, a weak concentration can be repeatedly applied and lead to deep involvement.

Judging the depth of the peel The key to a successful resurfacing is choosing and safely reaching the appropriate endpoint. A superficial peel wounds the epidermis, and although it can improve pigmentation and give a bright look, it does not improve real wrinkles. A medium-depth peel reaches the papillary dermis. Deep peels go to the upper and mid-reticular dermis, and it is this layer that must be reached to have significant improvement of stubborn wrinkles. The recovery is dependent on the depth reached and croton oil peels require more time for re-epithelialization and resolution. Any other modality touting a quicker recovery, such as fractionated laser, will not have a similar result. Typically, in most cases, different depths are reached in different areas of the face depending on skin thickness and clinical need. Peeling deeper than the mid-reticular dermis can lead to hypopigmentation and scarring. During the peel, specific attention must be paid to appearance and quality of the frost as this is the way to judge the depth. The clues to look for are background color, “thickness”, and opacity. A thin, transparent frost with a pinkish background means that acid has traversed through the epidermis into the papillary dermis. There is a quality of translucence that allows visualization of the horizontal vessels of the dermis, resulting in the pink color (Fig. 8.5.8). This may well be the endpoint in some areas. With further application, the acid passes into the reticular dermis and forms a solid, opaque, evenly colored organized frost (Fig. 8.5.9). The action of the acid has destroyed the more superficial dermal vessels and the opacity does not allow visualization of the deeper subdermal plexus, therefore the pink background is not seen. In thicker areas, such as around the mouth, the peel is stopped at this point and the frost is allowed to subside, or “defrost”. If the upper to mid-reticular dermis has been successfully reached, the defrosting takes about 15 minutes, and the skin takes on a reddish-brown overtone (Fig. 8.5.10). This is a very reliable sign and if it is not seen, further peeling may be needed. A gray–white appearance of the frost suggests reaching the lower reticular dermis and is not recommended.

Full-face peel

103

A A

B B Figure 8.5.8  Progressive frosting. (A) The patient is sedated and the skin degreased. (B) The first passes are made, and a thin translucent frost appears with a pink background. (From Bensimon RH. Croton oil peels. Aesthet Surg J. 2008;28:33–45.)

Figure 8.5.9  Progressive frosting. (A) As more passes area are made, the frost becomes more organized and opaque, with a pink background still evident. This denotes reaching the papillary dermis. (B) After more passes in the thicker glabella, and the frost has become thicker, organized, and opaque. The peel has passed into the reticular dermis. (From Bensimon RH. Croton oil peels. Aesthet Surg J. 2008;28:33–45.)

Another visual cue to assess the depth of peel, especially in thin skin like the eyelids, is epidermal sliding. Epidermal sliding is a phenomenon that occurs when the peel reaches the papillary dermis and the tight bond between the epidermis and dermis is broken, allowing the epidermis to slide as a single sheet. This sliding disappears when the peel goes deeper and the epidermis and dermis bond as a single protein block. The progression from superficial to deep is gradual, orderly, and the visual changes are easily recognizable and predictable. The advantage of the modern peels is that the surgeon has control. This is based on going slow enough to recognize the various stages, stop at the appropriate depth and go no deeper.

Full-face peel The following is a step-by-step description of the author’s (RHB) approach to a full-face peel. The patient is sedated and has received clonidine 0.1 mg p.o. prior. This is based on empirical experience that it helps prevent arrhythmias. Endotracheal gas anesthesia is an option, but it is my preference to avoid it. The head of the bed is slightly elevated to prevent drops from flowing into the eyes. The skin is degreased with acetone and no ophthalmic ointment or corneal protection is used. Sterile surgical gloves offer more protection than

Figure 8.5.10  The red-brown appearance after defrosting is a reliable sign that the reticular dermis has been reached. (From Bensimon RH. Croton oil peels. Aesthet Surg J. 2008;28:33–45.)

non-sterile ones. A surgical towel is clipped to the shoulder of the scrub shirt and draped over the front. A preliminary pass of 50% phenol is made for the anesthetic effect, starting on the forehead. This is done slowly for a light frost and being vigilant for a change in pulse. Allow the frosting to subside, then proceed with peeling.

104

SECTION II

CHAPTER 8.5  • Injectables and resurfacing techniques: Chemical peels

The various solutions have been pre-mixed and placed in clearly labeled bottles. Small glass bowls are available to pour solution into for dipping. Extra gauze and irrigating ophthalmic solution are kept within easy reach in case washing out of the eyes should be needed. The bottle of the solution to be used is gently shaken to evenly mix the ingredients and a small amount is poured into a glass bowl. A 2 × 2 gauze is folded twice, dipped into the bowl and then wrung out until damp but not dripping. A second glass bowl is placed over the first to trap the fumes. The damp gauze is set in a safe place, the hands are wiped on the clipped towel, then the gauze is retrieved for peeling. I start on the perioral area as I usually want to peel to the reticular dermis and then move on to other areas as the mouth defrosts. Starting on the upper lips, a first pass is made, and the skin is examined. I usually use 0.8% concentration or possibly 1.2% with the solutions using Novisol on deeper wrinkles. A light frost appears and as more passes are made, the frost becomes denser and more concentrated. A translucent frost with a pink background means that the papillary dermis has been reached. With more passes, redipping the gauze as necessary, the frost becomes progressively more dense, more opaque, losing the pink background as the upper reticular dermis is reached. As previously mentioned, this is a slow, orderly process and the surgeon can stop at any point if a lesser peel is desired. The skin is stretched to allow even application of the acid between wrinkles. The commissures are also spread and

respond well to deep peeling. The lower lips and chin area are peeled in a similar manner to an opaque solid white frost. The margin of the peel is the inferior border of the mandible and chin (Fig. 8.5.11). The peel can now proceed to the next area while monitoring the defrosting over the next 15–20 minutes, observing for the tan, red-brown overtones. This confirms having reached the upper to mid-reticular dermis. If this color change is not evident or too faint, the area can be repeeled. The next area is the glabella and nose, which have roughly similar thickness as the mouth; the glabella in particular can have deeply etched lines and can be peeled to the reticular dermis. The lower nose does not wrinkle, but “roughness” and deep pores respond well to similarly deep peeling. The skin of the forehead is thicker centrally and thins out superiorly and laterally. Aside from the glabella and transverse lines, the forehead does not have generalized wrinkles. A common approach is to peel centrally with 0.4%, feathering superiorly. The rest of the forehead is peeled with 0.2% to the papillary dermis and peeling lightly in the temporal area as it is delicate and not usually wrinkled (Fig. 8.5.12). The transverse lines and glabella lines can be targeted deeper, as will be discussed later. The peels do not affect hair growth, so peeling should continue to hairline and brows in order to avoid a demarcation. Treating the dynamic lines of the upper face with botulinum toxin 2 weeks prior is recommended to decrease mobility during healing. The face between the eyes and mouth are peeled next. The skin of the posterior face is densely attached and less mobile,

A

B

C

D

Figure 8.5.11 Progressive peeling of the perioral area. (A) Light translucent frost of upper lip as the early passes are made. (B) More passes have been made in the upper lip and the frost is solid and opaque. The lower lip and chin still show a pink background. (C) Both upper and lower lips/chin demonstrate solid, dense frost indicative of reaching the reticular dermis. (D) The commissures do well and can be specifically targeted. (From Bensimon RH. Croton oil peels. Aesthet Surg J. 2008;28:33–45.)  

Full-face peel

105

Figure 8.5.12  The peel of the forehead is deeper centrally, tapering superiorly and laterally. The glabella is often peeled to the reticular dermis whereas the superior and lateral skin shows a light frost with a pink background, which represents peeling to the papillary dermis. (From Bensimon RH. Croton oil peels. Aesthet Surg J. 2008;28:33–45.)

Figure 8.5.14  The lower eyelids are peeled with 0.1% croton oil solution to a point of epidermal sliding and an even white frost. The upper lids are peeled with 0.1% solution or possibly 0.05%, depending on the degree of laxity. The peel stops at the tarsal fold unless obvious laxity is seen below the fold. (From Bensimon RH. Croton oil peels. Aesthet Surg J. 2008;28:33–45.)

Figure 8.5.13  The central face is peeled to the papillary dermis. Deeper wrinkles can be individually targeted. (From Bensimon RH. The technical use of croton oil peels. In: Tonnard P, Verpaele A, Bensimon R, eds. Centrofacial Rejuvenation. New York: Thieme; 2018:323–377.)

therefore usually less wrinkled. The posterior area is usually peeled with 0.2% to the papillary dermis, with light application in the preauricular area which is delicate (Fig. 8.5.13). Peeling should continue to the sideburn, tragus, and earlobe. The earlobe responds nicely and can be peeled with 0.4%. The anterior face, showing more mobility, is usually more wrinkled. Depending on the individual case, this area is peeled with 0.2% or 0.4% to the papillary dermis or slightly deeper and individual wrinkles can be targeted as necessary. The anterior face can be tricky, because on occasion, there can be deep wrinkles in an area where the skin is not as thick, therefore the patient must be advised that complete correction may not be possible. The peel should extend to about 1 cm below the mandible and the entire corridor of the mandibular border between the mandibular angle to the geniomandibular groove is delicate and rarely wrinkled, therefore it should be peeled lightly. The eyelids are an excellent area for peeling, especially the lower eyelids, because they can show great improvement and

are very predictable. The skin is very thin, but it responds well to a weak solution such as 0.1%. The solution is applied with two cotton-tipped applicators which are dipped into the bottle after it has been shaken. The wet applicators are touched to a gauze or drape to slightly dry them, and then applied to the skin. The peel begins in the lower part of the lid and then proceeds gradually superiorly, approximating the ciliary margin. The relative dampness of the applicators and the number of passes made determine the depth. The cheek is gently pulled down to fully expose the skin and smooth out the wrinkles. With progressive passes, the friction of the application will demonstrate epidermal sliding and the frost will become an even white color. When the cheek is released, the soft tissue moves up and the degree of epidermal sliding can be easily seen. When the epidermis is loose and there is an even white frost, the opposite lid can be addressed. After defrosting, a prominent wrinkle or redundancy may be seen at midheight which can be repeeled, possibly with 0.05% solution (Fig. 8.5.14). Having a detailed photograph present is useful to see the precise location of the wrinkles. Due to the tightness that is created, precipitating an ectropion is always a possibility, so testing the laxity of the lid preoperatively is important. If there is concern about laxity, a preemptive canthopexy or tarsorrhaphy suture can be performed or sequential lighter peels can be done. Patients may experience tightness in the lower lids after peeling, but this responds promptly to upward massage. The skin of the upper lids respond to peeling by shrinking, which looks quite nice and can mimic a blepharoplasty. If laxity is present, peel with 0.1%, and it is usually stopped at the tarsal fold. If there is laxity below the fold, the peel can approximate the lashes. One nuisance of peeling the upper lid is that the eye may swell shut, usually until the next day.

106

SECTION II

CHAPTER 8.5  • Injectables and resurfacing techniques: Chemical peels

Figure 8.5.15  Precise deeper peeling of more pronounced wrinkles is possible with a wetter application, then quickly drying as the frost appears. This is repeated until the desired depth is reached. This is an extremely valuable tool in the perioral area. (From Bensimon RH. Croton oil peels. Aesthet Surg J, 2008;28:33–45.)

Beware of the medial upper lid, where there may be “double peeling” from the nose. The peel is then extended onto the neck with a very dilute solution of 0.25% or even weaker. This is done with very light, wispy strokes and a barely moist sponge, leaving a faint frost that is scattered and disorganized. This peel is done only to prevent a line of demarcation and not to improve wrinkles; the neck skin is delicate and lacks the healing potential of the face. Attempting to improve wrinkles is likely to cause hypopigmentation or scarring. A weak TCA peel in the neck is an option and liposuction of the neck with any peeling is not recommended. Likewise, a brow lift, even if performed at a deep level, is to be avoided. At this point, the entire face is inspected to see if any further peeling is needed. Areas where the intention was to reach the mid-reticular dermis are examined for the re-brown color. If not present or faint, they should be repeeled. If there is uneven blending of areas peeled with different concentrations, then a light overpeel with a dilute solution such as 0.1% is needed. This is most common in the midface. Precise peeling of individual deeper rhytids without affecting the surrounding areas is an extremely valuable tool, especially in the perioral area, chin, glabella, and forehead. A wetter cotton-tipped applicator is used to paint the individual line and then quickly drying it as the frost appears. This is repeated until the desired depth is reached (Fig. 8.5.15). This is particularly useful in stubborn radial lines around the mouth and can have a profound effect. Another approach is to saturate a toothpick and “flood” the valley of the wrinkle and leave it in place for a few seconds before drying it. Transverse forehead lines are stubborn, but improvement can be expected from this technique. This is also true for glabella lines, transverse nasal lines, and crow’s feet. Various croton oil concentrations have been recommended in the previous sections, but keep in mind that the concentration of the solution is only one variable, and the surgeon needs to monitor the appearance of the frost at all times and

decide the depth at which to stop. Repeated passes of whatever concentration will have an additive effect and the safety of a weaker concentration is a relative one. The patient should be well hydrated and under cardiac monitoring during a full-face peel. The surgeon should be aware of the pulse rate, and, if it increases, back off until it slows down. Resist the temptation of peeling too fast, especially as experience is gained. A full-face peel should take between 45 minutes and 1 hour. If arrhythmias are seen, stop the peel for some minutes until the rhythm reverts to normal. In all likelihood, treatment will not be necessary.

Aftercare Dealing with the skin after the peel is perhaps the most challenging aspect of deep chemical peels. There is, in essence, an open wound and the aim is to provide a good environment to promote re-epithelialization in the fastest time with the least difficulty for the patient. Keep in mind that to obtain a significant result, there must be an injury into the dermis, and as a result, there is a real recovery. Any other process that has a quick recovery has not adequately injured the dermis and will not give a comparable result. The traditional technique of aftercare, which I used for the first 14 years of my peeling experience, involved using triple antibiotic ointment mixed with lidocaine jelly and constantly applying it to the face. This technique works and is a viable option, but it is messy and gives the patient a dramatic view of the “aftermath” and requires constant touching of the face. Moreover, sensitization to the antibiotics can cause breakouts and rashes. Milia were common and there was the impression that the subsequent erythema was more intense. What follows is my present regimen which I instituted to improve the patient experience and have used successfully for the past 8 years. This is an older technique used by various peelers around the world and was taught to me by Jean-Luc

Aftercare

Vigneron, an accomplished peeler from France. Once the peel is finished and all the frosting has subsided, all the peeled areas are covered with zinc oxide tape. This is the pink tape commonly used by anesthesia providers to secure the endotracheal tube. Petrolatum ointment is applied to the brow and hairline to prevent sticking, and no taping is done to the skin of the upper lid below the tarsal fold (Fig. 8.5.16). Typically, when patients awaken from the peel, they may feel some stinging which is not intense and may or may not necessitate medication. This is not long-lasting, and when discharged in about 1 hour, they are comfortable. Unlike the very difficult recovery from the Baker peel (and ablative lasers), this is usually the last discomfort felt. The tape mask remains in place overnight, at which point the patient returns to the office. The tape mask is removed from inferior to superior without difficulty and without discomfort. The patient should be warned that any discomfort felt is simply some hair caught in the tape. An inconvenience of peeling the upper lid is that it may swell shut the night of the peel or the tape may impede the lid from opening. Vision

Figure 8.5.16  Zinc oxide tape is applied to peeled areas at the end of the peel. (From Bensimon RH. The technical use of croton oil peels. In: Tonnard P, Verpaele A, Bensimon R, eds. Centrofacial Rejuvenation. New York: Thieme; 2018:323–377.)

A

B

107

is restored the next day when the tape is removed. Displaying the “trophy” of the removed mask to the patient is a common source of amusement (Fig. 8.5.17). The peeled skin is examined and gently cleansed with a saline gauze in order to remove any loose fibrous material. The edge of a tongue depressor can also be used to gently “shave” the skin. The next step is to mix the bismuth subgallate powder with water to create an even, creamy paste with a consistency reminiscent of cake frosting. A small bit of ophthalmic gel can be added to give a more even texture. The paste is applied to all peeled surfaces with a tongue depressor or a mini silicone spatula (available in a kitchen store). A fan-shaped make-up brush works well on the eyelids. The paste is not applied below the tarsal fold. Organic coconut oil is applied to the vermillion and the lightly peeled neck (Fig. 8.5.18). Once the bismuth mask is on, it is allowed to dry and form a crust. The patient is admonished that from this point on, they are to strictly avoid touching the face. Over the next 7–12 days, the skin beneath will re-epitheliaze and shed the crust piecemeal. Again, the patient is advised not to pick at, wash, or touch the face. At about day 7, the patient is seen and a heavy petroleum ointment is applied to any remaining crust and allowed to seep in during that day. On day 8, the patient can shower gently (deflect the full force of the shower with a hand), gently pat dry with clean hands and clean towel, and re-apply the ointment (which is supplied to the patient) on remaining crust. This is repeated daily until the mask is completely shed and the new pink skin is evident (usually 9–12 days) (Figs. 8.5.19 & 8.5.20). This approach with the bismuth has the disadvantage of looking bizarre but the typical reaction has been one of amusement and patients are very tolerant of it. The handsoff approach is appreciated and office visits and worried calls have been significantly cut down in the first 2 weeks. Any questions are easily handled via smart phone photo. The bismuth has proven less reactive than ointment and the post-peel erythema is much less. For any skeptics, bismuth is a heavy metal with many wellknown curative properties and surgeons are surely familiar

Figure 8.5.17  (A) The tape mask is removed the day after the peel. (B) Appearance immediately after tape mask removal. (From Bensimon RH. The technical use of croton oil peels. In: Tonnard P, Verpaele A, Bensimon R, eds. Centrofacial Rejuvenation. New York: Thieme; 2018:323–377.)

108

SECTION II

CHAPTER 8.5  • Injectables and resurfacing techniques: Chemical peels

with it through Xeroform medicated gauze, whose active ingredient is 3% bismuth tribromophenate. Once skin is exposed, a medical quality moisturizer is applied with clean hands and continued for the ensuing weeks. Strict sun avoidance is important for the early periods, and usually a physical sun block can be used on the third week giving the patient increased freedom. The erythema can last 8–12 weeks but is easily covered with make-up or tinted sunblock. To be sure, there are many other techniques to treat resurfaced skin, but the tape–bismuth approach has proven to be effective and practical. Some patients may consider the process too onerous, but in reality, the 2-week early recovery is quite short when considering there is no other treatment equal in quality and longevity. As more practitioners perform these peels, an improved healing technique may come to light.

A

Materials and suppliers

B Figure 8.5.18  (A) Bismuth subgallate paste. (B) Bismuth paste applied to face. (From Bensimon RH. The technical use of croton oil peels. In: Tonnard P, Verpaele A, Bensimon R, eds. Centrofacial Rejuvenation. New York: Thieme; 2018:323–377.)

A

B

Phenol

Most pharmacies, Delasco

Croton oil

Delasco (Delasco.com)

Novisol

Young Pharmaceuticals (Youngpharm.com)

Bismuth subgallate powder

Delasco, McKesson, Amazon, multiple medical suppliers

5-FU

McKesson, Medline, multiple medical suppliers

Zinc oxide tape (Hy-Tape)

Delasco, McKesson, Amazon, multiple medical suppliers

Glass bottles, phenolic caps

SKS Bottle & Packaging (sks-bottle.com), Bottles and More (bottlesandmore.com)

Glass bowls (Duralex, Pyrex)

Amazon, kitchen supply stores

Silicone spatula

Amazon, kitchen supply stores

C

Figure 8.5.19 Process of healing with bismuth subgallate paste. (A) Day 1. (B) Day 5. (C) Day 7. Note that erythema is more where peel is deeper (glabella), but overall is mild. (From Bensimon RH. The technical use of croton oil peels. In: Tonnard P, Verpaele A, Bensimon R, eds. Centrofacial Rejuvenation. New York: Thieme; 2018:323–377.)  

Variation of peels

A

C

109

B

D

Variation of peels Partial or segmental peels are a possibility but must be done judiciously so as not to create a mismatch in color. This is particularly true in patients with widespread solar damage, making a full-face peel a better choice. For example, if an isolated peel is performed, the true color of the skin will be brought out and this could be in harsh contrast to surrounding sun-damaged skin. In these situations, a lesser peel may be preferable in order to avoid the need for make-up. Some individuals with

Figure 8.5.20  Healing process for segmental peel. (A) Taping immediately after peel. (B) Day 1, tape removal and application of bismuth subgallate paste. (C) Interim healing. Partial shedding of crust. (D) Appearance after complete shedding of crust. Note that erythema is mild and easily concealable. (From Bensimon RH. The technical use of croton oil peels. In: Tonnard P, Verpaele A, Bensimon R, eds. Centrofacial Rejuvenation. New York: Thieme; 2018:323–377.)

isolated upper lip lines without extensive sun damage elsewhere can benefit from a peel of the mustache area (Fig. 8.5.21). The eyelids are an excellent area for segmental peeling. Signs of early aging are often seen first around the eyelids in late 30 s to mid-40s. The upper lids exhibit slight redundancy, and the lower lids show crisscrossing, visible wrinkling, and crepiness. These changes are bothersome to patients as they are often the only signs of aging and the myriad of creams and treatments available do little. A simple peel, often performed in the office without anesthesia in 10 minutes, can greatly improve the problem. The thin lid skin, if peeled, within the

110

SECTION II

CHAPTER 8.5  • Injectables and resurfacing techniques: Chemical peels

A

B

Figure 8.5.21  Isolated mustache peel. (A) 54 year old women with fine wrinkling of upper lip and large pores. (B) One year after isolated mustache peel.

A

B

Figure 8.5.22  (A) A 44-year-old man with crepiness and slight redundancy of lower lid skin as the main expression of aging. A lower lid blepharoplasty might have further accentuated the rounding of his outer canthi. (B) Result 6 months after peel of lower eyelids. This is an excellent option for this problem. (From Bensimon RH. The technical use of croton oil peels. In Centrofacial rejuvenation, p.323–377. New York: Thieme Publishers, 2018.)

boundary of the orbital rim responds very well and is easy to hide with make-up or glasses. If more result is desired, the peel can be repeated with little expenditure in time or materials. In a real sense, the patient can obtain as smooth a lid as they wish. There is great versatility in these eyelid peels: if a quicker recovery is needed, a lighter peel can be done with the thought of repeating it at a later time. A lower eyelid peel tightens the anterior lamella and tends to soften the early bulging of fat in younger patients. Likewise, the skin of the upper lid reacts by shrinking, giving a bright, natural look without surgery. The combination of a transconjunctival blepharoplasty and a lower lid peel is an excellent choice that gives predictably good results without changing the shape of the eye (Figs. 8.5.22 & 8.5.23). An evolving tactic is to peel the eyelids of young patients when this is the only sign of aging. After some years go by and there is some further deterioration, the peel is repeated, and the skin is brought back to its previous condition. This

is an effective way to keep up with aging. These peels (and any touch-ups) can be done with mild oral sedation and a first pass of 50% phenol. After about 12 seconds of stinging, the skin is numb, and you can proceed to the next lid. Once all areas are anesthetic, the peel can proceed. This preemptive approach can be applied to the whole face as fine wrinkling and the dullness of solar elastosis begins to appear. This may be the situation in younger patients not contemplating any surgery, but also not seeing adequate results from superficial peels, microdermabrasion, etc. In these circumstances, a lighter peel can be done, targeting any problem areas such as the eyelids or lip lines. The recovery will be quicker, but the result will be more profound than with TCA or fractionated laser. Any persistent wrinkle can be easily touched up. This treatment plan is applicable to a large portion of the population, and, if repeated appropriately, will prevent more obvious aging.

Results

Figure 8.5.23  (A) A 48-year-old man with early changes of upper face and overall “rough” appearance. (B) Result after upper blepharoplasty, neuromodulators, skin care, and lower lid peel. Relatively simple procedures have produced considerable impact.

B

A

A

111

B

C

Figure 8.5.24  (A) A 45-year-old woman with generalized elastosis and chin wrinkles. (B) One year post peel. The skin looks healthier with bright reflection of light and improvement of chin wrinkles. (C) Six years postoperatively. There is remarkable stability of results. (From Bensimon RH. Croton oil peels. Aesthet Surg J. 2008;28:33–45.)

Results In its basics, croton oil peels injure the skin to a particular level and elicit an acute inflammatory response that stimulates the deposition of collagen and elastin. Histology of peeled skin shows a significant new layer of collagen in the dermis that is aligned in an orderly way and is remarkably stable for years, even decades. The positive result in patients in their 60 s can be considered permanent. The qualitative improvement of the skin is by means of a true regenerative process that changes the skin anatomy. The skin looks younger because, in a real

sense, younger skin has been created. The haphazard arrangement of epidermal cells is reordered: light penetrates the dermis and is reflected back brightly, replacing the dull, ashen, sallow look of sun damage and elastosis. The generalized qualitative improvement of the skin radiates the luminescence of youth. There is an intangible quality that no surgery can provide. In fact, the results of a well-done facelift without radiant skin is incomplete and still looks old. The longevity of peels is unequalled by any other process and, rather than showing loss of effect, the skin appears to improve with time. Figs. 8.5.24–8.5.32 are representative of the results that can be seen with these deep chemical peels.

112

SECTION II

A

CHAPTER 8.5  • Injectables and resurfacing techniques: Chemical peels

B

C

D

Figure 8.5.25  (A) and (C) A 47-year-old woman with widespread sun damage, elastosis, pigmentary changes, and opaque skin. (B) Four years after croton oil peel. Global improvement in the quality of the skin and even pigmentation area evident. (D) Detail of periorbital area 1 year after peeling. The qualitative improvement consists of softening of the hard lizard-like skin and the natural absorption and reflection of light. (From Bensimon RH. The technical use of croton oil peels. In Centrofacial rejuvenation, p.323–377. New York: Thieme Publishers, 2018.)

Microscopic studies of peeled skin show destruction of actinic keratoses and cancer cells within the dermis before they become clinically evident.12,13 This is to be expected because deep peels go to the depth that these cells are found. The impression of experienced peelers is patients that have been peeled do not develop facial basal cell or squamous cell cancer. Individuals with a previous history of skin cancer show a significant decrease in frequency or even complete eradication. In fact, dermatologic studies have shown that resurfacing techniques are successful in keeping susceptible patients free of non-melanoma skin cancer for the studied 5 years.14 In recent years, there has been increased attention in addressing the loss of volume that is seen in aging. The use of fat transfer or lipofilling is becoming more important not only for replenishing lost volume in the face, but also for the regenerative effect of stem cells and epidermal growth factors. With experience, it has been found that lipofilling and croton oil peels can be done at the same time and are very

synergistic. This is a powerful combination, and there are many instances where this approach may afford a greater aesthetic impact than a facelift. Of course, if all three components of aging are corrected, the result can be very dramatic.

Complications The main complications of croton oil peels are similar to other deep resurfacing procedures. The most feared complication, scarring, has occurred mainly if the patient picked at their face during the healing process or if they inadvertently transferred genital herpes to the face. This infection is more virulent and has resulted in scarring. If healing is delayed longer than 14 days or thickening develops, this is suggestive that the peel has reached the deep reticular dermis and scarring may ensue. The suggested treatment is to apply a fluorinated topical steroid 5 days on

Complications

LA

113

RA

RB

LB

Figure 8.5.26  Left, a 59-year-old woman with the classic ashen, sallow look of sun damage, prominent upper lip lines and rough chin skin. Right, 1 year after croton oil peeling. Generalized improvement of skin quality and pigment, along with stark improvement of upper lip lines and elevation of the vermillion. No other modality has equaled these results. (From Bensimon RH. Croton oil peels. Aesthet Surg J. 2008;28:33–45.)

A

B

Figure 8.5.27  (A) A facelift on this 65-year-old woman without resurfacing would be an aesthetic failure as the prominent lines of the face would be minimally improved and around the mouth and upper face, not at all. (B) One year after croton oil peeling. It could be argued that the peel has provided more global rejuvenation than surgery. (From Bensimon RH. Croton oil peels. Aesthet Surg J. 2008;28:33–45.)

114

SECTION II

CHAPTER 8.5  • Injectables and resurfacing techniques: Chemical peels

A

Figure 8.5.28  (A) This 75-year-old woman demonstrates obvious centrofacial aging in contrast with relatively unaffected posterior face. (B) Results 5 years after facelift and 1 year after croton oil peeling. This demonstrates the power of surgery and subsequent peeling. (Or vice versa.) (From Bensimon RH. Croton oil peels. Aesthet Surg J. 2008;28:33–45.)

B

A

B

C

Figure 8.5.29  (A) A 63-year-old woman with structural changes of aging, jowling, neck laxity, mild hollowing of upper lids, and prominent line especially periorally and upper face. (B) One year after facelift and lipofilling. The lack of improvement in the texture distracts from the result and despite the improvements, she still looks “old”. (C) At 18 months after peeling. A natural, comprehensive result as all three components of facial aging (structure, volume, texture) have been addressed. (From Bensimon RH. Croton oil peels. Aesthet Surg J. 2008;28:33–45.)

and 5 days off with careful monitoring. If a scar develops, a useful treatment is the intralesional injection of 5-fluorouracil (5-FU). 5-FU is a common intravenous chemotherapeutic agent with a long history of use by dermatologists and plastic surgeons. The intralesional injection is considered off-label. The schedule of injection can be as frequent as every 1 or 2 weeks, depending on results. Steroid can be mixed with 5-FU, but it appears that 5-FU alone is more effective without the complications of the steroid.

Particular attention should be paid to the temporal area, preauricular area, the geniomandibular border, and the medial upper lid, as these areas are delicate and could lead to scarring. The region of the mandibular border from angle to chin should not be over-peeled as it is delicate and rarely wrinkled. The medial upper lid may be peeled deep when peeling the nose, therefore special care is advised. Hypopigmentation can result if the peel goes too deep and was the norm with older peels. This is largely

Complications

LA

RA

LB

RB

LC

RC

LD

RD

LE

RE

115

Figure 8.5.30  Left, this 61-year-old woman is a classic example of negative skin aging due to sun damage and long-term smoking; her structural changes are mild, therefore a facelift would not be a first choice. She has prominent perioral and periorbital wrinkles, blotchy pigment throughout, and thick, opaque skin. Right, the changes 6 months after peeling alone clearly show the power of this technique. The overall appearance is bright and healthy. She has a look of youth that was not present before. The wrinkles around the mouth and upper face have been nicely eradicated without depigmentation. Note the skin tightening, shrinking of upper lid skin, and shortening of upper lip. The improvement of skin quality of the midface is quite dramatic. (From Bensimon RH. The technical use of croton oil peels. In Centrofacial rejuvenation, p.323–377. New York: Thieme Publishers, 2018.)

116

SECTION II

A

CHAPTER 8.5  • Injectables and resurfacing techniques: Chemical peels

Figure 8.5.31  (A) This 70-year-old woman shows considerable facial wrinkling, but also generalized deflation, which is a prominent feature of her appearance. (B) Result at 14 months after lipofilling and croton oil peeling. This synergistic combination has the potential of providing a greater aesthetic impact than a facelift.

B

A

B

Figure 8.5.32  (A) Early skin thickening or scar. (B) Result after one injection of intralesional 5-FU.

preventable with the modern iteration of these peels as proposed in this chapter. If an individual has very deep wrinkles and tough leathery skin, it may be necessary to peel so deep as to cause hypopigmentation. In general, this hypopigmentation is well worth it and does not have the artificial, porcelain look of the older peels. Careful assessment preoperatively is important because there are patients that have lighter upper lip skin naturally which may become more obvious once the solar damage is improved. Also, it is prudent to point out to the patient if there is hypopigmentation due to previous dermabrasion or carbon dioxide laser treatment. Sun exposure in the early recovery can result in hyperpigmentation, usually in dark-skinned individuals. Strict sun avoidance in the first 2 weeks, along with pretreatment to suppress melanocytes, is important. After the first 2 weeks, most patients can tolerate a physical sun block, resulting in considerably more freedom. Hyperpigmentation can be treated with tretinoin and hydroquinone 4%, but it can look blotchy and linger for a few weeks. A herpetic infection is a constant fear; therefore all patients are treated prophylactically with valacyclovir 500 mg twice a day starting 3 days prior to the peel and continuing for 7 days after. If an outbreak is suspected, the dose of the antiviral is doubled and a topical antiviral such as penciclovir is used.

This is carefully applied with a cotton-tipped applicator so as not to spread the infection. As has been discussed, the potential of spreading genital herpes to the face can be very troubling. All patients must be considered potential carriers, so they need to be warned to wash their hands before touching their face when allowed on day 8. To date, we have seen no herpetic infection since switching to the bismuth paste and a no-touch technique. One of the positive effects of the peels is skin shrinkage. This could potentially precipitate an ectropion, therefore the lower lid should be examined for laxity preoperatively. If present, segmental lighter peeling and a tarsorrhaphy suture are options. If more extensive laxity is seen, a formal canthopexy may be needed. Mild tension in the lower lid is not uncommon and responds well to upward massage. Milia were common when occlusive ointments were used; they are much less frequent with the bismuth mask. Milia can be treated with tretinoin (after 6 weeks) or carefully excised with a fine needle. Erythema lasting more than 12 weeks is possible, but it always subsides completely and has not required treatment as was sometimes needed with ablative CO2 lasers. There has been a notable decrease in erythema since the use of taping and bismuth subgallate paste.

Conclusion

Conclusion The finding that croton oil is the critical peeling ingredient has been pivotal in the evolution of deep chemical peeling. By modulating the croton oil concentration, the process has been slowed, giving the surgeon control of the peel; by using appropriate application technique, the desired clinical result is possible without causing hypopigmentation. By lowering the croton oil concentration, the feared “all-or-none” action in older peels is gone and now surgeons have an excellent option for effective skin resurfacing. Peeling older patients with established wrinkles is an obvious indication for croton oil peels and peeling younger patients incrementally to keep up with aging is an interesting prospect that opens up these peels to a much wider audience. The prevention and potential treatment of non-melanoma skin cancer is an intriguing proposition that deserves more interest and research.

Access the reference list online at   Elsevier eBooks+

117

Although laser resurfacing, especially erbium, is a viable alternative, there are cellular differences. Laser resurfacing results in increased collagen but elastin is not elicited. The clinical observation is that erbium laser simply does not improve perioral lines and chin wrinkles like croton oil peels. Lasered skin is thinner and there is a degradation of results after a few years. The surprising stability of results, if not permanence, is a hallmark of croton oil peels. If a practitioner owns a laser and wishes to use it, a croton oil peel can be used in the perioral and periorbital areas where lasers show less results. When discussing laser vs. peels, the very high cost of lasers must be considered. With the insignificant cost of peels, it is my belief that lasers would have to be much better to justify recommending them. One of the main purposes of this chapter is to give readers practical guidance to try these peels before spending large sums on a laser.

References

References 1. Monheit G. The Jessner’s + TCA peel: a medium-depth chemical peel. J Dermatol Surg Oncol. 1989;15(9):945–950. 2. Brody H. Variations and comparisons of medium depth peeling. Dermatol Surg Oncol. 1989;15:953–963. 3. Obagi ZE, Obagi S, Alaiti S, Stevens MB. A TCA-based blue peel: a standardized procedure with depth control. Dermatol Surg. 1999;25(10): 773–780. 4. Justo AS, Lemes BM, Nunes B, Wambier C. Characterization of the activity of croton tiglium oil in Hetter’s very heavy phenol–croton oil chemical peels. Dermatol Surg. 2021;47(7):944–946. 5. Hetter GP. An examination of the phenol-croton oil peel: part II. The lay peelers and their croton oil formulas. Plast Reconstr Surg. 2000;105:240–248. 6. Baker TJ. The abolition of rhitides by chemical means: a preliminary report. J Fla Med Assoc. 1961;48:451–454. 7. Baker TJ. Chemical face peeling and rhytidectomy: a combined approach for facial rejuvenation. Plast Reconstr Surg. 1962;29: 199–207.

117.e1

8. Hetter GP. An examination of the phenol-croton oil peel: part I. Dissecting the formula. Plast Reconstr Surg. 2000;105:227–239. 9. Bensimon RH. Croton oil peels. Aesthet Surg J. 2008;28:33–45. 10. Hetter GP. An examination of the phenol-croton oil peel: part IV. Face peel results with different concentrations of phenol and croton oil. Plast Reconstr Surg. 2000;105:1061–1083. 11. Bensimon RH. Technical use of croton oil peels. In: Tonnard P, Verpaele A, Bensimon R, eds. Centrofacial Rejuvenation. New York: Thieme; 2018:323–377. 12. Kaminaka C, Yamamoto Y, Yonei N, et al. Phenol peels as a novel therapeutic approach for actinic keratosis and Bowen disease: prospective pilot trial with assessment of clinical histological and immunohistochemical correlations. J Am Acad Dermatol. 2009;60: 615–625. 13. Kaminaka C, Yamamoto Y, Furukawa F. Nevoid basal cell carcinoma syndrome successfully treated with trichloroacetic acid and phenol peeling. J Dermatol. 2007;34:841–843. 14. Hantash BM, Stewart DB, Cooper ZA, et al.Facial resurfacing for non-melanoma skin cancer prophylaxis. Arch Dermatol. 142:976-982,2006.

 

SECTION II •  Aesthetic Surgery of the Face

8.6 Minimally invasive multimodal facial rejuvenation Luiz S. Toledo

SYNOPSIS

We have been performing “refreshing” techniques for the past 35 years, offering an alternative to the classical facelift for facial rejuvenation. We can start treating some of our patients at an earlier age, and, as well, improve the aspect of faces that have been “over-stretched” by several rhytidoplasties. With these techniques we can improve the facial appearance of patients of all ages, using our technique of superficial syringe liposculpture – SSL – with fine cannulas aspirating fat to recontour the jawline, and injecting fat with fine needles in the nasolabial, malar, and glabellar regions, postponing the first facelift, or complementing our older patients’ facelift. The “refreshing techniques” would not, however, give the same results of rhytidoplasty, neither do we advocate this operation to be abandoned. Refreshing is a combination of gentle facial contouring procedures that can be used alone or as an adjunct to rhytidoplasty, a complement to other techniques.

Introduction In 1992 we organized for the third time in São Paulo a symposium called Recent Advances in Plastic Surgery, RAPS III,1 where we encouraged plastic surgeons to present new ideas and new techniques in all areas of aesthetic surgery. As in the previous two meetings we published the Annals with all the presented papers.2 In our articles, we showed different options to the two accepted facial rejuvenation techniques at the time, blepharoplasty and rhytidoplasty, which were minimally invasive procedures that could enhance the looks of the patient and could be used as an alternative, or in conjunction with the traditional techniques. The role of skin retraction became an important consideration, something that would be explored in the following years, through many new devices and techniques.

Rejuvenation: changing attitudes and new procedures We have to look at facial rejuvenation without the rigid confines taught in the early years of plastic surgery. Instead, we

appreciate the wants of the patient, looking to improve the appearance with minimal morbidity through simpler, faster procedures, as an option to the traditional “cut and stretch” techniques. We can offer smaller procedures under local anesthesia, with no need for hospitalization, a major factor in the patient’s considerations. Rejuvenation could be described as a state of mind and by improving the appearance we can also help to improve the state of mind. “It feels much better to look younger and have less wrinkles, than to carry the burden of an older face all your life,” a patient of mine once said. The interesting point is that the changes do not need to be drastic to provoke a more youthful appearance and elevate the spirit of the “tired“ face. The best compliment to the patient and the surgeon is when friends notice “You look great!“ without perceiving any drastic changes. The worst is when the patient enters a room and it is noticed that “You’ve had something done!“, or worse, “You’ve had plastic surgery!“ Human appearance is the sum of several components. It has been studied for centuries by artists and more recently by psychologists and plastic surgeons. In 1845, in his Essai de Physiognomonie,3 published in Geneva, Rodolphe Töpffer explained what is now considered “The Töpffer law”4: Any configuration that can be interpreted as a human face, badly drawn as it may be, will have, ipso facto, its own expression and individuality (Fig. 8.6.1). Based in his work, almost a hundred years later, in 1937, Vienna psychologist Egon Brunswik5 confirmed our extreme perception to the smallest changes in the physiognomy. In his studies he explains that small variations in the proportions of the human face can affect our judgment of the person’s personality. Our subconscious mind judges people by their appearance, even if consciously we know we should not. The division of the face in thirds of similar proportion, the forehead, the eyebrows to nose tip and nose tip to chin, is considered to be proportions of beauty. A wide forehead is considered a sign of intelligence and a short one, stupidity. Big ears are often taken as a sign of a “dumbo“, a receding chin, or “weak chin“ is equated to indecisiveness, while a big chin will have the opposite judgment,

Rejuvenation: changing attitudes and new procedures

119

Figure 8.6.1  Rodolphe Töpffer’s original illustration of expressive character in the human face. (From Toepffer R. Essai de Physiognomonie. Geneva, 1845.)

no matter what the real qualities are. A woman with thin lips can be thought of as mean and another with full, pout lips, as generous and good. The extreme, the anomalous, usually sticks in our mind and gives us preconceived diagnosis and ideas. Caricaturists distort and exaggerate facial features so as to portray their subject in a few lines. It could be a dangerous profession.6 In France, Charles Philipon was fined 6000 francs for portraying King Louis-Phillipe as a pear in 1831 – the king as an imbecile, although Philipon was not sure which phase of the transformation he was being condemned for (Fig. 8.6.2). It is important to try to balance the facial proportions, to achieve what the patient seeks, which most often is a feeling of similarity with their peers and “normality”. I altered my concept of facial rejuvenation when I became uncomfortable performing facelifts on young, 35–45-yearold patients. First of all, I do not like to place the extensive and permanent scar on “borderline age“ cases, and I do not like to only stretch the skin to accomplish the “younger look“. The stigma of a stretched face, the “what’s happening? look“, although it can be avoided by a good surgeon, can alter the facial expressions and outwardly the personality of the patient. Even a good result will leave marks that cannot be disguised. I still, of course, perform the procedure, when indicated, but I find it is less often, and in patients usually 45 years old and over. Patients in this age group will come to me and ask for rejuvenation, to ”have something done“ to improve their appearance without undergoing rhytidoplasty; we can help with this. Before liposuction, little could be done. The so-called “minilift” of the midface, temporal, or cervical regions still holds the same stigmas of rhytidoplasty. We can use

Figure 8.6.2  Charles Philipon’s caricature of King Louis-Phillipe of France as a pear. (history_docu_photo / Alamy Stock Photo.)

120

SECTION II

CHAPTER 8.6  • Minimally invasive multimodal facial rejuvenation

the blepharoplasty procedure, solving excess skin, muscle, and fat within the orbital region. Blepharoplasty is a wonderful procedure and there is no substitute for it. It solves the eyelid problems thoroughly and leaves inconspicuous scars. In the early 1980s we started using liposuction to improve facial contours. Facial cannulas were thick in those days, 4– 6 mm, and results were, as in all cases of liposuction at that time, limited by the patient’s skin quality and the depth of suction. A patient was considered a good candidate for liposuction if young and with good skin tone. Otherwise, a skin resection was usually recommended to complement the facial sculpting. By the mid 1980s we had started fat grafting of the face and body, and by 1986 we were using 10-cc disposable syringes for facial sculpturing. This facial procedure has become very delicate with much finer cannulas. We use cannulas of 1.5-mm to 3-mm gauge for the face and neck. Anesthesia has improved and we started suctioning and injecting fat as an office procedure under local anesthesia. Office surgery became more frequent. The ease and safety of the procedure, allied with a global financial recession, has drastically cut the number of hospital surgeries. Fat grafting became an accepted alternative after an initial phase of discredit related to high reabsorption rates of the injected fat, due to the mistreatment of the fat cells. We have perfected our technique and have a high rate of patient satisfaction. In the 1990s we started performing endoscopic brow lifts and midface lifts. Although endoscopic procedures use minimal scarring, they are hardly minimally invasive as the dissection of the tissues can be very traumatic. After Botox and fillers were introduced, we could substitute the endoscopic brow lifts and finally start treating younger patients with non-surgical procedures. With Botox we can treat the fine wrinkles that do not disappear with the surgical procedures and with fillers we can improve folds and highlight the angles of the face. The option of deep chemical peels and dermabrasion has limited use in dark-skinned individuals and was responsible for the unpredictable scarring and hyperchromia that has always limited these procedures in certain ethnic populations. Peelings have become gentler. In the 1990s TCA peels experienced a comeback, allied to Retin A and alpha-hydroxy acid (AHA) peels.7 We can now treat both patients of Caucasian origin and darkskinned patients all year round, providing they follow strict recommendations of skin care and the use of sun-blocking agents. The idea of “refreshing“ rejuvenation has become extremely popular and public education has brought to our offices a new kind of patient, those afraid of the drawbacks of the traditional rejuvenation techniques. These patients, instead of waiting for their face to “fall“ at the age of 50, now came to our clinic in their early 30 s, or even late 20 s, looking for maintenance procedures until the facelift age finally arrives. We learned that all these small procedures can also be used in conjunction with rhytido- and blepharoplasty, enhancing their results. Perioral wrinkles, never treated with rhytidoplasty, could now be improved with fat grafting.

Techniques We classify facial rejuvenation procedures as surgical and non-surgical. Usually, the non-surgical options are indicated for younger patients, also older patients who do not want to undergo a surgical procedure, as well as to complement or improve the results of a surgery. Today Botox and fillers have been popularized and I have utilized these options from early on in my practice and have always offered this to my patients regardless of their age. I know some surgeons prefer not to, but I have felt that if we as plastic surgeons do not offer it, other specialties would start entering our field. Also, eventually, when these patients feel they need surgery, they would come to us and there would be an element of continuity.

Botox In the younger patient, we start treatment with Botox when the first wrinkles start to show in the forehead, glabella, and periorbital areas (crow`s feet) (Figs. 8.6.3 & 8.6.4). We also use Botox to elevate the corners of the eyebrows, to reduce platysmal bands in the neck, and lip vertical wrinkles (so-called code bar wrinkles). Botox is a trademarked product (Allergan Aesthetics). There are other botulinum toxins on the market, but we prefer to use the original. I prefer never to inject too much to avoid the “frozen”-look face. I tell my patients to return after a week and if they need a touch up it will be included in the original fee. This way I can control the amount to inject and avoid injecting too much. Patients are informed the treatment will last from 4 to 6 months. I also often administer Botox for bruxism and migraine, with good results.

Fillers When the nasolabial folds start showing we inject hyaluronic acid (HA) fillers. The next step also includes injection of the

Figure 8.6.3  Botox injection on the forehead with eyebrow elevation and glabella.

Figure 8.6.4  Botox injection on the forehead and glabella.

Techniques

malar region when fat here starts to be reabsorbed or displaced by gravity (Figs. 8.6.5 & 8.6.6). This malar injection also enhances the nasolabial area, giving it the support the skin has lost. The glabellar region is next, with a fold or two forming between the eyebrows. I never inject the periorbital area with sharp needles, to avoid any undue complications. We use the sharp needle to perforate the skin, then change to a blunt cannula to administer the injection. Although fillers and fat are not the natural substitute for bone, we can use them to accentuate a weak chin or facial angles, by injecting the zygomatic area, the chin, or the mandible angle (Fig. 8.6.7). Working in the Middle East we saw in our practice some disasters caused by the injection elsewhere of permanent fillers in the face. Some practitioners injected substances that were not approved by the proper health authorities, such as hydrogel. The result was traumatic (Fig. 8.6.8) exceedingly difficult and sometimes impossible to correct. We always advise patients they should only have temporary fillers injected, and to keep the label with the make of the filler. Although many

121

patients still ask for a “more permanent filler” we should always discourage them. We only use HA fillers from reputable companies (Chapter 8.2 offers details of approved products). Patients are informed the treatment will last from 4 to 6 months and they should return in due course for a “top up”. If patients want a more lasting result, I offer them fat grafting; one to three procedures should last for up to 2 years. Lip augmentation with fillers is one of the most soughtafter procedures. We avoid injecting the lips as if they were a sausage, instead we recreate the normal lip volumes (Fig. 8.6.9). I always finish the procedure by accentuating the Cupid’s bow and the lower lip border to redefine it.

Facial liposculpture The results we can obtain by only suctioning the excess fat from the submental area and neck can be impressive (Figs. 8.6.10–8.6.12). It is at a time, usually when our patients reach their late 30 s and are looking for more than Botox

Figure 8.6.5  Filler injection to augment chin and mandible angles.

Figure 8.6.6  Filler injection in the zygomatic area and chin.

122

SECTION II

CHAPTER 8.6  • Minimally invasive multimodal facial rejuvenation

Figure 8.6.7  Filler injection to augment chin.

Figure 8.6.8  (Left) Patient with infection and allergic reaction to unknown filler 3 years after injection. (Right) Six months after several treatments, including drainage, local and systemic corticosteroids, and antibiotics.

Figure 8.6.9  Filler injection to augment lips should produce a natural-looking result (right). The author injects in an oval shape in the orbicularis muscle, and finishes with a small amount in the Cupid`s bow.

Techniques

123

Figure 8.6.10  Submental and neck syringe liposuction to define the neck and mandible line.

Figure 8.6.11  Before and 12 years after neck syringe liposuction and three fat grafting procedures in the nasolabial folds and periorbital region.

and fillers, that we discuss with them the option of facial liposculp­ture, a combination of aspiration and injection of fat. This is a procedure for patients who do not have excess skin. We start with suction of the jowls and submandibular area, combining suction with injection of fat in the mandible angle and chin, redefining the “lost“ jawline. Fat is aspirated with a 10-mL syringe and 3 mm gauge cannula, decanted, and transferred from one syringe to another. We can use syringes varying from 1 to 3 mL for a more precise injection.

Suction is usually performed once and injection two or three times, following the Fournier principle of “over-inject in time, not in space”. Injection is performed in threads and can be repeated after 35 days. This means, in reality, that a facial liposculpture patient, is ready to return to normal activities the following day if they had only injection, in 2–3 days if they had suction, depending on the amount of fat removed and on patients’ predisposition to bruising. Corrective make-up is useful for clients with a busy schedule. Some patients might not need three fat injections and so do not repeat this

124

SECTION II

CHAPTER 8.6  • Minimally invasive multimodal facial rejuvenation

Figure 8.6.13  (Top) The 5-mm gauge cannula for aspiration and injection of fat. (Bottom) The 1.5-mm two-holed flat-tipped 15-cm long cannula, both are adapted to a 10-mL Luer-Lock syringe.

Figure 8.6.12  Submental and neck syringe liposuction to define the neck and mandible line.

procedure. This procedure is ideal for men and women who cannot stay away from work too long. In 1987 we were using 3-mm gauge cannulas to treat the face and the neck areas. Our results were good, but we felt we could improve them if we went even more superficially, even closer to the skin, using the same principle we were using to provoke skin retraction in the abdominal and femoral regions with superficial syringe liposculpture. In 1990 we developed a 1.5-mm two-holed flat-tipped 15-cm long cannula, to be adapted to a 10-mL Luer-Lock syringe, the same syringe we use for facial suction and injection (Fig. 8.6.13). A similar cannula, 3.7-mm gauge, had been used to treat hydro adenitis, scraping the skin from underneath, removing sweat glands. Our modification works well, especially in patients with flaccid skin of the jowls and submental areas. After fat suction, the cannula is turned, the holes facing the dermis, to scrape the skin, provoking an even, controlled retraction of the area. This refinement of the technique needs to be performed by an experienced plastic surgeon with, naturally, the utmost care and concentration.

Fat suction We have seen sequelae of superficial suction of the face, with unacceptable retracted skin areas around the neck, which are difficult to correct. The difference here lies in the words even,

uniform, and controlled retraction. Retraction occurs only when and where it is indicated. Even using this technique, some patients will still have excess skin, usually diagnosed as a case for resection. We were surprised reoperating these patients, after the local anesthetic infiltration, that when we suctioned, fat would appear in the syringe, and so in many cases we managed to recontour the neck superficially without having to resect skin or muscle (Fig. 8.6.14).

Fat injection To treat the face we aspirate fat with a 10-mL Luer-Lock syringe and a 3-mm gauge cannula. Initially we would centrifuge the syringes filled with aspirated fat and anesthetic fluid for one minute at 1500 rpm. Lately our preferred method to separate the substances is to decant the syringes for 10 minutes. The result is similar. After ejecting the local anesthesia fluid, we transfer the fat to the syringe we will use to inject fat. Fat injection should be made in “threads,” as the cannula is being removed, leaving space between grafts for neovascularization7 (Fig. 8.6.15). Grafts should not be thicker than 3 mm, or a central necrosis of the fat will occur (Fig. 8.6.16). We also use the Fournier “autolipocollagen” technique8 when we need to inject through finer needles to improve subcutaneous dermis in areas like the cleavage wrinkles, or to refine the Cupid`s bow. This technique, published by Fournier in 1991, gained projection recently under a different name, Nanofat. The passage of the fat between two syringes through transfers of smaller gauge will emulsify fat and make it possible to be injected with a 27 G needle. We have used syringe liposculpture (the suction and injection of fat) with success since 19889 (Figs. 8.6.17–8.6.23), always following the principles stipulated by Carpaneda,10 keeping the grafts small, maximum 3-mm thick.

Techniques

125

Figure 8.6.14  Before and after two submental fat suction procedures on a 55-year-old patient, after regular subdermal scraping to retract the skin. Only fat suction and injection. No rhytidoplasty.

“Plumping” of the skin

Fat “threads” should be injected as we remove the cannula

Figure 8.6.15  Fat cells should be injected as the cannula is removed, leaving space for neovascularization.

Viable cells

Central necrosis

Inflammatory tissue

Figure 8.6.16  If the grafted cells are around 1-cm diameter, there will be necrosis in the center of the graft. Around the necrosis is the viable graft, 1.5- to 2-mm thick. Around the graft is the inflammatory tissue, which lasts around 35 days.

Figure 8.6.17  Before and 5 years after three procedures of fat grafting in the malar and nasolabial areas.

126

SECTION II

CHAPTER 8.6  • Minimally invasive multimodal facial rejuvenation

Figure 8.6.18  Before and 1 year after fat grafting of the nasolabial and lips, plus skin treatment with 70% hydroxy acid peels and home exfoliating treatment.

Figure 8.6.19  Patient shown 1 year after rhytidoplasty. Her perioral area was treated with three procedures of fat grafting.

Figure 8.6.20  Before and 1 year after two fat grafting procedures of nasolabial and lips.

Figure 8.6.21  Before and 6 months after fat grafting of the lower eyelids. No blepharoplasty.

Techniques

127

Figure 8.6.22  Before and 1 year after upper blepharoplasty and fat grafting of the lower eyelids.

Figure 8.6.23  Fat grafting of the earlobes rejuvenates the ears and helps with the use of earrings.

Figure 8.6.24  Before and 1 year after three fat grafting procedures in the malar and nasolabial areas.

Other procedures Fat grafting is a good procedure to correct “runner`s face”. Runners tend to lose fat on the face and a simple fat injection can improve the areas and give the patient a healthy younger look (Fig. 8.6.24). In the 1990s I started performing laser skin resurfacing, but again, although the improvement of the skin can be remarkable, it is an overly aggressive procedure, with a long

recovery time, so it is not recommended for every patient (Figs. 8.6.25–8.6.27). Light chemical peels can be combined with daily exfoliation with hydroxy acid creams to improve facial rejuvenation. The peels improve fine wrinkles and old age spots, giving the skin a more youthful and healthy appearance. AHA peels are done fortnightly in the office in conjunction with a line of home care daily creams (Fig. 8.6.28).

128

SECTION II

CHAPTER 8.6  • Minimally invasive multimodal facial rejuvenation

Figure 8.6.25  CO2 laser resurfacing in the periorbital area. It is better to treat the full face to avoid a noticeable difference in the skin quality with the untreated areas.

Figure 8.6.26  Before and 1 week after laser resurfacing of the lower eyelids. Women can hide the redness with make-up.

Figure 8.6.27  Before and 1 year after laser resurfacing of the face. Good improvement in the periorbital area and in the quality of the skin.

Conclusion

129

Figure 8.6.28  Before and after upper blepharoplasty on a 72-year-old patient. She had only a lower transconjunctival procedure to remove excess fat. The skin was treated with 30% TCA chemical peel.

Conclusion The safety limits established for facial rejuvenation, in our hands, have changed. Subtle changes can radically alter our perception of a human face. Combining Botox, fillers, suction,

Access the reference list online at   Elsevier eBooks+

fat injection, and the use of light chemical peels, the results can be comparable to the results obtained through more extensive surgery, that frequently involves hospitalization and a higher risk and cost. The traditional procedures have not been abandoned by any means, but their indications have been revised according to the development of modern plastic surgery.

References

References 1. Toledo L.S. Facial rejuvenation – the role of skin retraction. Annals of the International Symposium “Recent Advances in Plastic Surgery“. RAPS III, March 14–15, 1992. Estadão, São Paulo, Brazil, pp. 30–37. 2. Toledo L.S. Superficial syringe liposculpture. Annals of the International Symposium “Recent Advances in Plastic Surgery“. RAPS/90, March 3–5, 1990. São Paulo, Brazil, p. 446. 3. Töpffer R. Essai de physiognomonie. Geneva; 1845. 4. Gombrich E.H., Hochberg J., Black M. Arte, percepción y realidad. Barcelona: Ed. Paidós; 1973:42. 5. Brunwick E, Reiter L. Eindrucks Charaktere Schematisierter Gesichter. Zeitschrift Psychol. 1937;142:67–134.

129.e1

6. Gombrich E.H., Hochberg J., Black M. Arte, percepción y realidad. Barcelona: Ed. Paidós; 1973:59. 7. Rubin M. Non-phenol chemical peels. Annals of the International Symposium “Recent Advances in Plastic Surgery“. RAPS/90. March 3–5, 1990. São Paulo, Brazil, p. 614. 8. Fournier P. Le Filling dermique au collagène autologue. Liposculpture, ma technique. Paris: Arnette; 1989:269–272. 9. Toledo LS. Syringe liposculpture: a two-year experience. Aesthetic Plast Surg. 1991;15:321–326. 10. Carpaneda CA, Ribeiro MT. Study of the histological alterations and viability of the adipose graft in humans. Aesthetic Plast Surg. 1993;17(1):43–47.

 

 

SECTION II • Aesthetic Surgery of the Face

9.1

Editors’ perspective: surgical facial rejuvenation Alan Matarasso

The publication of these volumes marks the 5th edition of this iconic series. Considering that plastic surgery is a specialty that is less than 100 years old, it is remarkable to note that these books have been in print for the majority of plastic surgery’s existence. The authors of these chapters are like a “Who’s Who” of the giants in plastic surgery, and the table of contents of each series is like a precious time capsule, reflecting the modern-day evolution in the expansion and scope of plastic surgery. From the inclusion of hand surgery and craniofacial surgery in the 1970s and 1980s to plastic surgery, to the nascent field of microsurgery that began in the late 1970s and early 1980s and its ultimate application to every part of the body, each of these textbook editions has incorporated these surgical areas, further underscoring our mantra about being the only surgical specialty not limited to one anatomic region. This series of textbooks has continued to mature with our specialty. In the 1980s and 1990s we saw the introduction and refinement of liposuction to plastic surgery, and a society (Lipoplasty Society) was established and devoted solely to the field of liposuction. Now as this volume of aesthetic surgery indicates, non-surgical injectables, fillers and energy devices herald another major addition to the field of plastic surgery that began at the turn of this century. These non-surgical and minimally invasive procedures have continued to expand at an unparalleled rate. Another relatively new field in plastic surgery is massive weight loss surgery. With the lifesaving explosion in bariatric surgery procedures, plastic surgeons stepped in to help patients complete their weight loss metamorphosis, and thus began the era of bariatric plastic surgery. Moreover, we are now experiencing the integration of the plastic surgeon’s skills that are derived from microsurgery, craniofacial surgery, body contouring surgery, and aesthetic surgery to the increasing population of transgender patients. Proving once again that plastic surgeons are, above all, innovators. We adapt our expertise to serve our patient’s needs.

None of these subspecialties in plastic surgery exists in a vacuum, rather the fundamental principles of all of them cross-pollinate the entire spectrum of plastic surgery. The cornerstone of facial rejuvenation is undoubtably a facelift. Many other related surgical and non-surgical procedures compliment, enhance, or even delay surgery, but there is currently no alternative that has the ability to achieve the same overall outcome of a facelift. Understanding the complex anatomy of the face is essential to understanding the aging process and selecting a tailored approach to each situation. In surgery, mastering a routine is useful. That routine should serve as a flexible template that can be adjusted to the unique goals, nuances and anatomy of each patient, in order to deliver consistent results. Facelift had long been an operation of wide tissue undermining, skin tightening, and defatting. As our understanding of aging and anatomy advanced, surgeons began to treat routinely the SMAS/platysma layers and, more recently, the fat compartments of the face that were deflated with advancing age. We have added adjunctive perioral rejuvenation for aging, elongated, deflated, or downturned lips, as well as resurfacing and treatments that are beneficial to the quality of the skin. Since the last edition of this textbook, the neck has also been parsed out as a separate part of a “full” facelift and is now often selectively treated independently. In selected cases of neck surgery, the deeper anterior neck structures can also be surgically modified to achieve a more sculpted and youthful appearance. What is evident throughout these chapters, is that we now have a firmer grasp on the anatomic etiology of facial aging and how to correct the stigmata it creates. Some of our finest surgeon contributors in the world demonstrate their methods throughout these volumes. From that, it is also clear that there are numerous different ways to reach the end zone.

SECTION II  •  Aesthetic Surgery of the Face

9.2 Facial anatomy and aging Bryan Mendelson and Chin-Ho Wong

Access video lecture content for this chapter online at Elsevier eBooks+

Introduction

Regions of the face

The pathogenesis of facial aging is largely explained on an anatomical basis, particularly the variations in the onset and outcome of aging seen in different individuals. Surgical anatomy is a particular branch of anatomy that focuses on specific surgical objectives. In contrast, traditional anatomy deals with bodily structure from an evolutionary and comparative perspective. Understanding of ambiguous dissection findings is explained by these related aspects. This chapter is on surgical anatomy of the face as it relates to the performance of facelifts. An anatomical approach to surgical rejuvenation of the face provides the way of obtaining a ‘natural’ result that is safe, with minimal morbidity and results that are lasting (Video Lecture 9.2.1). Fundamental to safety when operating in the face is the surgeon having a firm grounding in the principles on which the facial soft tissue layers are constructed.1 Understanding of the facial nerve branches and their relation to the soft tissue layers, retaining ligaments and soft tissue spaces is crucial in predicting the location of the facial nerves. This is most important in addressing the overriding concern when performing surgery, the course and location of the facial nerve branches. The development of facial laxity with aging of the face occurs primarily in the mobile superficial fascia, immediately superficial to the ‘deep plane’ or layer 4 as will be described. A core principle of plastic surgery, as advocated by Pare, is to ‘restore to their place things which are displaced’.2 Many facelift techniques have been utilized using various planes of dissection. Operating in the surgical plane is therefore the logical plane to dissect in facelifts. The surgical anatomy described here is intended for surgeons to enhance their ability and margin of safety when performing deep plane facelift surgery.

The traditional approach to assessing the face is to consider the face in thirds (upper, middle and lower thirds).3 While useful in selecting surgical procedures to address the patient’s concerns, this approach limits conceptualization, as it is not based on the function of the face. From a functional perspective, the face has an anterior aspect and a lateral aspect, which is distinctively different. The anterior face, which is the face proper, is highly evolved for communication, including facial expression. In contrast, the lateral face, which is concealed by hair in most animals including non-human primates, essentially covers the structures involved in mastication.4 A vertical line descending from the lateral orbital rim is the approximate division between the lateral and the anterior face. This corresponds internally with a series of facial retaining ligaments located along this line, which provide the structural basis for the demarcation (Fig. 9.2.1). The mimetic muscles of the face are located within the superficial fascia of the anterior face, predominantly in relation to the eyes and the mouth. This highly mobile area of the face is designed to allow fine movement, which predisposes it to the development of laxity with aging. In contrast, the lateral face is relatively immobile as it passively overlies the structures to do with mastication, which are located in relation to the deep fascia, the temporalis and masseter muscles, with the parotid gland and its duct. The only significant superficial muscle in the lateral face is the platysma in the lower third, which extends up to the level of the oral commissure. The soft tissues of the anterior face should be considered in two parts: (A) the part that overlies the skeleton proper; and (B) the highly specialized sphincters that overlie the bony cavities.5 The soft tissues that overlie the orbital and oral cavities are modified, as the cavities cannot have a deep fascia layer to provide support. An adaption is needed to compensate for

132

SECTION II

CHAPTER 9.2  • Facial anatomy and aging

this absence of usual support from behind. From necessity, the support comes from a system of specialized retaining ligaments attaching to the rim of the bony cavities. The fixation at the transition zones (between areas that overlie the skeleton and the bony cavities) is not apparent in youth, but become increasingly evident with aging.

the five-layered arrangement are most clearly understood by studying the scalp and forehead, whose soft tissues have been ‘distended’, as a consequence of the evolutionary expansion of the underlying cranial vault (necessary to accommodate the highly developed frontal lobe in humans) (Fig. 9.2.2). Layer 4

Surgical anatomy of the face, layered anatomy, SMAS, facial spaces and retaining ligaments Conceptually the facial soft tissues are organized in five concentric layers:1,5 (1) skin; (2) subcutaneous tissue; (3) musculo-aponeurotic layer; (4) loose areola tissue; (5) deep fascia. Significantly, the layers are not uniform across the face. Each layer varies in thickness according to the particular type of contained tissue, in accordance with the specific function of the region. Even the skin, the simplest layer to understand, is not homogeneous. The thickness of its epidermis and dermis varies according to the region of the face. The principles of

Figure 9.2.1  Regions of the face. The mobile anterior face is separated from the relatively fixed lateral face by a vertical line of ligaments (shown in red). The mobile anterior face is functionally adapted for facial expression while the lateral face passively overlies the masticatory structures. The ligaments are (from above): temporal, lateral orbital, zygomatic, masseteric and mandibular ligaments. The prezygomatic space allows a functional separation of the crowded midcheek structures into two separate but overlapping parts. The orbital-related structures, orbicularis oculi and the orbicularis retaining ligament, are superficial, extending into the roof of the prezygomatic space (shaded blue). The perioral part below is deeper (shaded yellow), where it has a skeletal attachment beneath the floor of the prezygomatic space. These deeply attached perioral structures include the zygomatic muscles and the zygomatic ligaments.

Figure 9.2.2  The basic five-layered construct of the facial soft tissues is most readily understood in the scalp. While this same construct continues over the entire face, for functional purposes there are significant regional modifications. Layer 4, the most variable layer, contains soft tissue spaces alternating with retaining ligaments. In addition, the facial nerve branches travel through layer 4, where they remain outside the spaces and then ascend to layer 3 in close relationship with retaining ligaments. (Inset). Showing the facial nerve branches ascend across layer 4 where they are under the protection of a ligament.

Surgical anatomy of the face, layered anatomy, SMAS, facial spaces and retaining ligaments

Layers

1

Dermis

2

Retinacular cutis

3

SMAS

133

Dissection level 2a. Subcutaneous, superficial

2b. Subcutaneous, deep 4. sub-SMAS

4

Retaining ligament

5

Periosteum 6. subperiosteal

(the loose areolar tissue) is the layer that allows the superficial fascia (defined as the composite flap of layers 1 through 3) to glide over the deep fascia (layer 5), as noted with facial expression. For example, the frontalis functions independent of the deeper muscle of mastication, the temporalis. The ‘simplified’ anatomy over the scalp gives the basic prototype of layer 4. For the most part, this plane is essentially an avascular gliding plane space. At the boundaries of the scalp across the supraorbital rim and along the superior temporal lines, the scalp of the forehead is firmly anchored by ligamentous attachments to the periosteum. Vital structures, the nerves, vessels and lymphatics, are not in the ‘space’, but are located in close proximity to the retaining ligaments when transitioning in their course from deep to superficial. The principles of construction remain the same in other parts of the face, although with greater complexity. This relates to the evolutionary compaction of the midface structure due to the absence of forward projection of the human mid face (as is present in other species) as well as the prominence of the orbital and oral cavities at the expense of solid bone. This reduces the amount of bony platform available for the attachment of muscles and retaining ligaments. The five soft tissue layers are secured to the facial skeleton by an elaborate system of retaining ligaments that bind the dermis to the skeleton (or deep muscle fascia, where the facial skeleton is covered by the muscles for mastication). The components of this multi-linked fibrous support system pass through all layers (Figs. 9.2.3 & 9.2.4).6 The descriptive terms layer and level are used almost interchangeably, although having a somewhat different connotation. The plane of surgical dissection of a target support layer, such as the SMAS (layer 3), is not within the layer but at a level above (deep subcutaneous level, layer 2) or below (in layer 4), or both (see Fig. 9.2.3). Layers 2 and 4 are the dissection layers and in them the surgical dissection level may be superficial or deep.

Layer 1: skin The epidermis is a cell-rich layer composed mainly of differentiating keratinocytes and a smaller number of

Figure 9.2.3  The multi-link fibrous support system concept, based around retaining ligaments, whose form can be likened to a tree. The ‘trunk’ of the ligament attaches the soft tissues to the periosteum of the facial skeleton or deep muscle fascia. The ligaments pass through all soft tissue layers, fanning out as multiple branches through the SMAS to eventually insert into the dermis. The ligamentous component in the subcutaneous layer is seen as the retinacular cutis. The possible dissection levels are indicated by the horizontal dotted lines.

Figure 9.2.4  The retaining ligaments of the face appear in three morphological forms: true ligaments, septae and areas of adhesion.

pigment-producing melanocytes and antigen-presenting Langerhans cells. A rich vascular plexus is an important component of the dermis. The thickness of the dermis relates to its function and tends to be inversely proportionate to its mobility. The dermis is thinnest in the eyelids and thickest over the forehead and the nasal tip. The thinner the dermis, the more susceptible it is to qualitative deterioration aging changes like wrinkling and creases formation.

134

SECTION II

CHAPTER 9.2  • Facial anatomy and aging

Layer 2: subcutaneous tissue The subcutaneous layer has two components: the subcutaneous fat, which provides volume, and the fibrous retinacular cutis that binds the dermis to the underlying superficial musculo-aponeurotic system (SMAS) of the face.7,8 Of note, the retinacular cutis is the name given to that part of the retaining ligament that passes through the subcutaneous tissues. The amount, proportion and arrangement of each component varies in different regions of the face. In the scalp, the subcutaneous layer has uniform thickness and consistency of fixation to the overlying dermis. In contrast, in the face proper, the subcutaneous layer has significant variations in thickness and attachments. In highly specialized mobile areas, such as the eyelids and lips, the subcutaneous layer is significantly compacted such that fat may appear non-existent. In other areas, such as the nasolabial segment, it is thick.5 In areas with thick subcutaneous tissue, the retinacular cutis lengthens significantly, predisposing its fibers to distention and weakening with aging. Within the subcutaneous tissue, the overall attachment to the overlying dermis is stronger and denser than the attachment to the underlying SMAS. This is a result of the tree-like arrangement of the retinacular cutis fibers (see Fig. 9.2.3), with fewer but thicker fibers deep as its rises through the SMAS then progressively divides into multiple fine microligaments as they reach the dermis. This explains why dissection is easier to perform at the deep subcutaneous level (just on the surface of the underlying SMAS) than more superficially nearer the dermis, as there are fewer retinacular cutis fibers and the subcutaneous fat here does not attach directly to the outer surface of the underlying SMAS. Furthermore, the retinacular cutis fibers are not uniform across the face. They vary in orientation and density according to the anatomy of the underlying deeper structures.7 As will be apparent when the anatomy of the underlying layer 4 is described, at the location of the retaining ligaments, the vertically oriented retinacular cutis fibers are most dense and are the most effective in supporting for the overlying soft tissues and in so doing, forms boundaries that compartmentalize the subcutaneous fat. These areas, such as the so-called McGregor’s patch over the body of the zygoma, often require sharp release to mobilize. In between these retaining ligaments in layer 4 are located the soft tissue spaces of the face, that facilitate the mobility of the superficial fascia over the deep fascia. Where the subcutaneous fat overlies a space, the retinacular fibers are less dense and oriented more horizontally. This has a surgical significance as the tissues tend to separate with relative ease, often with just simple blunt finger dissection (Fig. 9.2.5). The variation in the density and orientation of the retinacular cutis fibers in the subcutaneous fat is the anatomical basis for the ‘superficial subcutaneous fat’ compartments.9–11 Dye injection into the subcutaneous fat results in staining of the fat in discrete compartments. While the relevance of superficial subcutaneous fat compartments remains debated, anatomically, the compartments are defined by their retaining ligaments boundaries.12

Layer 3: musculo-aponeurotic layer The muscles of facial expression are unique and fundamentally different from skeletal muscles beneath the deep fascia

Figure 9.2.5  The effective strength of the retinacular cutis fibers varies in different areas of the face. Overlying the retaining ligaments, the fibers are more vertically orientated, more densely arranged and resist aging changes. Whereas, overlying a space the retinacula fibers are more horizontal and less dense. This structure allows the mobility required for muscle contraction, but the less supported roof over the spaces is prone to laxity with aging.

because of their situation within the superficial fascia and the tissues they move are not bone but the soft tissues of which they are a part. All muscles of facial expression have either all or the majority of their course within layer 3. They are predominantly located over and around the orbital and oral cavities. In the prototype scalp, the occipital-frontalis moves the overlying soft tissue of the forehead, while its undersurface glides over the subgaleal aponeurotic space (layer 4). Layer 3 is continuous over the entire face, although for descriptive purposes, different names are given to certain parts according to the superficial muscle within. It is called the galea over the scalp, the temporoparietal (superficial temporal) fascia over the temple, the orbicularis fascia in the periorbital region, the SMAS over the mid and lower face and platysma in the neck.13 Within layer 3, the facial muscles themselves have a layered configuration, with the broad, flat muscles forming the superficial layer over the anterior aspect of the face. The frontalis covers the upper third, orbicularis oculi the middle third and the platysma the lower third. The muscles of this superficial muscle layer have minimal direct attachment to the bone. They are stabilized indirectly to the skeleton by the vertically oriented retaining ligaments at their periphery, as noted earlier. The frontalis is fixed along the superior temporal line by the superior temporal septum, the orbicularis oculi laterally by the lateral orbital thickening and the orbicularis retaining ligament, and the platysma at its upper border by the lower key masseteric ligament and medially by its mandibular attachment. The deeper muscles in layer 3 have bony origins to provide greater functional control of the sphincters over the bony cavities. Particularly around the mouth, the dynamic aperture of the expansile oral cavity, which has elevators (zygomaticus major and minor, levator labii superioris, levator anguli oris). Levator labii superioris alaeque nasi and depressor muscles (depressor anguli oris, depressor labii inferioris) and mentalis.1 In relation to the orbital cavity, deep muscles are limited to the corrugator supercilii and procerus.

Layer 4 Layer 4 is the plane in which dissection is performed in subSMAS facelifts, aptly named by Hamra as the deep plane.14,15 It is a layer of significant complexity that contains the following structures: (1) soft tissue spaces; (2) retaining ligaments; (3)

Anatomy over the cavities in the skeleton

*

Figure 9.2.6  Topographical anatomy of layer 4 over the lateral face. Spaces (blue), ligaments (red) and areas of important anatomy (stippled). The vertical line of masseteric retaining ligaments demarcates the transition between the stable lateral face and the highly mobile anterior face. The spaces over the zygoma and over the masseter allow for intermediate mobility. The triangular-shaped non-space areas, immediately above and below the arch of the zygoma, contain important anatomy; namely, the temporal and zygomatic branches of the facial nerve respectively, which proceed from lateral into the anterior face. The asterisk indicates the uppermost premasseteric area.

deep part of the intrinsic muscles, where passing from their more definitive superficial soft tissue position to obtain a deeper (level 5) bone attachment; and (4) facial nerve branches, passing from deep to superficial. Functionally, there is a series of soft tissue spaces in layer 4 that allow for movement of the periorbital and perioral muscle of facial expressions (located in the roof of the spaces) independent of the major muscles of mastication, which are beneath the deep fascia floor of the spaces.16 The retaining ligaments of the face are strategically placed within the boundaries between the soft tissue spaces (Fig. 9.2.6). In the lateral face, immediately in front of the ear, extending 25 to 30 mm forward of the ear cartilage to the posterior border of the platysma, is a broad area of ligamentous attachment, described by Furnas as the platysma auricular fascia (PAF).7 As no active facial expression occurs in this region, the dermis, subcutaneous tissue, aponeurotic part of the SMAS and the underlying parotid capsule (layers 1 to 5) are bound together as an area of retaining ligament. Layer 4 is reduced to a fibrous fusion layer, without a soft tissue space, as mobility of the superficial fascia is not required here. Whereas, in the anterior face where there is considerable movement, not only over but also around the bony cavities, the ligaments are significantly compacted and arranged around the rim of the bony cavities. The bone boundaries provide the last position where underlying deep fascia is present for ligamentous attachment. These important ligaments provide support for the mobile shutters of the cavities, the eyelids and lips. Importantly for the surgeon, the retaining ligaments also act as transition points for the facial nerve branches to pass from deep to superficial on their way to innervate their target muscles.

135

The soft tissue spaces of the face are in two forms: (1) those described overlying bone, where the spaces allow the overlying superficial fascia to glide freely over the deeper layer 5; and (2) those overlying the bony cavities, such as the preseptal space of the eyelid over the orbit and the vestibule of the oral cavity under the lips and the lower nasolabial segment of the cheek.

Layer 5 Of potential confusion to surgeon anatomists is the definition of deep fascia; a term used to describe the dense connective tissue related to skeletal muscles and organs. It is accepted that the superficial fascia denotes several layers based on the loose connective tissue, layer 2, linking the layer 3 muscle and the skin. According to this way of describing fasciae, the deep fascia is considered to be all the connective tissue deep to the superficial fascia. From this perspective, layer 4 as described, would be considered part of the deep fascia. However, from a surgeon’s perspective of facial anatomy, layer 4 is a well-defined transition layer that functionally separates the superficial fascia from the deep fascia. The deep fascia, the deepest soft tissue layer of the face, has multiple components. It is formed by the periosteum where it overlies bone. Over the lateral face, where the muscle of mastication (temporalis and masseter) overlie the bone, the deep fascia is instead the fascial covering of the muscles, i.e. the deep temporal fascia and masseteric fascia. Over the anterior face there is not a deep fascia layer within the lids and lips, the mobile shutters that overlie the bony cavities. Here, the deep fascia is replaced by a mobile lining from the cavities, the conjunctiva and oral mucosa. The recently described ‘deep fat compartments’ is fat located in layer 5, having more generally been called preperiosteal fat.11,12 In the neck, the corresponding layer is the investing layer of deep cervical fascia, which covers the suprafyoid muscles and splits to form the submandibular space containing the submandibular gland. In contrast to expectation, the investing deep cervical fascia is thin, being almost translucent but tough and quite flexible, consistent with the significant mobility of the neck.

Anatomy over the cavities in the skeleton The general pattern of the five-layered anatomy is modified over the anterior face where the orbital, nasal and oral cavities are present (Fig. 9.2.7). Only the superficial fascia, the outer three-layer composite, continues into the soft tissue overlying the cavities. The SMAS layer within this composite includes the sphincteric orbicularis muscles that extend to the free edge of the soft tissue aperture of the eyelids and the lips. The retaining ligaments, which are such a key feature of the five-layered anatomy, are not present over the cavities. There are functional and anatomical transitions from the relative stability over the fixed areas to the high mobility of the soft tissue shutters over the cavities. In order to support this composite, the retaining ligaments are condensed, being compacted along the bony orbital rim (Fig. 9.2.8). This is the anatomical basis for the periorbital ligament around the orbit, of which the lower lid part is the orbicularis retaining

136

SECTION II

CHAPTER 9.2  • Facial anatomy and aging

Figure 9.2.8  The system of retaining ligaments situated across the temple and around the bony cavities, the orbital and oral, stabilize the soft tissue both over and around the cavities.

Figure 9.2.7  The soft tissue anatomy over the midcheek, showing the arrangement of the spaces (preseptal, prezygomatic and premaxillary) and the related ligaments (orbicularis retaining above and zygomatic and maxillary below).

(orbito-malar) ligament, which stabilizes the orbicularis oculi to the orbital rim periosteum.18–21 Around the oral cavity, the zygomatic ligaments arise from the periphery, being the body and arch of the zygoma and from the deep fascia near the medial edge of the masseter.22 The deeper components of the eyelids and lips are derived from the cavity they cover and are not an extension of the facial soft tissues. In the eyelids, the deeper lid muscles with their related aponeurosis (levator and capsulopalpebral fasciae) and the orbital fat are retained by a fascial system, the septum orbitale. The free edges of the upper and lower eyelids obtain their ligamentous support from the tarsal plates, with their canthal tendon attachments to the medial and lateral orbital rims. In the pretarsal area, the superficial and deep lid structures, the anterior and posterior lamellae, merge. Whereas, in the preseptal part, between the pretarsal area of the lids and the orbital rim, the lamellae remain separated by a soft tissue space, the preseptal space of the lower lid, which allows movement of the preseptal orbicularis over the orbital septum. This space provides the surgeon an atraumatic and bloodless dissection plane to access the lower eyelid and the midcheek further inferiorly. There is not an equivalent space in the upper lids as the preperiosteal fat pad over the superior orbital rim continues down on the surface of the septum orbitale adherent to the fascia on the underside of the orbicularis. The vestibule of the oral cavity overlies a significant extent of the buccal surface of the maxilla and mandible. This part of the skeleton underlying a ‘space’ is unavailable for deep

ligamentous support, as ligaments cannot cross the space of the vestibule. The large area of the perioral soft tissues that overlies the extensive vestibule has compromised support. Along with the extreme mobility of the lips and, particularly, the adjacent cheek with jaw opening, these tissues are particularly susceptible to aging changes. In fact, the indication for a lower facelift is largely to correct aging laxity of this unsupported tissue.

Facial spaces The subSMAS layer 4 is not homogeneous, but varies significantly in the type of content according to the different functional areas. In the lateral face especially, a large component of layer 4 consists of soft tissue ‘spaces’, which allow for mobility. The spaces have defined boundaries that are reinforced in strategically important areas by retaining ligaments.5,22,23 Significantly, these described spaces are actually areas of loose areolar connective tissue that are anatomically ‘potential spaces’. These are easily converted to ‘surgical spaces’ by blunt surgical dissection within the loose connective tissues. Even then, the created surgical space may not necessarily extend all the way to the structural boundaries of the space. By definition these are anatomically ‘safe spaces’, as no vital structures cross within the areolar tissue space, meaning all facial nerve branches are outside these spaces. The mobile roof is the least-supported part of the space, being more prone to developing laxity with aging, compared to the ligament-reinforced boundaries. This differential laxity accounts for much of the characteristic changes that occur with aging. Once a space has been surgically defined to its boundaries, the retaining ligaments in the boundary can then be precisely defined and released under direct vision to achieve the desired mobilization, while the vital structures

Facial spaces

137

The upper temporal space provides safe surgical access to the lateral brow and upper midcheek.25,26 The space can be readily opened by blunt dissection to its boundaries. Once identified, the boundaries can then be released by precise dissection. The STS can be released sharply, taking care only to preserve the lateral (deep) branch of the supraorbital nerve, which runs parallel to the septum about 15 mm medial to it.18 The ITS provides a marker to the important anatomy here as the temporal branches of the facial nerve are located parallel to and immediately inferior to this septum. To release the ITS, the ceiling of the space is gently lifted off the deep temporal fascia floor, which three-dimensionalizes the septum in preparation for gentle release at the level of the floor, bearing in mind the frontal branches are located on the underside of the temporoparietal fascia in the ceiling, under the roof of the lower temporal area. Once released, the sentinel vein comes into view. Contrary to what is suggested by its name, the sentinel vein is not necessarily a good ‘sentinel’ to warn the surgeon of the imminent proximity of the temporal branches when dissecting inferiorly from the temple approach. See further discussion in section Facial nerve branches.

Prezygomatic space Figure 9.2.9  Structures around the orbital cavity in level 4. Above is the upper temporal space between the retaining ligaments of the temple; the superior temporal septum (STS) and the inferior temporal septum (ITS), both being extensions of the temporal ligamentous adhesion (TLA). There are no structures in the upper temporal space. The TLA continues medially as the supraorbital ligamentous adhesion (SLA). Below the bilaminar inferior temporal septum is the triangular-shaped lower temporal compartment (stippled), where the temporal branches of the facial nerve (TFN) course immediately inferior to the septum on the underside of the temporoparietal fascia. Also crossing level 4 in this area are the medial and lateral branches of the zygomaticotemporal nerve within the orbicularis retaining ligament, and the sentinel vein. The periorbital septum (PS, green) outside the orbital rim contains two areas of ligamentous thickening, the lateral orbital thickening (LOT) and the lateral brow thickening (LBT). ZFN, Zygomaticofacial nerve.

closely associated with the ligaments are preserved. A brief description of the surgically significant facial soft tissue spaces follows.

Upper temporal space In the temple overlying the temporalis muscle fascia are two compartments that are separated by the obliquely orientated inferior temporal septum (Fig. 9.2.9). The upper compartment is a surgical space while the lower compartment is not a space, but an area containing important anatomy.19 Both compartments are interposed between the superficial temporal fascia (temporoparietal fascia) and the deep temporal fascia (temporalis muscle fascia). Anatomically, the upper compartment is an extension of the forehead anatomy down into the upper temple, while the lower compartment is an upward extension of the upper cheek anatomy into the lower temple.24 The upper temporal space is separated from the forehead by the superior temporal septum (STS) along the superior temporal line, whereas antero-inferiorly, the inferior temporal septum (ITS) separates the upper space from the triangular-shaped lower temporal area that contains important anatomy. These two septae merge anteriorly at the triangular-shaped zone of adhesion called the temporal ligament.18

This triangular-shaped space overlies the body of the zygoma, its floor covering the preperiosteal fat and origins of the zygomatic muscles. The space allows contraction of the orbicularis oculi (pars orbitale) in its roof, independent of the zygomatic muscles under the floor. Contraction of the overlying orbicularis elevates the prezygomatic soft tissue roof. When these tissues have significant laxity the contraction results in significant movement of the skin toward the lateral canthus, forming zygomatic smile lines (below the crow’s feet) (Fig. 9.2.10).19 With aging laxity the resting position of the roof of the space is at a lower level. This results in a greater amplitude of movement on orbicularis contraction, which exaggerates the zygomatic smile lines.

Premaxillary space This quadrangular-shaped space overlies the maxilla, medial to the prezygomatic space. Its floor is formed by the levator labii superioris on which it overlies. The space allows independent movement of the closely related muscles, orbicularis oculi in the roof, and levator labii superioris under the floor (Fig. 9.2.11). Laxity of the roof of the premaxillary space contributes to deepening of the nasolabial fold with aging.

Premasseter spaces The area overlying the lower two-thirds of the masseter, inferior to the parotid gland, is a large area of ‘glide plane’ space, which is analogous to the temporal space in that it overlies the deep fascia of a muscle of mastication (Fig. 9.2.12).22 This gliding soft tissue plane allows wide jaw opening without restriction or distortion of the overlying soft tissues. The roof of the larger, lower premasseter space is formed by the platysma, which continues over the anterior face to the oral commissure. The upper edge of the platysma is stabilized in position by the lower key masseteric ligament, and does not extend higher than this to be in the roof of the adjacent upper space. Laxity in the roof of the lower space, particularly

138

SECTION II

CHAPTER 9.2  • Facial anatomy and aging

Figure 9.2.11  The anatomy and key relations of the prezygomatic and premaxillary spaces and the tear trough ligament. The prezygomatic space overlies the origins of zygomaticus major and minor. The premaxillary space overlies levator labii superioris with the infra-orbital nerve beneath, the angular vein immediately lateral to the space and the angular artery immediately medial. ORL, Orbicularis retaining ligament; TTL, tear trough ligament. Figure 9.2.10  The prezygomatic space overlies the body of the zygoma. The origins of the zygomatic muscles extend under the floor between preperiosteal fat. The roof is formed by the orbicularis oculi lined by the thin suborbicularis oculi fat. The upper ligamentous border, formed by the orbicularis retaining ligament, is not as strong as the zygomatic ligament-reinforced lower border.

anteriorly, where it has a weakened attachment to the anterior masseter and its inferior boundary, contributes to the formation of the jowl.

Middle premasseter space The middle premasseter space is a small rectangular space cephalad to the lower premasseter space (Fig. 9.2.13).27 As in the lower space, the floor of the upper space is formed by the masseter fascia, but the roof is formed here by the SMAS without platysma. The upper space is important in subSMAS facelifts, as it provides an anatomically safe area to dissect, in proximity to the upper and lower buccal branches of the facial nerve. Significantly, the nerves are located immediately outside the space, within its upper and lower membranous boundaries respectively. The parotid duct is closely associated with the upper membranous boundary of the space, where it courses immediately deep to the upper buccal branch of the facial nerve.

Buccal space The buccal space is located in the anterior face above the level of the oral commissure. It is a deep facial space, being like

the submandibular space (which contains the submandibular gland), in that it is deep in the deep fascia (layer 5).28,29 The space and its major content, the buccal fat pad, facilitate movement of the overlying nasolabial segment of the midcheek as well as buffering this area during major jaw opening. With aging and attrition of the boundaries, particularly of the most inferior masseteric ligaments, the platysma becomes less firmly bound to the masseter. This allows the buccal space to enlarge, as a consequence of which, the buccal fat prolapses inferiorly below the level of the oral commissure into the lower face. As the buccal fat then comes to overlie the anterior border of the lower part of the masseter, its volume contributes to increased prominence of the labiomandibular fold and jowl.

Retaining ligaments of the face It is a fundamental concept that the retaining ligaments function to bind all five layers of the facial soft tissues. As a consequence, the ligaments are the anatomical basis for the formation of cutaneous grooves (seen between areas of laxity/ bulges). As an example, the midcheek, where the tear trough– orbicularis retaining ligament complex is the key retaining ligament of the upper midcheek.30 It is located just outside the orbital rim and closely follows the edges of the rim. This retaining ligament system separates the bony cavity (the orbit) from the bony platform of the midcheek skeleton below. This ligament functions to stabilize and secure the soft tissues of

Retaining ligaments of the face

139

Figure 9.2.12  The rhomboidal-shaped lower premasseter space overlies the lower half of the masseter. The platysma forming the roof does not extend over the middle space. The posterior border of the space extends to edge of the parotid. The anterior border curves forward inferiorly, reflecting the shape of the lower masseter and is reinforced by the masseteric ligaments near the anterior edge of muscle. The inferior boundary is mobile, mesentery-like and does not contain any ligament. Weakness of the platysma roof at the lower anterior and inferior boundaries contributes to the formation of the jowl, immediately behind the strong mandibular ligament. The buccal space containing the buccal fat is anterior to the key masseteric ligaments. All facial nerve branches course around and outside the spaces. The surgically important mandibular branch, after leaving the parotid, courses under the inferior boundary of the space then rises onto the masseter surface before reaching the mandibular ligament.

the lower eyelid where it transitions from the relative stability over the bone to the mobile area over the orbital cavity. The tear trough ligament is a true osteocutaneous ligament originating from the maxilla and inserting into the dermis of the nasojugal groove, the tear trough, passing through and binding all five soft tissue layers.30 This ligament is the anatomical basis for the tear trough deformity (see Fig. 9.2.11). The tear trough ligament continues laterally as the orbicularis retaining ligament, which is the anatomical basis for the palpebromalar groove. The continuity of the tear trough ligament with the orbicularis retaining ligament explains the observation that, as aging progresses, the tear trough becomes continuous with the palpebromalar groove to form the prominent cutaneous groove, sometimes called a prominent ‘lid–cheek junction’. This demonstrates the key role of the retaining ligaments in the formation of the cutaneous grooves that appear with aging. Figure 9.2.13  The middle space, overlies the anterior masseter, cephalad to the lower space and within the anterior concavity of the parotid. The upper and lower buccal trunks of the facial nerve course immediately outside the space, as does the parotid duct, just within the upper and lower membranous boundaries. The masseteric process of the buccal fat pad, when large, is the only content in this space.

Facial nerve branches The danger zones for facial nerve injury are well described in the literature. However, this is of limited value to the

140

SECTION II

CHAPTER 9.2  • Facial anatomy and aging

Figure 9.2.15  Modular construction of the face showing in layer 4 the ligaments and neurovascular structures passing outward in the interval between spaces.

Figure 9.2.14  Illustration to emphasize the location of the facial nerve branches and their course relative to the spaces and ligaments. The nerves course outside the spaces at all times in the lateral face. As they approach the ligamentous boundary into the mobile anterior face, the facial nerve branches ascend from deep in layer 4 to superficial layer 4, always in close, protective relationship with the retaining ligaments within the boundary. The interconnecting nerve branches between adjacent nerve trunks are located ii immediately sub-SMAS.

surgeon due to the topographical 2D perspective this gives of the expected course of the nerve relative to surface landmarks.31–33 Surgical confidence when approaching the nerve surgically comes from having a 3D understanding of the course of the nerve relative to the layered anatomy as described above and visually identifying the nerves in relation to defined landmarks (Fig. 9.2.14).34 The trunks of the facial nerve, while having some variability in their exact location as they travel to innervate their target muscles of facial expression follow certain anatomical principles. Specifically, nerve branches transition from deep to superficial in close association with retaining ligaments as these provides protection for the vulnerable nerves. The facial nerve branches enter the face at a deep level as they emerge from the parotid gland, then continue in the deep fascia of the lateral face. As they approach the anterior face near the anterior border of the masseter, the branches traverse layer 4, ascending to reach the underside of the mimetic muscles layer (layer 3). It is at these transition points across layer 4 that the nerves are at greatest risk of injury during facelift surgery 27,35,36 (Fig. 9.2.15). Surgical release of these ligaments, performed to obtain the needed mobility, must be performed with extreme care on account of the proximity of the nerves. The temporal and mandibular branches are the most significant in terms of surgical risk because of the lack of cross innervation of their target muscles. The surface marking of the temporal branch of the facial nerve along the Pitanguy line, is from a point 0.5 cm below the tragus to a point 1.5 cm lateral to the supraorbital rim.37–40 It is traditional teaching that once the temporal branches exit the parotid, they immediately travel superficially from the deep fascia and come to lie just deep to the SMAS where they cross the arch of the zygoma. Because of its superficial location, surgical

transection of the SMAS here, so-called high SMAS transection (i.e., at or above the arch), had generally been discouraged. However, it is now apparent that the temporal nerve branches cross the zygomatic arch deeper than previously thought. A histological study confirmed that the temporal branches are in transition from where they exit the parotid inferior to the zygomatic arch, to where they enter the underside of the temporoparietal fascia some 2 cm above the arch.41 They course deep in layer 4, superficial to the periosteum, here protected by a fascial, fatty layer, which is an upward prolongation of the parotid-masseteric fascia, named the parotid-temporal fascia. The temporal branches make their transition to the underside of the temporoparietal fascia (layer 3) between 1.5 cm and 3 cm above the zygomatic arch. From here the nerves remain on the underside of the temporoparietal fascia (layer 3). The transition is always before the nerve reaches the sentinel vein further cephalad. When dissecting from the temporal approach, once the sentinel vein is visualized, the temporal branches are in the lower temporal compartment in a wafer-like layer of fat on the underside of the temporoparietal fascia.18 Accordingly, when approaching from the temple, dissecting in the temporal space (layer 4), the safe plane of dissection is right on the deep temporal fascia floor, as the temporal nerves are located just superficial in level 4 above the level of dissection on the floor. Once the sentinel vein is clearly visualized, the dissection would have passed the temporal nerves. For this reason, the name sentinel nerve is misleading as the vein is supposed to herald the temporal branches. However, when the dissection is from above, logically through the temporal space once the vein is visualized, the dissection has already passed these branches. The zygomatic branch exits the parotid gland deep, inferior to the zygomatic arch and cephalad to the parotid duct. It travels with the transverse facial artery horizontally across the masseter on the masseter fascia, heading toward the major zygomatic retaining ligament (that arises from the lower border of the body of the zygoma), immediately lateral to the origin of zygomaticus major. As the nerve approaches the lateral border of the ligament, it gives off a small vertically oriented motor branch to orbicularis oculi that enters the muscle at its inferolateral corner.42 The main zygomatic nerve continues its course by passing beneath zygomaticus major and then zygomaticus minor, which it supplies from their deep aspect.42–44

Aging changes of the face

The use of precise dissection in this area of important anatomy, using gentle vertical spreading of blunt-tipped scissors, is fundamental to avoiding damage to the zygomatic nerve and the orbicularis motor branch while always staying superficial to zygomaticus major. The upper buccal trunk exits the parotid approximately in line with the parotid duct, but is superficial to it, and continues deep to the parotid–masseteric fascia, within the membranous upper boundary of the upper premasseter space.27 Approaching the anterior edge of the masseter, this branch leaves the masseter fascia floor and continues forward on the inferior aspect of the upper key masseteric ligament (see Fig. 9.2.14). The lower buccal trunk emerges from the parotid lower down, approximately at the level of the earlobe and remains within the masseter fascia floor of the lower premasseter space as it approaches the membranous interval between the premasseter spaces. Similar to the upper buccal branch, upon approaching the anterior masseter, the lower buccal trunk, while now in the interval just outside the space, transitions from deep to gain the underside of the SMAS in close association with the superior aspect of the lower key masseteric ligament. When immediately forward of the ligament on the underside of layer 3, the upper and lower buccal trunks send an interconnecting branch to each other before continuing their course to innervate the mimetic muscles of the anterior face. The upper buccal also sends an interconnecting nerve with the zygomatic trunk, as does the lower buccal branch share an interconnecting branch with the mandibular. This accounts for the overlap in muscle innervation by these nerves. The marginal mandibular nerve exits the anterior-inferior portion of the parotid near the angle of the mandible and remains deep to the platysma, in the investing deep cervical fascia. Its location is variable here, initially being somewhat inferior to the mandibular rim, although it can be located above or as low as 3 cm below the inferior border of the mandible (see Fig. 9.2.14). The nerve swings upwards before the mid body of the mandible and then transversely crosses superficial to the facial vein and artery. It is always located above the lower border of the mandible anterior to the facial artery. It innervates the depressor quadratus labii inferioris and mentalis from their deep surfaces. It may anastomose with the cervical and buccal branches to supply the depressor angularis oris and the cephalic portion of the platysma. It is at risk where fixed by its close association with retaining ligaments, both early in its course, within the PAF around the angle of the mandible, and then well anteriorly close to the mandibular ligament.45–48 Early in its course, the mandibular branch is in relation to the inferior boundary of the premasseter space. When dissecting here it is safer to focus on the underside of the platysma, which, being muscular, has inherent mobility where it overlies the mandible and the submandibular area. It is not necessary to dissect in the immediate vicinity of the mandibular branch, which is deeper with some mobility where it is in relation to the inferior extent of the lower premasseter space; hence, the reported variability of the location in this part of its course. The mandibular branch becomes more at surgical risk once it crosses the rim of the mandible and over the anterior-inferior corner of the masseter in a thin layer of fat, in which it remains until it intimately crosses the facial vein and then the artery, then the short distance between the artery and the mandibular ligament. The danger zone for injury extends from the angle

141

of the mandible to its crossing of the facial artery over the area from the body of the mandible to a parallel line 3 cm below. The cervical branch exits the inferior part of the parotid gland slightly anterior to the angle of the mandible deep within the deep fascia. Early in its course the cervical trunk is close to the marginal mandibular nerve. As the nerves runs more distally, the cervical branch continues caudally while the marginal mandibular turns forward and then more cephalically to be located above the lower border of the mandible.49 The cervical trunk continues inferiorly parallel to the anterior border of the sternomastoid, approximately 1 cm anterior to the muscle, within the deep fascia. A series of smaller branches coming off the cervical trunk pass forward initially deep in the deep fascia, transitioning to more superficial at the deep surface of the platysma, sending terminal branches innervating the platysma along the deep surface. Cervical branch injury, either by traction or transection, is not uncommon in facelifts, with an incidence as high as 3%.50 Injury results in paralysis of the lip depressors (depressor angularis oris) of the affected side in patients who have a communicating branch with the marginal mandibular nerve. This injury has been called ‘marginal mandibular nerve pseudo-paralysis’ as it may mimic an injury of the marginal mandibular branch. Cervical branch injury can be distinguished from marginal mandibular nerve injury by the ability of the patient to evert the lower lip, an action of the mentalis that is innervated by the marginal mandibular branch. Fortunately, cervical branch injury has an excellent prognosis with expected full recovery in most patients within 3 weeks to 6 months. The danger point for injury of the cervical branch is at its point of transition from the deep investing fascia to the underside of the platysma.50,51 To mobilize the platysma, subplatysmal dissection may be needed. The platysma should be mobilized 4 cm below the angle of the mandible and bluntly elevated with a Trepsat dissector.52 Unfortunately, there is not yet sufficient detail on the cervical branch to satisfy the creative needs of surgeons. For example, in which part of the course of the cervical branch would it be logical and safe to perform a functional disruption, e.g., cryotherapy, of the cervical branch in order to overcome the clinical problem of recurrence of contractile platysma bands following platysma transection?

Aging changes of the face The youthful face has the general appearance of high rounded fullness, while the aging process is characterized by a look of depletion and sagging, suggestive of tiredness. Changes with aging occur at every level of the facial anatomy, starting with the facial skeleton. Current understanding of the aging process remains largely empirical, given that it is based on the effectiveness of treatments designed to satisfy the requirements of patients for a younger appearance. Historically, stretching of loose facial skin (traditional facelift), removal of apparent tissue excess (traditional blepharoplasty), tightening the dermis and evening the complexion (early phenol peels and CO2 laser resurfacing), and in recent years soft tissue volume augmentation (lipofilling and soft tissue fillers) have all had a positive impact on rejuvenating appearance. The success of each is attributed to having reversed a component of facial aging. Yet, when each of these modalities is continued as the

142

SECTION II

CHAPTER 9.2  • Facial anatomy and aging

sole treatment, to further reverse the aging appearance and contend with ongoing aging, the results tend to be bizarre, leading to the conclusion that multimodal therapy is required to appropriately reverse what must be multiple components of the aging process. An understanding of the changes that occur in the layered anatomy forms the basis for logical treatment. Changes of the skin are readily observable and changes in the skeleton affecting layer 5 can also be observed radiologically. Because the changes within the superficial fascia (layers 2 and 3) are not directly measurable, empiricism has remained prevalent. A correlation of the surface anatomy changes of aging with the anatomy of layers 2, 3 and 4 indicates that bulging occurs over the roof of soft tissue spaces, which stand out in contrast to the absence of bulging of the adjacent cutaneous grooves. The grooves reflect the restriction imposed by the dermal insertions of the retaining ligaments at the boundaries of the spaces. The extent to which the bulging reflects true elongation from primary tissue degeneration and laxity and how much is ‘apparent’ laxity secondary to loss of volume (skeletal and soft tissue) has yet to be defined.

Skin Skin aging is influenced by genetics, environmental exposure, hormonal changes and metabolic processes.53–59 With aging, the supple skin of youth becomes thinned and flattened, with loss of elasticity and architectural regularity. Atrophy of the extracellular matrix is reflected by the decreased number of fibroblasts and decreased levels of collagen (especially Types I and III) and elastin in the dermis. While chronological skin aging and photoaging can be readily distinguished and considered as s separate entities, both share important molecular features: altered signal transduction that promote matrix-metalloproteinase (MMP) expression, decreased procollagen synthesis and connective tissue damage. Oxidative stress is considered of primary importance in driving the aging process, resulting in increased hydrogen peroxide and other reactive oxygen species (ROS) and decreased antioxidant enzymes. These changes result in gene and protein structure alterations. Other environmental factors, notably smoking, accelerate skin aging by between 10 and 20 years. Increased collagenase and decreased skin circulation have been suggested as possible mechanisms. The muscles of facial expression flex the skin in a specific pattern. As the underlying collagen weakens and the skin thins, the dermis loses its capacity to resist the constant force of the muscles and these lines becomes etched in the skin and ultimately, even at rest.

Subcutaneous tissue The fibrous and fat components in the subcutaneous tissue are not uniform but arranged in discrete compartments. Due to the prominence of the subcutaneous fat in particular sites, specific names have been given, such as the malar fat pad and nasolabial fat.60,61 The boundaries of these subcutaneous compartments correspond to the location of the retaining ligaments, which pass superficially to insert into the dermis. In youth, the transition between compartments is smooth and non-discernible. With aging, the appearance changes to a series of convexities over these compartments separated by concavities between. These changes have been attributed to a

number of causes including fat descent, selective atrophy and hypertrophy and attenuation of the retaining ligaments that causes fat compartment malpositioning. It is, however, now apparent that fat descends minimally with aging.62–64 Distinct compartmentalization by the retaining ligaments holds the fat in its relative position.

Muscle aging Skeletal muscles, in general, have been noted to atrophy up to 50% with age.65 This is presumably applicable to the muscle of mastication, such as the temporalis and masseter as a result of decreased demand and deterioration of the dentition with aging. As yet, no specific study on the effect of aging on these muscles has been reported. The mimetic muscle of the face, in contrast to skeletal muscles, may not undergo the same degree of degeneration with aging because of their constant use with facial expression. The orbicularis oculi has been noted to remain histologically unchanged with no loss of muscle fibers, adherence to surrounding tissues or ptosis with aging.66 The upper lip elevators, zygomaticus major and levator labii superioris were also noted to remained unchanged with aging, based on magnetic resonance imaging (MRI) of their length, thickness and volume.67 In contrast, the upper lip orbicularis atrophies with aging, with decreased muscle thickness, smaller muscle fascicles and increase in surrounding epimysium.

Facial spaces and retaining ligaments The multi-linked fibrous support system attenuates with aging, with decreasing strength of the ligaments and increasing laxity. In general, the spaces expand with aging in proportion to the amount of movement. This is greatest with the lower premasseter space from the related mandibular movement and least over the zygoma. Expansion is related to the laxity that develops in the roof of the spaces and to a degree in the ligamentous boundaries, resulting in bulges between areas of relative fixation. Accordingly, the spaces dissect more easily in older patients, and the boundaries widen as the ligaments weaken. In young people, the spaces are more potential than real and do not open so easily with blunt dissection (Fig. 9.2.16). This aging changes of the prezygomatic space, with bulging of its roof, accentuated by its well-supported upper boundary, is the anatomical basis for the clinical entity variously described as malar mounds, bags or malar crescent. The presence of this ‘deformity’ indicates significant laxity, with the treatment directed to tightening the laxity of the roof. Surgically, the prezygomatic space forms an area of surgical reprieve, in contrast to the region inferior to it where there is not a space. Instead, here is an area of surgically important anatomy, in which safely locating zygomaticus major is a key objective. By first dissecting the prezygomatic space, the level of the upper surface of zygomaticus major is readily found, immediately beneath the floor of the space.

Bone changes The facial skeleton changes significantly with aging (Fig. 9.2.17) and this has a profound impact on the appearance of

Bone changes

143

Figure 9.2.16  In youth, the spaces are tight glide plane spaces. With aging, and the reduction of tissue tone, the spaces expand, and to a larger degree where facial movement is greater, namely in the lower face where the lower masseteric ligament fence distends the most. The weakened attachment of the platysma to the masseter here allows this corner of the lower premasseter space to expand, contributing to the jowl. The reduction of ligament tone also allows descent of the buccal fat into the labiomandibular fold.

Figure 9.2.17  The arrows indicate the areas of the craniofacial skeleton most susceptible to resorption with aging and the relative degree according to the arrow size.

the face with aging (Fig. 9.2.18).68–80 At birth, the facial skeleton is underdeveloped and rudimentary. This explains why infants and toddlers often transiently have visibly distinct midcheek segments (despite excellent tissue quality), which disappear with the expansion of the midcheek skeleton with growth. Peak skeletal projection is probably attained in early adulthood. Thereafter, while certain areas continue to expand, selective areas of the facial skeleton undergo significant

Figure 9.2.18  Skeletal aging and its consequences. The stippled areas on the skeleton indicate the location where bone is resorbed and the relative amount. On the subjects left side, the stigmata of aging present in the facial soft tissues correspond to the areas of weakened skeletal support as a result of bone resorption.

144

SECTION II

CHAPTER 9.2  • Facial anatomy and aging

resorption. These are predominantly the soft dental bones, the maxilla and mandible, following the eruption of the secondary dentition, which had grown in these bones. The area with the most significant resorption is the midface skeleton, particularly that part contributed by the maxilla, including the pyriform area of the nose and, to a lesser degree, the superomedial and inferolateral aspects of the orbital rim and the prejowl area of the mandible.81,82 The resultant deficiencies in the skeletal foundation have a significant effect on the overlying soft tissues. In the midcheek in particular, retrusion of the maxilla results in increased prominence of the tear trough and the nasolabial folds. The retrusion of the facial skeleton causes the origin of the multi-linked fibrous retaining ligaments to be displaced posteriorly. This pulls the skin inwards, exaggerating the concavity between the areas of relative convexity that develop with aging. This loss of projection with deepening grooves gives the visual impression of tissue descent with aging. In patients who have a congenitally weak, meaning inadequately projecting, skeletal structure, the skeleton may be the primary cause of the manifestations of premature aging. Accordingly, in patients who suffer premature facial aging, a weakness of the relevant part of the underlying skeleton is immediately suspect and should be addressed in order to obtain better aesthetic results.

Regional changes observed with the aging face temple and forehead The skin of the temple differs from that of the forehead, being thinner and less firmly supported to the underlying layers. The loose attachment reflects the underlying temporal space, which is extensive, as well as the nature of the surrounding temporal ligaments. These are unlike other facial ligaments, being septal-like and do not continue through the thin, loose subcutaneous layer 2 over the temple. This explains why deep layer procedures in the temple are not as effective in toning the overlying skin as they are, for example, in the cheek. Corrugator muscle contraction is associated with the emotional states of grief and sadness.83 The transverse head of corrugator supercilii moves the eyebrow medially and produces vertical glabella lines. The oblique head of the corrugator, the depressor supercilii and the medial fibers of the orbicularis oculi act in concert to depress the medial brow and produce oblique glabella frown lines. The procerus, also a brow depressor, causes transverse nasal skin lines. Laterally, the action of the lateral fibers of the orbicularis oculi with the transverse head of the corrugator supercilii promotes lateral brow ptosis. The ptosis of the lateral brow together with, and to a lesser extent, the laxity of the skin with aging produces a pseudoexcess of the upper eyelid skin. Frontalis muscle hypertonicity from lateral brow skin hooding and its reaction to the action of antagonistic muscles (corrugator supercilii, orbicularis oculi and procerus) results in the development of transverse forehead skin lines.84 The medial brow, in contrast, seldom descends with aging and in fact may rise.85–87 The mechanism responsible for this includes the chronic activation of the frontalis muscle. This elevation of the brow/eyelid complex is to relieve visual field obstruction from either hanging excess eyelid

skin or from chronic ptosis from levator system weakness.84 Anatomically, the lateral extent of the frontalis muscle is at approximately the temporal fusion line (STS). Lateral to this, there is not an upward vector to counteract the downward pull of brow depressors and gravity on the lateral brow, which may explain why more descent occurs at the lateral brow.

The midcheek The midcheek is the anterior part of the midface.5 It is triangular in shape, bounded superiorly by the pretarsal part of the lower eyelid, medially by the side of the nose and the nasolabial groove below, and laterally around the lateral cheek where the arch of the zygoma meets the body. A smooth, rounded midcheek is a powerful image of youth and gives a certain freshness to the face. With aging, the three distinct segments of the midcheek become clearly discernible, as they become separated by the three cutaneous grooves of the midcheek: the nasojugal, palpebromalar and midcheek grooves. This “segmentation” of the midcheek has a profound impact on appearance that is responsible for the ‘tired’ look we associate with aging. The three segments of the midcheek reflect its structure, with each segment or module overlying a specific part of the midcheek skeleton (Fig. 9.2.19). The lid–cheek segment overlies the prominence of the inferior orbital rim, the malar segment overlies the body of the zygoma, and the nasolabial segment overlies the maxilla. The skeletal foundation of the midcheek borders the three bony cavities of the anterior face, the orbital, nasal and oral

Figure 9.2.19  The midcheek has three segments, of which the lid–cheek segment (blue) and the malar segment (green) are within the periorbital part. These are adjacent to the nasolabial segment (yellow), which is in the perioral part overlying the vestibule of the oral cavity. The boundaries of the three segments are formed by the three grooves, which interconnect like the italic letter Y. The palpebromalar groove (1) overlies the inferolateral orbital rim. The nasojugal groove (2) overlies the inferomedial orbital rim, then continues into the midcheek groove, or furrow (3).

Considerations for correcting aging changes of the face based on facial anatomy

cavities. Because of the many spaces and, therefore, limited bony support available, there is some intrinsic structural weaknesses of the midcheek. Three factors make the midcheek susceptible to aging changes: (1) the wedge shape of the soft tissue of the midcheek, which is thin above and thicker below; (2) the natural posterior incline of the midcheek skeleton, from the relative prominence of the infra­ orbital rim; and (3) the significant retrusion that occurs with aging as a result of resorption of the maxilla. This is not uniform, as the maxilla recedes more medially and inferiorly.82 With early aging, the retrusion of the maxilla, along with a slight descent of the wedge-shaped cheek soft tissue, results in an appreciable reduction of volume of the upper cheek. The result is that the small amount of orbital fat over the prominent edge of the inferior orbital rim (originally concealed by the volume of the upper cheek) now becomes revealed, especially the underside of the lid fat bulge over the middle part. The visual impression is of a ‘lengthened’ lower lid. At the same time, the increased thickness of the soft tissue mass over the lower cheek tends to conceal the degree of maxillary resorption and gives the profound visual impression that the soft tissue mass has descended into the lower part of the midcheek. Of the three segments of the midcheek, the lower lid segment changes the most dynamically with aging. It has two distinct grooves across its surface that vary in their expression during the aging process, often coexisting. The upper is the infratarsal groove at the junction of the pretarsal and preseptal parts of the eyelid. It defines the lower boundary of the pretarsal bulge. The pretarsal bulge in youth is the visual separation of the lid above and the cheek below. This so-called ‘high lid–cheek junction’ is located well above the infra-orbital rim and is a characteristic of youth. The infratarsal groove location does not change with aging, although its contour usually fades. The lower groove is the lid–cheek junction that relates to the lower edge of the preseptal part of the lid. It is not present in youth and appears with aging and then progressively deepens and descends slightly over time. Its shape, when it first appears, is a gentle “C”-shaped contour, but as it “descends”, particularly in its central portion, its shape changes to a progressively more angulated “V” shape with the medial side being formed by the developing nasojugal groove and the lateral side by the palpebromalar groove. The center of the V, the lowest and deepest part, has the nasojugal groove continuing down the cheek as the midcheek groove that separates the cheek into the malar and nasolabial segments. The reason why this contour demarcation changes, while the skin itself does not descend, is explained by the difference in the tissue layers. The orbicularis retaining ligament is not rigid where it is over the center of the inferior orbital rim in contrast to the medial and lateral ends. Accordingly, distention results in relative sliding between it and layer 3, the orbicularis oculi. As the lid–cheek junction becomes more prominent, it visually takes over from the infratarsal groove and becomes the new separation between the lower eyelid and the cheek. This is the basis for the commonly used, but inaccurate phrase “lengthening of the lid–cheek junction with aging”, which is, in fact the result of a visual shift from the prominence of the infratarsal groove in youth to the lid–cheek junction with age. Correction of the aging of the lid–cheek segment of the midcheek, has gained the colloquial name of ‘blending the lid–cheek junction’.

145

Lower face The jowl and the labiomandibular fold in the lower face are not present in youth and develop with aging. With the description of the concept of soft tissue spaces of the face, and specifically the premasseter space, the mechanism for the formation of the jowl can now be understood on an anatomical basis.22 With the onset of aging, laxity develops in the roof of the premasseter space associated with attenuation of the anterior and inferior boundaries. The major retaining ligaments, the key masseteric and the mandibular, in contrast remain relatively strong and at these locations the superficial fascia remains firmly fixed to the underlying deep fascia. Distention of the weaker masseteric ligaments at the anterior border of the lower premasseter space (below the key masseteric ligament) and inferior displacement of the buccal fat (within the buccal space) is the anatomical basis for the development of the labiomandibular fold. The mandibular ligament demarcates the transition from the labiomandibular fold above and medial and the jowl below. The jowl develops as a result of distention of the roof of the lower premasseter space with resultant descent of the tissues below the body of the mandible. The more prominent the jowl, the more apparent will be the cutaneous tethering provided by the mandibular ligament. Accordingly, the anatomical solution to correcting these aging changes is to reduce the inferiorly displaced buccal fat and to tighten laxity in the roof of the premasseter space near the mandibular rim.

Considerations for correcting aging changes of the face based on facial anatomy Dissection planes The subcutaneous plane of dissection (layer 2) is historically the most commonly used plane in facelifts, either in isolation or more commonly with some form of SMAS management from the superficial aspect (Fig. 9.2.20).88–90 A distinction should be drawn between subcutaneous dissection over the lateral face from that over the anterior face. This plane of dissection is intrinsically “safe” as dissection remains superficial to the facial nerve branches at all times, this being the main appeal of the subcutaneous plane of dissection. The subcutaneous dissection can be performed either in the superficial subcutaneous level or deep subcutaneous level. In the former, there is a more uniform density of the retinacular cutis fibers as the multi-linked ligaments branch out before inserting into the dermis. The deep subcutaneous plane of dissection is on the outer surface of the SMAS (layer 3), also called supraSMAS, where fewer ligament fibers and vessels are encountered, although these are thicker and stronger. The deep subcutaneous layer is not uniform in its tenacity; rather, it mirrors the underlying anatomy in layers 3 and 4. Where it overlies the facial spaces it is inherently easier to dissect, while the areas that overlie ligaments are more strongly attached and usually require sharp surgical release. For example, over the malar eminence at McGregor’s patch, where the zygomatic ligaments are

146

SECTION II

CHAPTER 9.2  • Facial anatomy and aging

Figure 9.2.20  Possible levels for dissection and redraping in facelift surgery. Dissection can be performed through any one of three alternative layers, namely subcutaneous (level 2), subSMAS (level 4) and subperiosteal (level 6) for the upper two-thirds of the face. Redraping traction (arrows) is applied either to the skin (level 1), the SMAS (level 3) or the periosteum (level 5).

located, sharp release of the overlying retinacula cutis is usually required. In contrast, in the more mobile lower face over the premasseter space, the subcutaneous layer separates quite readily, usually requiring only blunt finger dissection, especially with the weakening and elongation of the facial structures with aging.

SubSMAS dissection (layer 4) In the scalp, this is the preferred tissue plane for dissection, as the scalp (the composite of layers 1, 2 and 3) readily separates from the underlying periosteum (layer 5) through the avascular areolar tissue with ease and inherent safety. Bruising and swelling is kept to a minimum because of this favorable anatomy. While the anatomical principles remain the same in the face proper, layer 4 is potentially the most dangerous plane to dissect in respect of the facial nerve branches which, having originated from deep in the face, transition through this layer, to innervate the facial muscles in layer 3. However, it should be appreciated that, similar to the situation in the scalp, where dissection performed to raise the flap in layer 4 gives a structurally integrated robust composite flap that can be effectively tightened, subSMAS dissection in the face offers the same advantages and potential benefits.91–93 Dissection can be performed safely in layer 4 by applying understanding of the 3D anatomy of the face described earlier; the key being the facial spaces, which provide safe access through this layer. Because these spaces are “predissected”, once correct access is obtained, the actual dissection is quick, atraumatic and unexpectedly easy. A prime example of this is the lower premasseter space, being the largest and most mobile space. To access the space, subcutaneous dissection is performed to approximately 30 mm anterior to the ear cartilage, through the zone of fixation, the PAF, where the fibrous SMAS is fused to the deep fascia including the parotid capsule.94 Because the objective of the surgery is to correct laxity in the mobile anterior face, the level of dissection used in the lateral face is of secondary importance. A further benefit of leaving the PAF intact is that the strength of this tissue is maintained, to be used for secure suture fixation. Once dissection has proceeded beyond the PAF (indicated by the posterior fibers of the platysma), the

Figure 9.2.21  Surgical entry into the lower premasseter space. As the premasseter space commences immediately forward of the anterior extent of the parotid, the surgical entry is planned to be through this part of layer 3, just forward of the platysma auricular fascia, which includes the parotid capsule. The ideal entry is immediately at the posterior extent of the platysma, as the platysma muscle is in the roof of the space. The posterior edge of the platysma may be more difficult to see with muscle atrophy with aging.

SMAS is then incised to provide direct access into the lower premasseter space (Fig. 9.2.21). The space can then be opened by gentle blunt dissection, to define the boundaries of the space. The premasseter spaces below and the prezygomatic space above form a series of spaces around the anterior face (Figs. 9.2.22 & 9.2.23). The boundaries of the spaces, reinforced by retaining ligaments, are where the important anatomy is located. These ligaments need to be precisely released to eliminate their tethering effect on the superficial soft tissues, which is inherently more difficult in younger patients as the ligaments are denser and stronger. Clear visualization, optimized by lifting the roof of the adjacent opened facial spaces, is beneficial. When blunt-tip scissors are used with repeated gentle, small-­amplitude vertical spreading of the blades, the surrounding fat and areolar tissue tends to separate, revealing the ligaments and the facial nerve branches in relation to

Summary

147

deep temporal space to the lateral brow, the preseptal space to the lower eyelid, and the prezygomatic and the premaxillary spaces to the midcheek.95

Level 5

Figure 9.2.22  The subSMAS facial spaces are located around the mobile anterior face. In subSMAS facelifts these are ‘safe spaces’ for surgical dissection. The spaces are: 1a, lower premasseter space; 1b, upper premasseter; 2, prezygomatic space; 3, temporal space. The asterisk locates the surgically important (nonspace) area of anatomy overlying the upper masseter, lateral to the main zygomatic ligament, and lateral to zygomaticus major. The zygomatic branch of the facial nerve crosses the masseter fascia here, from the parotid border to continue deep to zygomaticus major.

Subperiosteal ‘lifts’ have the appeal of safety as far as facial nerve risk is concerned as the nerves are superficial to the dissection plane and the remote nerves never cross this plane.96–99 Subperiosteal lifts, however, have inherent limitations. The accumulated aging changes across all five tissue layers are elevated as part of the subperiosteal lift. Overcorrection is required to effect the desired changes of soft tissue shape and especially skin tone, to compensate for the ‘lift-lag’ phenomenon, which is proportionate to the thickness of the soft tissues and amount of laxity. Accordingly, subperiosteal lifting works best in those areas where the layers are more compact, as the lift-lag is minimized. This explains the popularity of subperiosteal brow lifts, as they are most effective. Where the layers are thicker, such as the nasolabial segment of the midcheek, the lift-lag phenomenon significantly limits the improvement that can be achieved. Because of the unyielding nature of the periosteum, extensive undermining beyond the target area is needed or alternatively a ‘periosteal release’ immediately beyond the area requiring the lift to isolate the area to a limited island of periosteum.

Placement of sutures

2

zm * 1b

1a

3

Figure 9.2.23  Intraoperative photograph of the deep plane facelift dissection (right side). The spaces are, from below: 1a, lower premasseter; 1b, upper premasseter; 2, prezygomatic; 3, upper temporal. The spaces on the masseter interconnect, providing for ease of surgical dissection with safety. Note the platysma roof of the lower space and the buccal branch crossing diagonally beneath the fascial floor of the lower premasseter space. *The upper premasseter area of surgically important anatomy between the lower border of the zygoma and the upper premasseter space is not a space. zm indicates zygomaticus major, which take origin off the body of the zygoma. The vertical orientation is surgical, due to the roof of the spaces being elevated by retraction. The lateral aspect of the tented-up muscle is partially concealed by the zygomatic ligament, also on stretch. The motor branch of the zygomatic nerve, also under tension, is seen passing straight up to the orbicularis.

them. With progressive lifting, the ligaments become more certainly defined as they vertically tighten further, at which time they can be safely released, while the nerves, being obliquely oriented, dislodge out of the way, unaffected by the controlled stretching. The subSMAS spaces can be used to safely and atraumatically access various part of the face, the

While adequate surgical release of ligamentous restraint is needed for mobility of areas of laxity medial to strong retaining ligaments, is the definitive surgical fixation achieves the desired effect by maintaining the mobilized soft tissues in their new position. The strength and tenacity of the superficial fascia is not uniform and diminishes with age. The areas where retaining ligaments are located have an inherent ligamentous reinforcement, making them ideal for suture placement (Fig. 9.2.24). It is also the location in which traction gives the most natural appearance, as these are the natural suspension sites of the face. Accordingly, the suture fixation should, in general, be placed where the retaining ligaments are located. Fixation sutures placed in subSMAS surgery function as replacements for the retaining ligaments that have either weakened or have been divided in order to mobilize the composite flap. Accordingly, the replacement sutures should replicate the quality of support provided by the original ligaments as the ‘mobile’ spaces remain. In this respect, braided permanent sutures are advantageous as they stimulate collagen and elastic fiber deposition within the suture, making it structurally similar to a ligament.100 The PAF, the diffuse ligamentous area on the preauricular part of the lateral face, provides an ideal area, both anatomically and physically, to fix the facelift flap, due to its inherent strength.

Summary This chapter has been structured to assist the surgeon reader to develop a conceptual understanding of facial anatomy and how it changes with aging. It is the framework that unifies the increasing amount of detailed anatomical information

148

SECTION II

CHAPTER 9.2  • Facial anatomy and aging

available in the literature. This chapter provides a foundation for understanding deep plane surgery, recognizing that surgeons with considerable experience are aware of more detail that is beyond the limited capacity of this chapter. Other observations may not yet be supported by formal anatomical studies, such as the subplatysma space. This knowledge, once understood, provides the anatomical foundation for the logical selection and application of surgical techniques for rejuvenation of the aging face.

Acknowledgments The authors wish to acknowledge the contribution of the Faculty of the Melbourne Advanced Facial Anatomy Course (MAFAC) for their input into the contents of this chapter. Also, we acknowledge the contribution of the MAFAC Tagliacozzi Research Fellow, Dr. Lennert Minelli, for critical review and anatomical updates. Figure 9.2.24  Concept of surgical fixation of the advanced flap harnessing the benefit of the ligament branching within the composite flap. This incorporates the diffuse ligamentous structural support within the sutured tissue of the flap to provide even and secure flap fixation into its advanced and tightened position.

Access the reference list online at   Elsevier eBooks+

References

References 1. Mendelson BC. Facelift anatomy, SMAS, retaining ligaments and facial spaces. In: Aston SJ, Steinbrech DS, Walden JL, eds. Aesthetic Plastic Surgery. London: Elsevier Saunders; 2012:53–72. 2. Rohrich RJ, Timberlake AT, Afrooz PN. Revisiting the fundamental operative principles of plastic surgery. Plast Reconstr Surg. 2021;148(5S):117S–120S. 3. Nahai F. Clinical Decision Making in Face Lift and Neck Lift. In the Art of Aesthetic Surgery: Principles and Technique. St Louis: Quality Medical Publishing; 2005:898–926. 4. Mendelson BC. Correction of the nasolabial fold: extended SMAS dissection with periosteal fixation. Plast Reconstr Surg. 1992;89(5):822–833. 5. Mendelson BC, Jacobson SR. Surgical anatomy of the midcheek; facial layers, spaces, and midcheek segments. Clin Plast Surg. 2008;35:395–404. 6. Stuzin JM, Baker TJ, Gordon HL. The relationship of the superficial and deep facial fascias: relevance to rhytidectomy and aging. Plast Reconstr Surg. 1992;89(3):441–449. A discussion of the concept of facial soft tissue being arranged in concentric layers, and the SMAS as the ‘investing’ layer of the superficial mimetic muscles of the face. The relationship between the deep and superficial fascias is described, with acknowledgement of ‘areola’ planes and areas of dense fibrous attachments, including true osteocutaneous ligaments and other coalescences representing the retaining ligamentous boundaries of the face. Age-associated laxity of the retaining ligament was noted to be a key component of facial aging. 7. Furnas DW. The retaining ligaments of the cheek. Plast Reconstr Surg. 1989;83:11. 8. Furnas D. The superficial musculoaponeurotic plane and the retaining ligaments of the face. In: Psillakis JM, ed. Deep face-lifting techniques. New York: Thieme Medical Publishers; 1994. 9. Rohrich RJ, Pessa JE. The fat compartments of the face: anatomy and clinical implications for cosmetic surgery. Plast Reconstr Surg. 2007;119(7):2219–2227. 10. Rohrich RJ, Pessa JE. The retaining system of the face: histologic evaluation of the septal boundaries of the subcutaneous fat compartments. Plast Reconstr Surg. 2008;121(5):1804–1809. 11. Rohrich RJ, Pessa JE. The anatomy and clinical implications of perioral submuscular fat. Plast Reconstr Surg. 2009;124(1):266–271. 12. Surek CC, Beut J, Stephens R, Jelks G, Lamb J. Pertinent anatomy and analysis for midface volumizing procedures. Plast Reconstr Surg. 2015;135(5):818e–829e. 13. Mitz V, Peyronie M. The superficial musculo-aponeurotic system (SMAS) in the parotid and cheek area. Plast Reconstr Surg. 1976;58:80. 14. Hamra ST. Deep-plane rhytidectomy. Plast Reconstr Surg. 1990;86:53. 15. Hamra ST. Composite rhytidectomy. Plast Reconstr Surg. 1992;90:1. 16. Muzaffar AR, Mendelson BC, Adams Jr. WP. Surgical anatomy of the ligamentous attachments of the lower lid and lateral canthus. Plast Reconstr Surg. 2002 Sep 1;110(3):873–884. 17. Deleted in proof. 18. Moss CJ, Mendelson BC, Taylor GI. Surgical anatomy of the ligamentous attachments in the temple and periorbital regions. Plast Reconstr Surg. 2000;105(4):1475–1490. A through description of the retaining ligaments of the temporal and periorbital regions is given. The term ‘ligamentous adhesion’ is introduced to increase the understanding of the system, and there is emphasis on the relations of the temporal branch of the facial nerve and the trigeminal branches to structures visualized in surgery rather than to less useful landmarks, which are not. A discussion of age-related changes to the region complements one of surgical approach with respect to the anatomy described. 19. Mendelson BC, Muzaffar AR, Adams Jr. WP. Surgical anatomy of the midcheek and malar mounds. Plast Reconstr Surg. 2002;110(3):885–896. discussion 897–911.

148.e1

20. Ghavami A, Pessa JE, Janis J, Khosla R, Reece EM, Rohrich RJ. The orbicularis retaining ligament of the medial orbit: closing the circle. Plast Reconstr Surg. 2008;121(3):994–1001. 21. Yousif NJ, Mendelson BC. Anatomy of the midface. Clin Plast Surg. 1995;22(2):227–240. 22. Mendelson BC, Freeman ME, Wu W, Huggins RJ. Surgical anatomy of the lower face: the premasseter space, the jowl, and the labiomandibular fold. Aesthetic Plast Surg. 2008;32(2):185–195. Introduces the concept of the ‘premasseter’ space, age-related changes, and utility for safe sub-SMAS dissection. Distinction is made between this space, over the lower part of the masseter, and another space overlying the upper part of the masseter where the neurovascular structures, the accessory lobe of the parotid gland and duct are located. The true shape of the anterior border of the masseter muscle is described, with the border ending antero-inferiorly at the mandibular ligament. This description completes the picture of the retaining ligaments as a continuous border separating the anterior and lateral parts of the face. The relations of the facial nerve branches, particularly that of the lower buccal trunk, to the masseter and its fascia is described. 23. Mendelson BC. Advances in the understanding of the surgical anatomy of the face. In: Eisenmann-Klein M, Neuhann-Lorenz C, eds. Innovations in Plastic and Aesthetic Surgery. New York: Springer Verlag; 2007:141–145. 24. O’Brien JX, Ashton MW, Rozen WM, Ross R, Mendelson BC. New perspectives on the surgical anatomy and nomenclature of the temporal region. Literature Review & Dissection Study. Plast Reconstr Surg. 2013;131:510. 25. Knize DM. Anatomic concepts for brow lift procedures. Plast Reconstr Surg. 2009;124(6):2118–2126. 26. Wong CH, Mendelson B. Facial soft-tissue spaces and retaining ligaments of the midcheek: defining the premaxillary space. Plast Reconstr Surg. 2013;132(1):49–56. 27. Mendelson BC, Wong CH. Surgical anatomy of the middle premasseter space and its application in sub-SMAS face lift surgery. Plast Reconstr Surg. 2013;132(1):57–64. 28. Kahn JL, Wolfram-Gabel R, Bourjat P. Anatomy and imaging of the deep fat of the face. Clin Anat. 2000;13(5):373–382. 29. Zhang HM, Yan YP, Qi KM, Wang JQ, Liu ZF. Anatomical structure of the buccal fat pad and its clinical adaptations. Plast Reconstr Surg. 2002;109(7):2509–2518. 30. Wong CH, Hsieh MK, Mendelson B. The tear trough ligament: anatomical basis for the tear trough deformity. Plast Reconstr Surg. 2012;129(6):1392–1402. 31. Baker DC, Conley J. Avoiding facial nerve injuries in rhytidectomy: anatomic variations and pitfalls. Plast Reconstr Surg. 1979;64:781. 32. Gosain AK. Surgical anatomy of the facial nerve. Clin Plast Surg. 1995;222:241. 33. Seckel BR. Facial danger zones. Avoiding nerve injury in facial plastic surgery. St Louis: Quality Medical; 1994. 34. Owsley JQ, Agrawal CA. Safely navigating around the facial nerve in three- dimensions. Clin Plast Surg. 2008;35:469–477. 35. Ruess W, Owsley JQ. The anatomy of the skin and fascial layers of the face in aesthetic surgery. Clin Plast Surg. 1987;14(4):677–682. 36. Roostaeian J, Rohrich RJ, Stuzin JM. Anatomical considerations to prevent facial nerve injury. Plast Reconstr Surg. 2015;135(5):1318–1327. 37. Pitanguy I, Ramos AS. The frontal branch of the facial nerve: the importance of its variations in facelifting. Plast Reconstr Surg. 1966;38 352–256. 38. Furnas DW. Landmarks for the trunks and the temporofacial division of the facial nerve. Br J Surg. 1965;52:694–696. 39. Stuzin JM, Wagstrom L, Kawamoto HK, Wolfe SA. Anatomy of the frontal branch of the facial nerve: the significance of the temporal fat pad. Plast Reconstr Surg. 1989;83(2):265–271. 40. Agarwal CA, Mendenhall 3rd SD, Foreman KB, Owsley JQ. The course of the frontal branch of the facial nerve in relation to fascial planes: an anatomic study. Plast Reconstr Surg. 2010;125(2):532–537. 41. Trussler AP, Stephan P, Hatef D, Schaverien M, Meade R, Barton FE. The frontal branch of the facial nerve across the zygomatic

148.e2

SECTION II

CHAPTER 9.2  • Facial anatomy and aging

arch: anatomical relevance of the high-SMAS technique. Plast Reconstr Surg. 2010;125(4):1221–1229. 42. Alghoul M, Bitik O, McBride J, Zins JE. Relationship of the zygomatic facial nerve to the retaining ligaments of the face: the sub-SMAS danger zone. Plast Reconstr Surg. 2013;131:245e–252e. 43. Lowe JB 3rd, Cohen M, Hunter DA, Mackinnon SE. Analysis of the nerve branches to the orbicularis oculi muscle of the lower eyelid in fresh cadavers. Plast Reconstr Surg. 2005;116(6):1743–1749. 44. Ramirez OM, Santamaria R. Spatial orientation of motor innervation of the lower orbicularis oculi muscle. Aesthetic Surg J. 2000;20:107. 45. Dingman RO, Grabb WC. Surgical anatomy of the mandibular ramus of the facial nerve based on the dissection of 100 facial halves. Plast Reconstr Surg. 1962;29:266. 46. Nelson DW, Gingrass RP. Anatomy of the mandibular branches of the facial nerve. Plast Reconstr Surg. 1979;63:479. 47. Conley J, Baker DC. Paralysis of the mandibular branch of the facial nerve. Plast Reconstr Surg. 1982;70:569. 48. Huettner F, Rueda S, Ozturk CN, Ozturk C, Drake R, Langevin C, Zins J. The relationship of the marginal mandibular nerve to the mandibular osseocutaneous ligament and lesser ligaments of the lower face. Aesthet Surg J. 2015;35:111–120. 49. Ellenbogen R. Pseudo-paralysis of the mandibular branch of the facial nerve after platysmal face-lift operation. Plast Reconstr Surg. 1979;63(3):364–368. 50. Daane SP, Owsley JQ. Incidence of cervical branch injury with "marginal mandibular nerve pseudo-paralysis" in patients undergoing face lift. Plast Reconstr Surg. 2003;111(7):2414–2418. 51. Kwon TK, Choi YH. Asian facelift. Facial Plast Surg Clin North Am. 2021;29(4):471–486. 52. Pelle-Ceravolo M, Angelini Matteo A, Silvi Erminia S. Treatment of anterior neck aging without a submental approach: lateral skin-platysma displacement, a new and proven technique for platysma bands and skin laxity. Plast Reconstr Surg. 2017;139(2):308–321. 53. Montagna W, Carlisle K. Structural changes in the aging skin. Br J Dermatol. 1990;122(suppl. 35):61–70. 54. Wulf HC, Sandby-Moller J, Kobayashi T, Gniadecki R. Skin aging and natural photoprotection. Micron. 2004;35:185–191. 55. Hall G, Phillips TJ. Estrogen and skin: the effects of estrogen, menopause and hormone replacement therapy on the skin. J Am Acad Dermatol. 2005;53:555–568. 56. Sander CS, Chang H, Salzmann S, Müller CS, EkanayakeMudiyanselage S, Elsner P, Thiele JJ. Photoaging is associated with protein oxidation in human skin in vivo. Invest Dermatol. 2002;118(4):618–625. 57. Chung JH, Seo JY, Choi HR, et al. Modulation of skin collagen metabolism in aged and photoaged human skin in vivo. J Invest Dermatol. 2001;117(5):1218–1224. 58. Freiman A, Bird G, Metelitsa AI, Barankin B, Lauzon GJ. Cutaneous effects of smoking. J Cutan Med Surg. 2004;8(6):415–423. 59. Haruko C, Okada HC, Alleyne B, Varghai K, Kinder K, Guyuron B. Facial changes caused by smoking: a comparison between smoking and nonsmoking identical twins. Plast Reconstr Surg. 2013;132:1085. 60. Gosain AK, Klein MH, Sudhakar PV, Prost RW. A volumetric analysis of soft-tissue changes in the aging midface using high-resolution MRI: implications for facial rejuvenation. Plast Reconstr Surg. 2005;115(4):1143–1152. discussion 1153–1155. 61. Gosain AK, Amarante MT, Hyde JS, Yousif NJ. A dynamic analysis of changes in the nasolabial fold using magnetic resonance imaging: implications for facial rejuvenation and facial animation surgery. Plast Reconstr Surg. 1996;98(4):622–636. 62. Lambros V. Observations on periorbital and midface aging. Plast Reconstr Surg. 2007;120(5):1367–1376. 63. Lambros V. Facial aging: A 54-year, three-dimensional population study. Plast Reconstr Surg. 2020;145(4):921–928. 64. Lambros V, Amos G. Three-dimensional facial averaging: a tool for understanding facial aging. Plast Reconstr Surg. 2016;138(6):980e–982e.

65. Faulkner JA, Larkin LM, Claflin DR, Brooks SV. Age-related changes in the structure and function of the skeletal muscles. Clin Exp Phamacol Physiol. 2007;34:1091–1096. 66. Pottier F, El-Shazly NZ, El-Shazly AE. Aging of orbicularis oculi: anatomophysiologic consideration in upper blepharoplasty. Arch Facial Plast Surg. 2008;10(5):346–349. 67. Penna V, Stark GB, Eisenhardt SU, Bannasch H, Iblher N. The aging lip: a comparative histological analysis of age-related changes in the upper lip complex. Plast Reconstr Surg. 2009;124(2):624–628. 68. Hellman M. Changes in the human face brought about by development. Int J Orthod. 1927;13:475. 69. Todd TW. Thickness of the white male cranium. Anat Rec. 1924;27:245. 70. Lasker GW. The age factor in bodily measurements of adult male and female Mexicans. Hum Biol. 1953;25:50. 71. Garn SM, Rohmann CG, Wagner B, Ascoli W. Continuing bone growth during adult life: a general phenomenon. Am J Phys Anthropol. 1967;26:313. 72. Kahn DM, Shaw Jr. RB. Aging of the bony orbit: a threedimensional computed tomographic study. Aesthet Surg J. 2008;28(3):258–264. 73. Pessa JE, Chen Y. Curve analysis of the aging orbital aperture. Plast Reconstr Surg. 2002;109(2):751–755. 74. Pessa JE, Zadoo VP, Mutimer KL, Haffner C, Yuan C, DeWitt AI, Garza JR. Relative maxillary retrusion as a natural consequence of aging: combining skeletal and soft-tissue changes into an integrated model of midfacial aging. Plast Reconstr Surg. 1998;102(1):205–212. 75. Pessa JE. An algorithm of facial aging: verification of Lambros’s theory by three-dimensional stereolithography, with reference to the pathogenesis of midfacial aging, scleral show, and the lateral suborbital trough deformity. Plast Reconstr Surg. 2000;106(2):479–488. 76. Shaw Jr RB, Kahn DM. Aging of the midface bony elements: a three-dimensional computed tomographic study. Plast Reconstr Surg. 2007;119(2):675–681. 77. Mendelson BC, Hartley W, Scott M, McNab A, Granzow JW. Age-related changes of the orbit and midcheek and the implications for facial rejuvenation. Aesthetic Plast Surg. 2007;31(5):419–423. 78. Zadoo VP, Pessa JE. Biological arches and changes to the curvilinear form of the aging maxilla. Plast Reconstr Surg. 2000;106(2):460–466. 79. Pessa JE, Slice DE, Hanz KR, Broadbent Jr TH, Rohrich RJ. Aging and the shape of the mandible. Plast Reconstr Surg. 2008;121(1):196–200. 80. Shaw Jr RB, Katzel EB, Koltz PF, Kahn DM, Girotto JA, Langstein HN. Aging of the mandible and its aesthetic implications. Plast Reconstr Surg. 2010;125(1):332–342. 81. Pessa JE, Zadoo VP, Yuan C, et al. Concertina effect and facial aging: nonlinear aspects of youthfulness and skeletal remodeling, and why, perhaps, infants have jowls. Plast Reconstr Surg. 1999;103(2):635–644. 82. Mendelson BC, Wong CH. Changes in the facial skeleton with aging: implications and clinical applications in facial rejuvenation. Aesthetic Plast Surg. 2012;36(4):753–760. This review paper consolidated the literature on the areas of the facial skeleton that are prone to resorption with facial aging. This regularly cited paper brought to attention the profound changes of the facial skeleton in aging and the application of the knowledge in surgical and non-surgical approaches in facial rejuvenation. Skeletal augmentation is an important aspect of natural and harmonious facial rejuvenation. 83. Schwartz GE, Fair PL, Mandel MR, Slat P, Mieske M, Klerman GL. Facial electromyography in the assessment of improvement in depression. Psychosom Med. 1978;40:355. 84. Knize DM. Anatomic concepts for brow lift procedures. Plast Reconstr Surg. 2009 Dec;124(6):2118–2126. 85. Knize DM. Muscles that act on glabella skin: a closer look. Plast Reconstr Surg. 2000;105:350.

References

86. Matros E, Garcia JA, Yaremchuk MJ. Changes in eyebrow position and shape with aging. Plast Reconstr Surg. 2009;124(4):1296–1301. 87. Jelks GW, Jelks EB. The influence of orbital and eyelid anatomy on the palpebral aperture. Clin Plast Surg. 1991;18(1):183–195. 88. Baker DC. Lateral SMASectomy. Plast Reconstr Surg. 1997;100:509–513. 89. Tonnard P, Verpaele A. The MACS-lift short scar rhytidectomy. Aesthet Surg J. 2007;27(2):188–198. 90. Aston SJ, Walden JL. Facelift with SMAS techniques and FAME. In: Aston SJ, Steinbrech DS, Walden JL, eds. Aesthetic Plastic Surgery. London: Elsevier Saunders; 2012:73–86. 91. Mendelson BC. Surgery of the superficial musculoaponeurotic system: principles of release, vectors and fixation. Plast Reconstr Surg. 2001;107(6):1545–1552. This article highlights the importance of adequate release of retaining ligaments of the SMAS in repositioning of the composite flap. Inadequate release can result in suboptimal advancement of the flap, and worse, distortion of the flap if the direction of pull is incorrect, due to unwanted rotation about the parts of the retaining ligamentous system that have been left intact. The biomechanical function of the retaining ligaments is described as ‘quarantining’ sections of the SMAS with less substantial fixation (areas now appreciated as subSMAS facial soft tissue spaces), preventing unwanted traction on areas of the face distant to the desired action in facial expression. There is discussion on the advantage of extensive SMAS mobilization in allowing multiple and varied force vectors to be applied, which allows proper anatomical repositioning of the soft tissue of the face.

148.e3

92. Wong CH, Mendelson BC. Extended transconjunctival lower eyelid blepharoplasty with release of the tear trough ligament and fat redistribution. Plast Reconstr Surg. 2017;140:273–282. 93. Wong CH, Hsieh MKH, Mendelson BC. Asian facelift with the composite facelift technique. Plast Reconstr Surg. 2022;149(1):59–69. 94. Labbé D, Franco RG, Nicolas J. Platysma suspension and platysmaplasty during neck lift: anatomical study and analysis of 30 cases. Plast Reconstr Surg. 2006;117(6):2001–2007. 95. Wong CH, Mendelson BC. Mid cheek lift utilizing facial soft tissue spaces of the mid cheek. Plast Reconstr Surg. 2015;136(6): 1155–1165. 96. Le Louarn C. The concentric malar lift: malar and lower eyelid rejuvenation. Aesthetic Plast Surg. 2004;28(6):359–372. 97. Sullivan SA, Dailey RA. Endoscopic subperiosteal midface lift: surgical technique with indications and outcomes. Ophthal Plast Reconstr Surg. 2002 Sep;18(5):319–330. 98. Ramirez OM. Three-dimensional endoscopic midface enhancement: a personal quest for the ideal cheek rejuvenation. Plast Reconstr Surg. 2002;109(1):329–340. 99. Rowe DJ, Guyuron B. Optimizing results in endoscopic forehead rejuvenation. Clin Plast Surg. 2008;35(3):355–360. 100. Huggins RJ, Freeman ME, Kerr JB, Mendelson BC. Histologic and ultrastructural evaluation of sutures used for surgical fixation of the SMAS. Aesthetic Plast Surg. 2007;31(6):719–724.

 

SECTION II •  Aesthetic Surgery of the Face

9.3 Principles and surgical approaches of facelift Richard J. Warren

Access video and video lecture content for this chapter online at Elsevier eBooks+

SYNOPSIS

ƒ Age-related changes occur in all layers of the face, including skin, superficial fat, superficial musculo-aponeurotic system (SMAS), deep fat, and bone. ƒ Patients presenting for facial rejuvenation surgery are usually middle-aged or older, thus increasing the chance of comorbidities. Risk factors such as hypertension and smoking should be dealt with prior to facelift surgery. ƒ Careful preoperative assessment will provide the surgeon with an aesthetic diagnosis regarding the underlying facial shape, the age-related issues that predominate, and the appropriate surgical procedures for every individual patient. ƒ Almost all facelift techniques begin with a subcutaneous facelift flap. Careful incision placement, tissue handling, and flap repositioning are important in order to avoid the obvious stigmata of facelift surgery. ƒ In its pure form, the subcutaneous, skin-only facelift has a limited effect on the position of heavier deep tissue. ƒ In SMAS plication, a skin flap is created with suture manipulation of the superficial fat and the underlying SMAS/platysma. ƒ In loop suture techniques (minimal access cranial suspension [MACS] lift), a skin flap is created with long suture loops taking multiple bites of superficial fat and platysma – fixed to a single point on the deep temporal fascia. ƒ The supraplatysma plane creates a single flap of skin and superficial fat mobilized and advanced along the same vector. ƒ SMASectomy involves a skin flap plus excision of superficial fat and SMAS from the angle of the mandible to the malar prominence, with direct suture closure of the resulting defect. ƒ A SMAS flap raised with skin attached (deep plane) creates a flap of SMAS/platysma, superficial fat and skin, all mobilized and advanced along the same vector. ƒ A separate SMAS flap (dual plane) creates two flaps, the skin flap and the superficial fat/SMAS/platysma, which are advanced along two different vectors.

ƒ The subperiosteal lift involves dissection against bone, with mobilization and advancement of all soft-tissue elements. ƒ Additional volume augmentation, and in some locations volume reduction, should be considered in all cases of facelift surgery. ƒ Facial aging is usually a pan-facial phenomenon. Therefore, in order to obtain a harmonious result, patients will often benefit from surgery to other components of their face. ƒ The most common complication of facelift surgery is hematoma. This problem should be dealt with promptly.

Introduction Complete facial rejuvenation involves the forehead, periorbital region, cheek, neck, and perioral region. In this chapter, we deal with the middle and lower thirds of the face – the cheek and neck. Terminologies for procedures that address these areas include rhytidectomy, rhytidoplasty, meloplasty, and facialplasty, although in this text, the more common term “facelift” will be used. Facelift surgery was originally conceived as a method of placing traction on the aging face by excising skin in the periphery of the face and closing the resulting defect under tension. Since that simple beginning over 100 years ago, the procedure has evolved to encompass a wide range of techniques which lift, augment, and rearrange facial tissues. Despite the development of many less invasive technologies, nothing can match a facelift in its ability to globally treat the face, returning its basic architecture to a more youthful configuration.

Access the Historical Perspective section online at Elsevier eBooks+

150

SECTION II

CHAPTER 9.3  • Principles and surgical approaches of facelift

Anatomy and patient presentation The classic stigmata of the aging face involve multiple changes (Fig. 9.3.1):   Visible changes in skin, including folds, wrinkles, dyschromias, dryness, and thinning.   Folds in the skin and subcutaneous tissue created by chronic muscle contraction: glabellar frown lines, transverse forehead lines, and crow’s feet over the lateral orbital rim.   Deepening folds between adjoining anatomic units: the nasojugular fold (tear trough), nasolabial folds, marionette lines, and submental crease.   Ptosis of soft tissue, particularly in the lower cheek, jowls, and neck.   Loss of volume in the upper two-thirds of the face, which creates hollowing of the temple, the lateral cheek, the central midface and in the upper lip, premaxillary area between the two nasolabial folds. The result is a more skeletal appearance in the temple, the periorbita, and the malar region as well as deepening of the nasolabial folds.   Expansion of volume in the neck and lateral jawline, which leads to the formation of jowls and fullness of the neck. The driving force behind our ability to explain these many changes has been an improved understanding of facial anatomy and how it changes over time. Facial aging occurs in all its layers, from skin down to bone; no tissue

Transverse forehead creases

is spared. The face can be considered a five-layer structure as described in Chapter 9.2: skin, subcutaneous fat, the superficial musculo-aponeurotic system (SMAS) and muscles of facial expression, fascial spaces, and deep fascia (Fig. 9.3.2). Underlying everything is bone, except over the oral cavity. The surgical significance of this concentric layer arrangement is that dissection can be done in the planes between the layers so that anatomical changes in each of the layers can be addressed independently.

Skin Skin is directly adherent to underlying subcutaneous fat via the retinacular cutis system. In certain predictable areas, the skin is tethered to bone or underlying muscle by condensed areas of connective tissue. These can be string-like cutaneous ligaments or ribbon-like septae. Because nerves and vessels often reach the skin adjacent to these vertically running fibrous structures, dissection of skin is more difficult and bloody where the skin is tethered. McGregor’s patch is such an area because of its association with the zygomatic cutaneous ligaments and a perforating branch of the transverse facial artery. Surface changes in facial skin are some of the most obvious signs of aging. Skin aging is both intrinsic and extrinsic. Intrinsic aging is the result of genetically determined apoptosis. The skin becomes thinner; there is a decrease in melanocytes, a reduced number of fibroblasts, and a loss of skin appendages, leading to dryness. In the

Frontalis contraction

Temporal wasting Temporal fat pad atrophy Upper lid sulcus hollowing Crow’s feet Tear trough Midface flattening Cheek descent Nasolabial folds Thinning lips Marionette lines Jowls

Transverse neck folds Platysma bands Vertical neck pleats

Lateral brow ptosis Obicularis contracture Lower lid laxity Obicularis oculi laxity Loss of midface fat Malar fat descent Elongation and volume loss in upper lip Perioral wrinkles Buccal fat pad ptosis Expansion and ptosis of jowl fat Excess preplatysmal and subplatysmal fat Platysma muscle laxity

Figure 9.3.1 The aging face exhibits changes in the skin including superficial wrinkles and deeper folds. There is ptosis of soft tissue, particularly in the cheek, along the jawline and in the neck. There is loss of volume in areas such as the temple, the upper cheek, the midcheek and the premaxilla.  

Historical perspective

Historical perspective Facelift surgery dates from the early part of the 20th century. Its colorful history has been thoroughly reviewed by Stuzin.1 In the past, the history of aesthetic facial surgery has been reported by a number of authors, including Rogers,2,3 Rees and Wood-Smith,4 Gonzalez-Ulloa,5 Rees,6 and Barton.7,8 There is still doubt as to who performed the first facelift, but most sources date it to the first decade of the twentieth century.3,9,10 According to Rogers,3 Hollander11 reported in a chapter entitled “Cosmetic surgery” in Handbuch der Kosmetik that “as a victim of the art of feminine persuasion”, he removed pieces of skin at the margins of the hairline and in the natural aging skinfolds of a woman to freshen up “her wrinkles and drooping cheeks”. In this chapter, Hollander did not date the procedure, but in 1932 he stated that his original procedure had been performed in 1901 for a Polish aristocrat.12 Lexer,10 however, reported in 1931 that he had performed a facelift for an actress in 1906 and that he was unaware of any such operation before that date. Joseph9 reported in 1921 that he had performed an operation in 1912 for correction of aging cheek tissues in a 48-year-old woman. By the time Hollander, Lexer, and Joseph reported their first procedures, a number of other prominent surgeons in Europe, such as Noel, Passot, Morestin, Bourguet, and Lagarde, were busy performing cosmetic surgical procedures. In the United States, Miller and Kolle had large cosmetic surgery practices. Passot13 in 1919 published an illustrated article showing sites of elliptic skin excision of the hairline, the forehead, and the temporal and preauricular areas to tighten the skin and an elliptic excision of skin and fat to reduce submental fat deposits. Bourguet14 reported elliptic skin excisions similar to those of Passot. He was the first to report fat excisions to correct herniated periorbital fat pads (1924)15 and to publish preoperative and postoperative photographs of fat pad excision (1925).16 Noel published a book in 1926,17 La Chirurgie Esthetique: Son Role Social, describing facialplasty, blepharoplasty, forehead lifting, and correction of loose skin of the neck, burns, scars, protruding ears, and laxity of the upper arms. Although her procedures were not aggressive by modern standards, Noel was a true master of that era. Miller18 published the first book in medical history devoted entirely to the subject of cosmetic surgery. Miller was described by Rogers3 as a “quack” on one hand and at the same time, “a surgical visionary years ahead of his academic colleagues … medicine’s first truly cosmetic surgeon.” Miller was a prolific writer. In 1906, he wrote the first article in the medical literature describing an attempt to remove excess skin from the eyelids.19 In 1907, he published the first article with a photograph illustrating lower eyelid incisions,20 and he also published three cosmetic surgery textbooks.18,21,22 Kolle was born in Germany and practiced in New York. His book Plastic and Cosmetic Surgery23 represented the second description of cosmetic surgery in medical history. The book was more than 500 pages in length and contained hundreds of illustrations, including preoperative and postoperative photographs of protruding ears; it took a rather aggressive surgical approach to the correction of excess skin of the eyelids. Bettman24 was the first to publish preoperative and postoperative facelift photographs and to describe a continuous temporal scalp, preauricular, postauricular, and mastoid area incision. With modifications, his incision is essentially that

150.e1

used for facialplasty today. Hunt25 published a book, Plastic Surgery of the Head, Face and Neck, that included facelifting and forehead/browlifting operations. All the early facialplasty procedures were limited to skin excision and wound closure without subcutaneous undermining. Bames26 described subcutaneous face and neck undermining, skin redraping, and excision of excess skin. The continuous incision described by Bettman24 and subcutaneous undermining recommended by Bames26 essentially established the basic facelift procedure for the next 40 years. As discussed by Rees,6 a great deal of secrecy surrounded early facelift procedures. Surgeons were reluctant to share their techniques because of professional jealousy and greed. The disdain for “vanity” surgery by both the medical profession and the public restricted most facelift procedures to private offices and small clinics. The extent of surgery in such settings was necessarily limited. Many prominent plastic surgeons in major medical centers were forced to perform their facelifts in small clinics or to hide their cases by misnaming the procedures on the operating schedule. Renowned plastic surgeons after the First and Second World Wars, such as Gillies, Blair, Davis, Pierce, McIndoe, Mowlem, Conway, and others, did a great deal of cosmetic surgery but were reluctant to publish on the subject.6 The conventional facelift operation (skin dissection only) failed to address the effect of aging and the force of gravity on the structures (e.g., muscle, fat, and superficial fascia) deep to the skin. Likewise, the classic skin dissection facialplasty failed to account for the wide variation in facial, jawline, and cervical deformities; in the location of fat deposits; in the asymmetry of anatomic structures; and in the genetically determined deformities, such as microgenia and the obtuse cervicomental angle. Aufricht27 discussed the limitations of the subcutaneous facelift, particularly its failure to correct submental fat deposits and platysma bands. Adamson and colleagues28 discussed correction of the platysma bands in the submental area, and Millard and co-workers29 recommended extensive submental defatting. Pennisi and Capozzi30 and Baker and Gordon31 described suture plication of the deep tissues of the cheek and lateral neck. Tipton32 challenged the deep suture techniques in a study of 33 patients in whom he performed unilateral plication. Two years postoperatively, there was no obvious difference in the two sides of the face. In 1973 Skoog33,34 described a technique of dissection of the superficial fascial layer in the face, in continuity with the platysma muscle in the neck and advancement of the myofascial unit in a cephaloposterior direction. This was the beginning of the modern era in facelifting. Subsequent to Skoog’s innovation, Mitz and Peyronie35 used cadaver dissections to define the superficial musculo-aponeurotic system (SMAS) in the face and noted that tightening of this layer would be beneficial in facialplasty. SMAS-platysma facelifting, wide skin undermining, and extensive fat removal soon gained worldwide popularity. Many surgeons went on to describe different techniques involving SMAS-platysma repositioning.36–44 Lemmon and Hamra and later Barton, modified the Skoog technique focusing on a composite flap of SMAS and skin. In 1989, Furnas,45 described the retaining ligaments of the midface, which led to a better understanding of anatomic areas where facial soft tissue is supported and the involvement of these ligaments in leading to the anatomic changes

150.e2

SECTION II

CHAPTER 9.3  • Principles and surgical approaches of facelift

that occur with aging. These ligaments were further defined by others46,47 who thought that loss of the support from the retaining ligament system allowed facial fat to descend inferiorly in the face, deepening the nasolabial fold and forming facial jowls with aging. Knowledge of the retaining ligaments led to modifications in procedures involving ligament release in subSMAS dissection,47–56 Stuzin, Aston, Connell and Owsley all advanced the concept of a separate skin and SMAS flap, with the SMAS used to reposition descended facial fat. Other surgeons, preferring subperiosteal rather than subSMAS dissection to reposition fat, developed procedures whose similar goal is to resuspend descended malar fat to the malar eminences using the subperiosteal plane.57–59

A combination of subperiosteal and subcutaneous lifting has also been described.60 In the neck, Connell and Feldman identified the platysma as a critical component to be modified for adequate rejuvenation of the entire face.38,61 In concert with attempts to reposition facial fat, astute observations were eventually made about the age-related deflation of the human face.62–65 This led to the use of injected fillers and injected fat (lipofilling), championed by Coleman, in order to re-inflate the aging face, either independently or at the same time as facelift surgery. Later, anatomic dissections determined that facial fat is in distinct compartments both in the superficial and deep layers of the face.62,66

Anatomy and patient presentation

151

Figure 9.3.2  The face is composed of concentric layers of soft tissue. The most superficial layer is skin and subcutaneous fat – elevated in this image. Next is the superficial musculo-aponeurotic system (SMAS), which is contiguous with the platysma inferiorly and with the superficial temporal fascia (temporoparietal fascia) and galea superiorly. Deep to the superficial fascia is the parotidomasseteric fascia, contiguous with the deep cervical fascia inferiorly and the deep temporal fascia superiorly. © Marco Swanson.

Galea aponeurotica Frontalis Procerus Corrugator supercilii Orbicularis oculi, orbital portion Orbicularis oculi, preseptal portion Orbicularis oculi, pretarsal portion Nasalis Levator labii superioris alaeque nasi Levator labii superioris Auricularis anterior Zygomaticus minor Zygomaticus major Levator anguli oris Masseter Buccinator Depressor septi nasi Risorius Orbicularis oris Depressor anguli oris Depressor labii inferioris Mentalis Platysma

Figure 9.3.3  Muscles of facial expression. The solid lines demonstrate overlying skin creases caused by repeated contraction of the underlying muscles. (Netter illustration from www.netterimages.com.© Elsevier Inc. All rights reserved.)

152

SECTION II

CHAPTER 9.3  • Principles and surgical approaches of facelift

dermal matrix, there is fragmentation of the collagen and impairment of fibroblast function.67,68 Thinner skin becomes more susceptible to the repeated contraction of underlying facial muscles, which leads to permanent skin folds in predictable locations (Fig. 9.3.3). Extrinsic forces include sun exposure, cigarette smoke, extreme temperatures, and weight fluctuations. The net result is that aging facial skin becomes weaker, thinner, and dryer. It also loses its ability to recoil, a condition called elastosis. This has surgical implications, because firm tight skin is youthful, and to varying degrees, the tightening of loose facial skin contributes to the surgical result. However, a facelift does not improve the quality or the texture of the skin. Therefore, patients with good-quality skin are likely to enjoy better results from facelift surgery than patients with poor-quality skin. When skin quality is poor, options such as injectable fillers and skin resurfacing may be more appropriate for rejuvenation than facelift surgery. In most cases of facial rejuvenation, medical and surgical therapies can work in concert for a more complete result.

Facial fat: ptosis, volume loss, and volume gain The face is carpeted in a layer of superficial fat immediately deep to the dermis. Between individuals, there is much variability in the thickness of this superficial fat layer. This has surgical implications because heavier patients have thicker, heavier tissues to reposition. With thinner patients, the weight of tissue to be lifted is less, but facial layers are packed closely together, like an onion, increasing the difficulty in surgical separation of the skin from SMAS and SMAS from underlying structures. The malar fat pad is a thickened area of superficial fat overlying the zygomatic body.54 This is a triangular-shaped mass bordered by the nasolabial fold, the infraorbital arch, and a diagonal line across the midcheek. Its apex is over the malar eminence (Fig. 9.3.4). One study looked at fat volume in the cheek and found 56% of the fat superficial to the SMAS and 44% deep to the SMAS and the muscles of facial expression.69 The superficial fat is separated by vertical septae into five distinct compartments: nasolabial, medial cheek, middle cheek, lateral temporoparietal, and the inferior orbital fat (Fig. 9.3.5).66 The two central fat compartments (medial and middle) are the primary components of the malar fat pad. The deep fat is also compartmentalized (Fig. 9.3.6). Current terminology identifies the pyriform space medially, the deep medial fat compartment and the suborbicularis oculi fat (SOOF) – medial and lateral portions.62,70,71 It has been theorized that age-related deflation in the deep fat leads to “pseudoptosis” of the overlying superficial fat and skin – ptosis that is real but caused by a lack of underlying support.62 Using computed tomography (CT) scans over time in the same subjects, a significant loss of fat was observed from both superficial and deep fat compartments, although there is a greater percentage of loss in the deep fat layer.72 This contributes to changes such as the “inverted V deformity” below the infraorbital rim.73 Using sophisticated photographic analysis and facial averaging, Lambros identified significant age-related loss of volume in the premaxillary and perioral zone. The result is

Orbicularis oculi Zygomaticus major

Malar fat pad

Figure 9.3.4  The malar fat pad is a triangular area of thickened superficial fat with its base along the nasolabial fold and its apex over the superolateral malar prominence.

decreased projection of premaxillary soft tissue, an elongated upper lip and deepening of the nasolabial folds.74 In youth, facial fat is tightly packed, creating surface contours which undulate smoothly from convexity to concavity. The malar fat pad creates the principal cosmetic highlight zone in the youthful face. In the aging face, fat is less tightly packed, and facial contours become more abrupt. In areas of tight ligamentous attachment, such as the preparotid area, the anterior jowl border, and the zygomatic ligament insertions, visible depressions develop.63 Surgeons have traditionally viewed superficial cheek fat as a ptotic layer that requires repositioning. In support of this theory, it has been demonstrated that the primary muscles of facial expression in the midcheek (zygomaticus major and minor) do not change in length, while the overlying fat migrates inferiorly.75 Another study, using CT scans, identified age-related inferior migration of the midfacial fat compartments as well as inferior volume shift within the individual compartments.76 In the lower face, the jowl area appears to thicken with age, making the mandible appear wider. Sometimes called radial expansion, this may be caused by fat hypertrophy, or by soft-tissue ptosis within the premasseteric space, a natural

Anatomy and patient presentation

153

the neck, the SMAS continues as the superficial cervical fascia, which envelopes the platysma muscle. Clinically, the thickness and strength of the SMAS varies between patients, and by location, being thicker and strongest posteriorly over the parotid and weakest anteriorly.83 During surgical dissection, the SMAS is most tenuous under the malar fat pad where it splits to encompass the zygomaticus major and the orbicularis oculi.53,84 The SMAS has several important surgical implications. Its fibrous attachments to skin allow it to act as a carrier for overlying subcutaneous fat; also it has been shown to be much more resistant to stretch than skin.85 Furthermore, below the zygomatic arch, all branches of the facial nerve are deep to the SMAS. Therefore, dissection superficial to the SMAS is safe. The relationship of the SMAS (superficial fascia of the face) to the deep fascia of the face involves areas of mobility interspersed between areas of attachment. SMAS is tethered to the deep fascia by retaining ligaments over the parotid gland, at the inferior border of the zygomatic body, and along the anterior edge of the masseter (see Chapter 9.2 and later in this chapter). Between these areas of fixation, the SMAS is free to move over the underlying deep fascia. These are the suprazygomatic zone where superficial temporal fascia slides over the deep temporal fascia, the midcheek where SMAS rides over the parotid masseteric fascia (premasseteric space), and the neck where the platysma lies unattached over the underlying strap muscles.

Facial muscles Figure 9.3.5  Superficial facial fat is compartmentalized by vertically running septae. In the midcheek, from medial to lateral, these compartments are the nasolabial, medial, middle, and lateral compartments. The nasolabial and medial compartments make up the malar fat pad.

glide plane”.77–79 Below the mandible, fat distribution in the neck evolves over time with a decrease in fat in the lower third of the neck, but an increase in the upper third, contributing to a more obtuse cervicomental angle.80

Change in facial shape The combination of volume loss in some areas, volume gain in others, and soft-tissue ptosis creates a cascade effect resulting in the loss of natural youthful curves (Fig. 9.3.7). Gradually, the cheek fullness of youth gives way to jowl formation and upper neck fullness associated with age. The face changes from a heart shape to a more rectangular shape, or from an egg sitting on its narrow end to an egg resting on its broad end. This has been called losing the “inverted cone of youth” and has been likened to a reversal of the “Ogee” curve, a natural S-shaped curve seen in architecture.60,81

Superficial musculo-aponeurotic system Immediately deep to the subcutaneous fat is the SMAS, described by Mitz and Peyronie in 1976.35 The SMAS can be thought of as a continuous fascial sheath encompassing the entire face and neck. Superiorly, it continues into the temple as the superficial temporal fascia (temporoparietal fascia) and then into the scalp as the galea aponeurotica.82 Inferiorly, into

The muscles of facial expression are found in two layers: superficial and deep. The superficial muscles are orbicularis oculi, orbicularis oris, zygomaticus major, zygomaticus minor, levator labii superioris, risorius, and depressor anguli oris. These muscles are innervated on their deep surface by branches of the facial nerve (VII). Consequently, surgical dissection on the superficial surface of these muscles will not endanger their innervation. The only facial muscles innervated on their superficial surface are the muscles in the deep layer: mentalis, levator anguli oris and buccinator. The three facial muscles most important to surgeons are orbicularis oculi and platysma – because they are often manipulated during facelift surgery – and zygomaticus major – because it is used as a landmark in certain facelift techniques (see Figure 9.3.3). Most muscles of facial expression take their origins from bone and insert into the dermis, thus allowing for voluntary and involuntary movement of facial soft tissues. Platysma is a purely subcutaneous muscle taking its origin from the fascia of the pectoralis and inserting into soft tissue of the face, with a small bony insertion on the anterior mandible. It is also tethered posteriorly to the sternocleidomastoid (SCM) muscle via the cervical retaining ligaments.86 The platysma interdigitates with the depressor labii inferioris and in some individuals the platysma provides some effect on the depression of the lower lip. The platysma is thickest in the neck and can be visualized when a patient grimaces. As the muscle courses superiorly, crossing the mandibular border, it becomes much thinner. In some individuals the platysma can be found extending well into the midcheek, occasionally approaching the lower fibers of the orbicularis oculi. While most muscles of facial expression do not change appreciably with age, the orbicularis oculi and the platysma

Anatomy and patient presentation

153.e1

A

ORL

SCS

ORL SOOF ZM

Nasolabial

Medial

Middle

Lateral

Figure 9.3.5  Superficial facial fat is compartmentalized by vertically running septae. In the midcheek, from medial to lateral, these compartments are the nasolabial, medial, middle, and lateral compartments. The nasolabial and medial compartments make up the malar fat pad.

154

SECTION II

CHAPTER 9.3  • Principles and surgical approaches of facelift

Figure 9.3.6  The deep facial fat is compartmentalized by septae. In this cadaveric dissection the levator labii superioris has been removed to expose the deep fat compartments. From medial to lateral, the deep fat compartments are the deep pyriform space, the deep medial fat compartment and the lateral fat compartment. White lines indicate the zygomaticocutaneous ligament and the orbicularis retaining ligament (ORL). Above the ORL are the medial (MS) and lateral (LS) components of the suborbicularis oculi fat. (From Cotofana S, Gotkin RH, Frank K, et al. The functional anatomy of the deep facial fat compartments: a detailed imaging-based investigation. Plast Reconstr Surg. 2018;143(1):53-63.)

undergo age-related changes. Both muscles have a large surface area and are relatively thin – a configuration lending them to potential redundancy if they lose tone or if their deep tissue attachment is attenuated. For example, in some individuals redundancy develops in the lower half of the orbicularis, a condition that is a speculated cause of lower eyelid festoons.87 Some have suggested that it is the loss of support of the orbicularis through attenuation of the orbicularis retaining ligament (orbitomalar ligament) that contributes to deformities of the lower eyelid/cheek junction.73 Similarly, the paired platysma muscles, which are encased by SMAS, appear to gradually fall away from their deep cervical attachment carrying the overlying fat and skin. The net result is a more obtuse cervicomental angle and the development of visible platysma bands at the anterior platysmal border. Another issue common to orbicularis oculi and platysma is that these are the only facial muscles that are undermined during certain surgical procedures, thus imperiling some of their motor innervation. Fortunately, the orbicularis has multiple motor nerve branches providing a

level of collateral innervation.88 There is a less-elaborate innervation to the platysma; two or three cervical branches can be identified just inferior and anterior to the angle of the mandible in the plane between the deep cervical fascia and the undersurface of the platysma. Preservation of these branches is potentially important because the platysma acts as a support structure and also influences lower lip depression, especially in those individuals with a “full dentition” smile.89

Retaining ligaments Facial soft tissue and skin are held in place by retaining ligaments running from underlying fixed bone or fascia, through facial fat, inserting into the dermis.45,46,48 (Fig. 9.3.8). These ligaments influence the way gravity affects the aging face by holding fixed points into position. They also impair the surgeon’s ability to mobilize ptotic soft tissue, thus requiring surgical release. Different authors differentiate between different types of fixation, depending on their density and configuration. As

Anatomy and patient presentation

A

B

155

Figure 9.3.7  This healthy 75-year-old woman has never undergone facial surgery, has gained 10 pounds, but has aged 50 years. She has lost fat in the periorbital region and middle third of her face, revealing underlying bone. The orbit seems to have enlarged. Overall volume has been lost in the middle third of the face. The soft tissues that remain appear to be ptotic, flattening her cheeks, and widening her jawline. The heart-shaped face of youth has become more rectangular.

Temporalis Upper edge of temporal fat Orbital ligaments Temporal fat pad

Zygomatic ligaments Platysma auricular fascia

Platysma auricular fascia

Zygomaticus major

Masseteric ligaments

Sternocleidomastoid

Cervical retaining ligament

Mandibular ligament

Platysma

Figure 9.3.8 Facial soft tissue is tethered to underlying bone by the orbital, zygomatic and mandibular ligaments. Soft tissue is tethered to underlying deep fascia by the masseteric cutaneous ligaments and by an area of attachment anterior and inferior to the earlobe, known by a number of different terms: platysma auricular ligament (Furnas), platysma auricular ligament (Mendelson), parotid cutaneous ligament (Stuzin), and a distinct area anterior to the earlobe known as Lore’s fascia.  

156

SECTION II

CHAPTER 9.3  • Principles and surgical approaches of facelift

a result, retaining structures are referred to by all these terms: zones of adhesion, septa and ligaments.45,46,73 There are two ligament systems, based on the tissue of origin.46 The first are osteocutaneous ligaments, tethering skin to bone: the orbital, zygomatic, and the mandibular ligaments. The orbital ligament is found at the junction of the superior and lateral orbital rims and constitutes the inferior thickening of the temporal crest line zone of fixation (zone of adhesion) (see Chapter 11). The zygomatic ligament is actually a group of ligaments originating from the lower half of the zygomatic body to join the zygomatic arch. The zygomaticus major bony origin is in this location. These ligaments stabilize the overlying malar fat pad, going through this structure to the overlying skin. In this area, a perforating branch of the transverse facial artery courses from deep to superficial, contributing to the clinical bleeding seen when the zygomatic ligaments are released in this area during superficial skin flap dissection (McGregor’s patch). A branch of the zygomaticofacial nerve also accompanies the ligaments in this area, coursing directly from bone to skin, providing sensation to the skin of the malar cheek prominence. As described in Chapter 9.2, the zygomatic ligaments constitute the lower border of the prezygomatic space and must be released if the malar fat pad is to be fully mobilized and elevated. The mandibular ligament is a short but strong structure originating from the parasymphyseal mandible, tethering the overlying skin and contributing to formation of marionette lines. Its release is often necessary to allow tightening of loose skin in the submental region. The second ligament system involves tethering structures not originating from bone, but rather tethering the SMAS to the deep fascia. Along the anterior border of the masseter, the masseteric ligaments extend in a line from the zygoma down to the lower cheek.46 These ligaments support the anterior cheek and are more clinically significant superiorly, where they intermingle with the zygomatic ligaments. The most superior fibers of the obliquely running platysma can be seen terminating in the most superior masseteric ligaments. Over the parotid gland, the superficial fascia is fused with the deep fascia. Continuing inferiorly, the fascia encompassing the platysma is attached to the SCM fascia via the cervical retaining ligaments.86 Where the SMAS is fixed to the parotid, authors have applied different names to the same structure: platysma auricular fasica,90 platysma auricular ligament,45 and parotid cutaneous ligament.46 Deep to this area and attaching the SMAS to the bone of the ear canal is Lore’s fascia.91,92 In this area, the soft tissue is tethered to such a degree that it does not become ptotic with age. The surgical significance of this immobile area is that the so-called “fixed SMAS” can be used to support the surgically mobilized more anterior “mobile SMAS”. A number of facelift techniques depend on this concept (Fig. 9.3.9 ). The importance of retaining ligaments in aging is potentially two-fold. One theory holds that with age, ligaments relax, causing a gravitational shift of overlying superficial fat and skin. In youth, these appear to be firmly adherent to underlying bone and deep fascia, while with age the same soft tissue appears to become ptotic. One area where this has been proposed is along the infraorbital rim, where the orbicularis retaining ligament may relax, leading to the V deformity at the lid–cheek junction.73,93–95 Over the malar highlight area, the ligament relaxation theory suggests that the zygomatic ligaments become attenuated and the malar fad pad becomes

ptotic, causing a migration of fat medially and inferiorly, contributing to the development of the nasolabial fold. The second way that retaining ligaments become an issue with aging is through their tethering effects. The concept of “pseudoptosis” suggests that a loss of facial fat volume leads to ptosis, but the ligaments tether the overlying skin, leading to depressions and grooves in the surface contour of the face. Examples of tethering include the midcheek groove, caused by the zygomatic ligaments; the nasojugular groove, partly caused by the orbicularis retaining ligament (orbitomalar ligament); and the jowl/marionette line, caused by the mandibular ligament.90–92,94

Deep fascia The deep fascial covers the deepest structures in the face, including the masseter muscle and the parotid gland, where it is fused with the parotid capsule; the combined complex is called the parotid masseteric fascia (parotidomasseteric fascia; see Chapter 9.2). When the SMAS is surgically raised anterior to the parotid gland over the premasseteric space, the parotid masseteric fascia can be seen as a thin shiny membrane – an important landmark, because in the cheek (unlike the neck and temple), all branches of the facial nerve are deep to this deep fascial layer. The equivalent layer in the temple is the deep temporal fascia covering the temporalis. The equivalent layer in the neck is the deep cervical fascia that covers the superficial strap muscles and the SCM. The deep fascia covering the SCM is fused to the overlying platysma through the cervical retaining ligaments. If the platysma is to be mobilized in this area, these ligaments need to be released, or the platysma needs to be incised anterior to the ligaments (Video 9.3.1 ).86

Bone The bony skeleton of the face was once thought to be quite stable in volume and shape as the body aged. However, there is ample evidence that atrophy in certain portions of the facial skeleton is a factor in facial aging.96–101 This is reviewed in Chapter 9.2. CT of young and old skulls has shown a retrusion of the infraorbital rim as well as recession of the maxillary face below the infraorbital rim (Fig. 9.3.10).98 This has been confirmed by others who have also demonstrated an enlarging orbital aperture (Fig. 9.3.11).102 Loss of bone has surgical implications because it contributes to an overall loss of volume, and more specifically, to a loss of soft-tissue support in critical areas such as the infraorbital rim. This contributes to development of the tear trough deformity and age-related flattening of the anterior midface. Bone loss can be replaced with solid facial implants and partially replicated with soft-tissue fillers and fat grafting.

Facial nerve The facial nerve exits the stylomastoid foramen, separating into an upper and lower division within the parotid glad. Classically, there are five branches arising and exiting the cover of the superficial lobe of the parotid: temporal, zygomatic, buccal, marginal mandibular, and cervical. There are typically two to three temporal branches; four to five zygomatic

Anatomy and patient presentation

156.e1

Figure 9.3.9  Mendelson’s interpretation of soft-tissue attachments (see Chapter 9.2). The fixed posterior soft tissue is held in place by the platysma auricular fascia (large red area). The anterior face is fixed by a vertical column of attachments: orbital ligament, lateral orbital thickening (superficial canthal tendon), zygomatic ligaments, masseteric ligaments, mandibular ligament). In the midcheek, there is some mobility of these ligaments, while there is limited mobility over the platysma auricular fascia. The so-called “fixed SMAS” is that portion attached to the parotid and the posterior border of the platysma. Anterior to this, is the “mobile SMAS”. (Courtesy of Dr. Levent Efe, CMI.)

Figure 9.3.10  Computed tomography of young and old skulls has demonstrated a retrusion of the infraorbital rim. (Courtesy of Pessa JE. An algorithm of facial aging: verification of Lambros's theory by three-dimensional stereolithography, with reference to the pathogenesis of midfacial aging, scleral show, and the lateral suborbital trough deformity. Plast Reconstr Surg. 2000;106:479.)

Anatomy and patient presentation

Figure 9.3.10  Computed tomography of young and old skulls has demonstrated a retrusion of the infraorbital rim. (Courtesy of Pessa JE. An algorithm of facial aging: verification of Lambros's theory by three-dimensional stereolithography, with reference to the pathogenesis of midfacial aging, scleral show, and the lateral suborbital trough deformity. Plast Reconstr Surg. 2000;106:479.)

A

B

Figure 9.3.11  Computed tomography scans of (A) a male patient in the younger age group and (B) a male patient in the older age group. The image from the older age group shows significant bony remodeling (arrows) both superomedially and inferolaterally. (Courtesy of Kahn DM, Shaw RB. Aging of the bony orbit: a threedimensional computed tomographic study. Aesthetic Surg J. 2008;28:258.)

branches; three buccal branches; two to three mandibular branches; and two to three cervical branches (Fig. 9.3.12). In fact, there is considerable variation in the anatomy of facial nerve branches. One study identified up to eight

157

branches exiting the parotid, with multiple connections between these branches.103–105 All facial nerve branches are found deep to the SMAS/ platysma/superficial temporal fascia. The temporal (frontal) branches exit the parotid superiorly, coursing obliquely across the middle third of the zygomatic arch. Like all other facial nerve branches, the temporal branches start out deep to the deep fascia of the midcheek (parotid masseteric fascia), but unlike all other facial nerve branches in the cheek, they become more superficial. At a point 1.5–3.0  cm superior to the zygomatic arch, the temporal branches transition from deep to superficial, traveling at first on the undersurface and then within the superficial temporal fascia (temporoparietal fascia), staying there until they terminate in the frontalis muscle, upper orbicularis, and corrugator supercilii. The surgical implication is that a SMAS flap can be safely raised from a point just superior to the zygomatic arch providing that surgical dissection does not extend superiorly to the level where the temporal branch transitions more superficially.106 A classic external landmark for the course of the temporal branch is Pitanguy’s line, which is drawn from a point 0.5 cm below the tragus to a point 1.5  cm lateral to the lateral eyebrow.107 Recent studies have found that the temporal branch consists of 2–5 individual branches that do not adhere completely to this landmark. These branches cross the middle third of the zygomatic arch, with an anterior safe zone 2 cm posterior to the lateral orbital rim and a posterior safe zone 1  cm anterior to the acoustic meatus. Once above the zygomatic arch, these branches are consistently found anterior and inferior to the anterior branch of the temporal artery, a palpable landmark in the temple.108 The zygomatic and buccal branches all exit the parotid deep to the parotid masseteric fascia. As they travel anteriorly, they often arborize with each other. Zygomatic branches course parallel to the transverse facial artery and course inferior to the zygomatic retaining ligaments to the undersurface of the muscles that they innervate: zygomaticus major, zygomaticus minor, and orbicularis oculi. Deep to the parotid masseteric fascia, within the premasseteric space, the parotid duct courses anteriorly along an imaginary line from the tragus to the corner of the mouth. Accompanying the duct is normally a buccal branch. Beyond the anterior border of the masseter, a buccal branch can normally be seen crossing the buccal extension of the buccal fat pad (fat pad of Bichat).109 The mandibular branches, normally two in number, exit the parotid within 1 or 2 cm of the mandibular angle deep to the parotidomasseteric fascia. They travel forward 80% of the time superior to the mandibular border and 20% of the time just below the mandibular border.110 Around 23 mm from the gonial angle, they encounter the facial artery and vein, where they become superficial to the deep fascia and turn superiorly, crossing the facial vessels on their superficial side. This is a danger zone for nerve injury when dissection is done deep to the platysma. From there they travel 9 mm superior to the mandibular ligament, innervating the depressors of the lower lip. (Note: at all times the nerve is deep to platysma.)110,111 The cervical branches, 1 or 2 rami, exit the parotid at its inferior border and course anteriorly below the mandibular border. The cervical branches innervate the platysma with the

158

SECTION II

CHAPTER 9.3  • Principles and surgical approaches of facelift

Temporal branches

Zygomatic branches Posterior auricular nerve Temporofacial division Cervicofacial division Parotid gland Buccal branches Marginal mandibular branch Cervical branch B

A

Figure 9.3.12  (A) A cadaveric dissection of the facial nerve. The skin has been reflected anteriorly. The superficial musculo-aponeurotic system (SMAS) has been elevated, held with clamps and the cut edge is highlighted with blue dashes. The facial nerve branches emerge from the parotid gland; they are identified by black arrows and are highlighted by blue background. OO, Orbicularis oculi; ZM, zygomaticus major. (B) Diagram of the facial nerve. The facial nerve exits the stylomastoid foramen and normally divides within the parotid gland into a superior and inferior division. Classically, five groups of branches are seen: temporal, zygomatic, buccal, mandibular, and cervical. There is arborization between branches, particularly between the zygomatic and buccal branches. (A from Hashem AM, Couto RA, Duraes EFR, et al. Facelift part i: history, anatomy and clinical assessment. Aesthetic Surg J. 2020;40 (1): 1–18, Figure 1, p. 2.)

point of innervation near the anterior muscle border at the level of the thyroid cartilage.112 There may be connections with the marginal mandibular branch and the transverse cervical nerve.89 Because the buccal and zygomatic branches are multiple and interconnected, there is a reserve capacity in the event of a single branch injury; therefore, permanent injury is uncommon. However, the temporal and marginal mandibular branches enjoy less collateral innervation, making permanent loss more likely if these branches are injured. Also, damage to the cervical branches has been suggested as a cause of “pseudo paralysis” of the lower lip, a phenomenon that has been questioned in recent studies.112,113

Sensory nerves The great auricular nerve, a branch of the cervical plexus, is sensory to the earlobe and lateral portion of the pinna. This nerve wraps around the posterior border of the SCM and courses obliquely across the muscle in a superior direction. The classic landmark for this nerve is McKinney’s point at the midportion of the SCM, 6.5  cm below the external auditory canal114 (Fig. 9.3.13). It runs parallel and about 1 cm posterior to the external jugular vein, which also crosses the SCM roughly along the same vector. The nerve is deep to the superficial fascia,

but the platysma is usually absent over the posterior SCM. Hence, the nerve is at risk of injury during surgical dissection along the posterior border of the SCM because, with lack of fascial cover, it is technically subcutaneous in that location.87,115 The auriculotemporal nerve, a branch of the trigeminal, is sensory to the preauricular skin and the lesser occipital nerve is sensory to the retroauricular scalp. The zygomaticofacial nerve exits through its foramen in the body of the zygoma, piercing the malar fat pad to provide sensation to the skin of the malar prominence; this nerve is often transected when the malar fat pad is surgically mobilized (Fig. 9.3.14).

Neck anatomy From the perspective of rejuvenation surgery, the key anatomic structures in the neck are the skin, the superficial and deep fat compartments, the platysma muscles, the retaining ligaments, the digastric muscles and the submandibular glands. The deep cervical fascia is analogous to the deep fascia of the face. The superficial neck fascia encases the platysma muscle and is analogous to the SMAS in the face. Motor nerves of concern are the mandibular and cervical branches of the facial nerve. The primary sensory nerve of concern is the great auricular nerve. This subject matter is thoroughly reviewed in Chapter 9.8.

Anatomic assessment

6.5cm

McKinney’s point Great auricular nerve External jugular vein

Figure 9.3.13  The great auricular nerve crosses the midportion of the sternocleidomastoid (SCM) at McKinney’s point, which is 6.5 cm inferior to the external auditory canal. It usually travels about 1 cm posterior to the external jugular vein. Anterior to McKinney’s point, the nerve is covered by the superficial cervical fascia and the platysma (SMAS), but at the posterior border of the SCM, the nerve is effectively subcutaneous. The most common point of injury is at the posterior border of the SCM muscle.

Patient selection Like any elective surgical procedure, the patient’s physical and mental status must be appropriate to withstand the rigors of surgery, recovery, and any potential complications. The patient’s expectations must be explored to determine if they are realistic and if they are technically achievable. The quality of surgical result will be affected by many patient-related factors including the facial skeleton, the weight of facial soft tissue, the depth and location of folds, and the quality of the skin. For every patient there are some issues that can be predictably reversed, others attenuated, and some may not be correctable at all. The patient presenting for facial rejuvenation will usually be middle-aged or older, thus increasing the chances of underlying medical problems. In an otherwise apparently healthy individual, specific issues that must be addressed are blood pressure, smoking history, and the use of medications or supplements that can promote surgical bleeding. Incipient hypertension is common in the general population and can promote postoperative hematomas if it is not identified prior to surgery. Hematoma is by far the commonest complication in facelift surgery; therefore, uncontrolled hypertension is a contraindication for surgery, while controlled hypertension is not a contraindication. The labile hypertensive can be the most insidious situation. If patients

159

have intermittent hypertension (the white coat syndrome), or they are simply type A individuals who are easily excitable, perioperative treatment with medications such as clonidine should be considered.116,117 Smokers can exhibit delayed wound healing due to microvasoconstriction and abnormal cell function.118 One study reported a 12.5 times greater chance of having skin flap necrosis in a smoking patient compared with a non-smoker.119 Long-term smokers have reduced arteriole function, which may never return to normal. Nevertheless, there are significant short-term effects that can be reversed by abstaining from tobacco use for 2–3 weeks prior to surgery. Tests for the metabolites of nicotine in the blood are available to confirm abstinence from smoking. Commonly used nonsteroidal anti-inflammatory medications (NSAIDs) and the consumption of certain dietary supplements may promote intra-operative and postoperative bleeding based on platelet function inhibition. Patients should avoid these medications for 3 weeks prior to surgery. Female patients in the facelift age group may be on hormone replacement and are therefore at increased risk for developing postoperative deep vein thrombosis (DVT) and a potentially lethal pulmonary embolism. For these patients, in addition to all recognized preventative measures, consideration should be given to stopping hormonal replacement 3 weeks prior to surgery. With respect to the surgical objectives in facelift surgery, patients will typically present with specific concerns about specific areas – often the soft-tissue ptosis in the neck or jowls, or the visible wrinkles and folds in the cheek and neck. Patients are usually unaware of the underlying anatomic changes that are causing the problems they see in the mirror. Nevertheless, it is important to recognize that what the patient can see is the patient’s primary concern. To help focus the discussion, old photographs are useful in determining which aging changes predominate and what features the patient would most like to correct. As with any cosmetic surgery, helping the patient develop realistic expectations is a critical component of preoperative consultation.

Anatomic assessment Before surgery, the entire face should be assessed. This examination is conducted in a well-lit space with the patient sitting vertically in a comfortable position. Examination should be orderly so that nothing is missed. The face is examined with the patient in repose and in animation, thus assessing facial nerve function. The face should be assessed as a whole – looking for the equality of facial thirds, the degree of symmetry, and the overall shape (round, thin, wide).120 Classic tenants of facial shape are reviewed at the completion of this chapter. Facial shape influences the choice of surgical procedure.78 For example, a wide, full face may be more suited to soft-tissue excision rather than overlapping facial fat in the midface. Fat grafting may not be necessary. Conversely, a long, thin face will require the preservation of all soft tissue, overlapping it rather than excising it, and potentially adding additional volume. Preoperative identification of asymmetries is important and should be pointed out to the patient because facelift surgery will make some asymmetries more obvious.

160

SECTION II

CHAPTER 9.3  • Principles and surgical approaches of facelift

Ophthalmic nerve V1

Supratrochlear nerve Supraorbital nerve Lacrimal nerve Zygomaticotemporal nerve

Maxillary nerve V2

Infratrochlear nerve External nasal nerve Zygomaticofacial nerve Auriculotemporal nerve Infraorbital nerve Buccal nerve

Mandibular nerve V3 Mental nerve

Figure 9.3.14  Major sensory nerves of the face.

Surgeons should develop an organized way to examine all the zones of the face: forehead, eyelids, cheeks, the perioral area, and the neck. In certain individuals, the appropriate procedure will be a correction of only one of these areas, but more commonly, all or most or the zones should be addressed in order to achieve a harmonious result. Assessment of the forehead and orbital area are discussed in Chapter 11. In the cheeks, the surgeon should assess the shape and prominence of the underlying skeleton, the volume and distribution of facial fat, the degree of soft-tissue atrophy and ptosis, and the relative mobility of the subcutaneous (superficial) fat. Significant hollowing or flattening should be noted, and conversely, any radial expansion (fat deposition) in the jowl and neck should be noted. With the diversity of surgical techniques available, a surgeon should think like a sculptor – considering the face in three dimensions with a view to adding tissue in some areas, removing tissue in other areas, and repositioning tissue to a more youthful location. In the perioral area, the plumpness of the lips should be assessed, and any elongation of the upper lip should be noted. On smiling and at rest, the amount of dental show is observed. In the young face, there is normally some visible incisor show with the mouth in the resting slightly open position. A distance from the columella base to Cupid’s bow exceeding 15 mm may signify an elongated upper lip. The skin should be assessed, its quality noted, along with the

depth of wrinkles and folds, including the nasolabial fold and the marionette lines. The neck is examined in various positions: neutral, flexion, and turning side-to-side. In lateral view, changes in neck contour can be assessed in comparison to the youthful state using photographs as well as a comparison to the ideal neck.121 Classically, the youthful neck should display a distinct inferior mandibular border and a cervicomental angle of approximately 105°. The presence of anterior plastysma bands at rest, called passive bands, are assessed. The patient is asked to contract the platysma by clenching the teeth and grimacing. This will identify active platysma bands and help determine platysma thickness and strength. Also, with palpation, the amount of subcutaneous fat superficial to the platysma can be determined when the plastysma is contracted. The amount of soft tissue deep to the platysma is also estimated. Structures to be assessed are subplatysma fat, the digastric muscles and the submandibular glands, all of which may require modification during neck rejuvenation. In looking ahead to the effect of facelift surgery, manual repositioning of the lower cheek soft tissue is a useful measure to assess the effect on the neck. The ear should be examined with a thought to the potential placement of incisions. Important factors include the size and orientation of the earlobe, the angle of attachment of the tragus, the difference in character of the cheek skin and tragal skin, and the size of the tragus. The density of the hair

Surgery

surrounding the ear, the location of the hairline in the temple, the sideburn, and posterior to the ear all influence incision choice. If the temple hairline to lateral canthal distance is greater than 5 cm the surgical incision should be planned to avoid increasing this distance. Careful assessment of the skin is also important to determine if anything non-surgical is indicated – before, during, or after facelift surgery. Assessment will include skin type, skin quality, skin excess, the depth of folds, the degree of fine wrinkling, and the amount of photoaging. In particular, perioral rhytides should be examined as they are often a significant concern for the patient. Issues with the skin should be pointed out to the patient and options discussed because facelift surgery itself will not improve the texture and quality of the skin – a common misconception. Excellent photographic documentation of the preoperative face is important, and should, at the minimum include frontal, oblique, and profile views. Other useful views include the smile view and the neck in repose, with platysma contracture and with the head flexed down. Changes in the face from facelift surgery may be more subtle than other aesthetic procedures, so a reliable record of the surgical starting point is imperative.

Surgery A facelift is a significant operation. It should be done under excellent conditions, with appropriate medical staff, appropriate equipment, and adequate backup.

Anesthesia Anesthesia can be safely done using intravenous sedation or with varying levels in the spectrum of general anesthesia. An anesthesiologist can decide in consultation with the surgeon what form of anesthesia is preferred for an individual patient. There should be proper intra-operative patient positioning, intra-operative monitoring, intra-operative warming, and intra-operative DVT prophylaxis.

Local anesthetic infiltration Regardless of the systemic anesthesia used, local anesthetic infiltration is a critical component in facelift surgery. Mixtures of Xylocaine and/or bupivacaine are routinely used along with epinephrine to reduce intra-operative bleeding. However, a problem with postoperative rebound bleeding has led some surgeons to operative without vasoconstriction.122 Another popular method of local anesthetic infiltration is the use of tumescence where up to 500 cc of dilute local anesthetic is injected into the face and neck.123 The advantages of this tumescence are a form of hydrodissection and a widespread local anesthetic effect. The addition of tranexamic acid to the infused fluid has gained popularity as has its intravenous systemic administration. Safely used in other surgical specialties, tranexamic acid blocks the conversion of plasminogen to plasmin, thus stabilizing clot. Tranexamic acid has been shown to reduce the time spent accomplishing hemostasis during facelift surgery.124 Also, given intravenously, it has been shown to reduce postoperative swelling and bruising.125

161

Surgical technique Historically, surgeons have been guided by the simple fact that people look younger when soft tissue in the cheek is shifted superiorly. Strategically placed volume augmentation can also make people look younger without any soft-tissue elevation at all.126,127 By combining these approaches – adding volume in some areas, repositioning ptotic soft tissue and subtracting volume in other areas, a modern facelift can more accurately restore the contours of youth. The repositioning of ptotic tissue is the principal objective since facelift surgery began. Many methods have been described. The choice of technique depends on the patient’s desires, the aesthetic diagnosis and the surgeon’s comfort level with particular procedures. In this section, the classic subcutaneous facelift will be described followed by a review of the most popular methods used to manipulate the deeper soft tissue of the face. In subsequent chapters, these techniques will be described in detail.

Subcutaneous facelift The first facelift, dating from the early twentieth century, was a simple skin incision at the temporal hairline and anterior to the ear; several authors have claimed this innovation.9–11 This method evolved into a subcutaneous dissection of a large random-pattern skin flap that was shifted in a superior–lateral direction.24,26 This procedure removes excess skin and relies on skin tension to reposition the underlying facial soft tissue against the force of gravity. The advantages of a “skinonly” facelift are its relative simplicity, a rapid postoperative recovery, and the use of a dissection plane that does not risk damage to the facial nerve or other deep structures. The inherent disadvantage of the “skin-only” facelift is that a thin flap placed under tension to support heavy underlying soft tissue will inevitably stretch, leading to a loss of surgical effect. Unfortunately, if a surgeon increases skin tension in a misguided attempt to reposition ptotic deep tissue, several problems arise. The face can be distorted as skin tension flattens facial shape, negating the rounded contours of youth. Tension can cause wrinkles and folds to become oriented abnormally. Incision line tension can cause malposition of the hairline, alopecia, distorted earlobes, widened scars, and possible skin flap necrosis. Despite these issues, an isolated skin lift procedure can be a useful in secondary or tertiary situations where the deep tissues have previously been repositioned and the primary problem is a recurrence of skin laxity.

Facelift incisions The purpose of a facelift incision is twofold. First and most importantly, the incision provides access for surgical manipulation of the deep tissues of the face – the primary goal of most modern facelift techniques. Second, the incision allows facial skin to be repositioned and for excess skin to be removed. The incision is designed to be hidden by hair and by contours of the ear. In the temple area, the incision can be placed in the hair, at the anterior hairline, or a hybrid of the two, with an incision in the hair plus a transverse extension at the base of the sideburn (Fig. 9.3.15). The advantage of the incision in the hair is

162

SECTION II

CHAPTER 9.3  • Principles and surgical approaches of facelift

A

C

B

D

E

Figure 9.3.15  (A) The traditional hidden incision in the temple hair is appropriate when the temporal hairline will not be shifted adversely. (B) A temple incision along the hairline is used if a hidden incision will adversely shift the hairline. (C) The distance from the lateral orbital rim to the temporal hairline should not exceed 5 cm. (D) The retrotragal incision follows the edge of the tragus. (E) The pretragal incision is placed in the pretragal sulcus.

that it is hidden, but when the flap is drawn up, the anterior hairline and sideburn will shift, the degree of this depending on skin laxity. If the incision is placed at the anterior hairline, the scar is potentially more visible, but there will be no shift of the hairline. A popular compromise is to place the incision at the base of the sideburn and to place the incision partly at the hairline and partly behind the hairline128 (Fig. 9.3.16). Several factors should be assessed before committing to an incision within the temple hair, including density of the hair and the distance between the lateral orbital rim and the temporal hairline. In youth, this distance is generally less that 4–5 cm, while in older patients, the distance increases.129 If the distance is already excessive, or if the expected movement of the temporal hairline will create a distance over 5 cm, then an incision

in the hair should be avoided. Several alternate solutions have been devised to hide incisions made along the temple hairline, including beveling the incision to encourage growth of hair through the scar and the use of zigzag incisions.130,131 The anterior hairline incision should be meticulously sutured under minimal tension. Anterior to the ear, the incision can be pretragal, or along the tragal edge. The advantage of the tragal edge incision is that it is hidden, but care must be taken to thin the flap covering the tragus in order to simulate a normal tragal appearance. Furthermore, as pointed out by Connell,129,132 the tragus looks like a rectangle, with a top and a bottom, and to preserve a distinct lower border, a short transverse cut at the inferior end of the tragus (the incisura) should be made. Before committing

Surgery

A

B

to a tragal edge incision, the quality of tragal skin and that of facial skin must be compared; if the difference is too great, drawing thick cheek skin onto the tragus may be problematic because the skin covering the tragus will not be anatomically appropriate. Therefore, in certain cases, a pretragal incision is preferred. For example, in men, the pretragal approach may be beneficial if it appears that thick-bearded skin will be drawn up onto the tragus and the surgeon is concerned that removing hair follicles and thinning the flap will not ameliorate the appearance of cheek skin on the tragus. Elsewhere in front of the ear, the superior portion of the incision should follow a curved line along the helix and a slightly straighter curve along the anterior attachment of the earlobe; a long, straight line incision in front of the ear should be avoided (Video 9.3.2 ). Around the earlobe, the incision can be place either in the cleft of earlobe attachment or 1–2 mm distal to the cleft, leaving a cuff of skin along the earlobe. This cuff will ease the process of insetting the earlobe on closure. In the retroauricular sulcus, the incision can be placed directly in the conchal groove as it courses superiorly. Various landmarks have been described to determine how high to carry this incision. These include the level of the external auditory canal, or slightly higher, at the level of the antihelix. A “short scar” facelift incision involves only the temple incision and the preauricular incision, extending into the retroauricular sulcus, but not beyond.133 The advantage is to eliminate an incision into the occipital hairline and the main indication is facial rejuvenation when the neck is not a problem. The main disadvantage is the reduced effect for patients with excess neck skin; attempts to deal with this may result in a gathering of skin in the retroauricular sulcus, creating vertical pleats. Also, access to deep tissues is somewhat limited and there is a tendency to draw the skin flap in a more superior direction, possibly requiring a pre-hairline incision in the temple and possibly causing traction lines and wrinkles to course superiorly.

163

Figure 9.3.16  (A) The author’s preferred anterior incision is just behind the hairline in the temple, across the base of the sideburn, follows the contours of the ear and is along the tragal edge. (B) When there is minimal skin shift expected, the posterior extent can be limited to the retroauricular sulcus (“short scar” technique). When more skin shift is expected from the neck, the incision extends across non-hair-bearing skin into the occipital hair. In this example a “lazy S” follows the occipital hairline for 1 cm before entering the occipital hair.

With the standard approach, the incision extends from the retroauricular sulcus across non–hair-bearing skin into the occipital hair. Many variations have been described, ranging from an incision that goes vertically into the scalp134 to an incision that courses inferiorly along the hairline of the neck. Most commonly, surgeons use an incision that is between these two extremes. The principal objective is to take up redundant neck skin while avoiding distortion of the occipital hairline. Commonly a “lazy S” pattern can be used, where the incision follows the occipital hairline for 1–2 cm, before angling more posteriorly into the scalp, as in Fig. 9.16. A rough guide is to use the lazy S approach if 2 cm or more of neck skin is to be removed at the incision line (Video 9.3.3 ).129

Facelift skin flap dissection Either the temple dissection or the postauricular dissection can be done first, depending on surgeon preference. Dissection is usually begun with a scalpel for the first 1–2 cm, at which point most surgeons switch to scissors. In the postauricular area, the flap is firmly attached to the deep cervical fascia. Also, this is the most common location to see skin flap necrosis, so the flap should be raised sharply under direct vision, keeping the dissection against the underlying deep fascia to maintain flap thickness. As the dissection continues inferior to the earlobe level, the surgeon must be cognizant of the great auricular nerve, which is most at risk over the posterior border of the SCM. By keeping the dissection in the subcutaneous plane, the nerve will be protected. In the temple, if the incision has been made along the anterior hairline, dissection begins directly in the subcutaneous plane. If the incision has been made in the hair-bearing scalp of the temple, dissection can be carried out in one of two planes: superficial to the superficial temporal (temporoparietal fascia), which will continue directly into the subcutaneous facelift plane, or between the superficial temporal fascia and the deep temporal fascia. If the deeper approach is used, the dissection

164

SECTION II

CHAPTER 9.3  • Principles and surgical approaches of facelift

proceeds quickly against deep fascia, but at the anterior hairline, the dissection plane must transition into the subcutaneous facelift plane. This change of plane results in a narrow ribbon of superficial temporal fascia that will contain the superficial temporal artery and vein and branches of the auriculotemporal nerve. This has been called the “mesotemporalis”, which must be divided, often requiring ligation of the superficial temporal vessels. The argument in favor of the deeper dissection is to protect temporal hair follicles, although vessels and a nerve must be sacrificed (Fig. 9.3.17A). The superficial plane has the reverse attributes: vessels and nerves within the superficial temporal fascia are preserved, but the hair follicles can be injured unless care is taken (see Fig. 9.3.17B). Anterior to the anterior hairline, the subcutaneous plane is developed. This is the “facelift plane” where the dissection normally leaves about 2 mm of fat on the dermis which creates a cobblestone appearance of fat on the underside of the flap. Techniques to keep the flap consistent include direct vision or transillumination. This dissection results in a large random-pattern skin flap, the survival of which will entirely depend on the subdermal plexus. In the upper face, this dissection normally continues anteriorly until the orbicularis oculi is encountered where it encircles the lateral orbital rim. Depending on the type of deep-plane surgery planned, the midcheek dissection may stop short of the malar fat pad, or alternatively, carry on over the fat pad, freeing it from the overlying skin in the temple and cheek. Lower in the cheek, anterior to the ear and overlying the parotid, the skin is tethered to fascia which, as described earlier, has been names different things by different authors, including platysma auricular fascia and the parotid cutaneous ligament. Beyond this zone, subcutaneous dissection proceeds

A

relatively easily. Once the skin flaps anterior and posterior to the ear have been raised, the two dissections are joined. The extent of the facelift flap dissection into the cheek and neck will depend on the type of deep tissue technique being employed. When a submental incision is used for midline platysma plication, it is important to widely mobilize the cervical skin from the underlying platysma in order to allow the cervical skin to be re-draped along a vector opposite to that in which the platysma is being moved. If, on the other hand, there is no submental incision and the neck platysma and neck skin are moved in the same direction, the neck dissection can be more limited (Figs. 9.3.18 & 9.3.19).

Deep tissue surgery As reviewed in Chapter 9.2 the anatomy of facial aging is a complex process involving all layers of the face, from the skin to the bone. Logically, surgical rejuvenation of the aging face should address all or most of these layers. The subcutaneous facelift flap allows for tightening and removal of excess skin but does not address the descent of the thicker and heavier underlying soft tissue. A host of surgical approaches have been described to do this. These are outlined here and in subsequent chapters.

SMAS plication After surgeons learned to raise large random-pattern skin flaps, it became apparent that facial shape could be more effectively changed by using sutures to manipulate the underlying soft tissue.27

B

Figure 9.3.17 (A) Facelift flap has been raised in two different planes, initially deep to the superficial temporal fascia, against the deep temporal fascia (seen as an oval window), with a change of planes near the anterior temporal hairline into the subcutaneous plane. The “mesotemporalis” is a bridge of tissue that develops between these two planes. In order to unify the planes, it has been divided with ligation of the superficial temporal artery. (B) Facelift flap has been raised in a single subcutaneous plane, with dissection directly on the superficial temporal fascia and deep to the hair follicles of the scalp. The purple line outlines the course of the anterior branch of the superficial temporal artery.  

Surgery

Figure 9.3.18  Subcutaneous facelift flap has been raised.

Suture plication creates an in-folding of the superficial fat, drawing fat from the lower face up to the point where the sutures are placed (Fig. 9.3.20). Areas of fixed tissue, such as over the parotid gland, are less movable and can act as an anchoring point, whereas anterior to the parotid, mobile tissues can be easily manipulated.135 Multiple sutures with customized vectors can be used, allowing reshaping of the superficial facial fat. The technique is relatively easy to master; it can be customized for the individual case and can be modified intraoperatively by removing and replacing sutures as necessary. The superficial fat can be shifted in a different direction than the skin, usually along a more vertical vector. When plication sutures are placed properly, there is little or no risk to branches of the facial nerve. Proponents of plication claim long-lasting results without the need for invasive dissection.136 The primary concern with plication is the potential loss of effect if sutures cut through the soft tissue (the “cheese wire” effect). Another concern is that the degree of improvement may be limited by the tethering effect of the retaining ligaments, which in this technique are not released at their deeper extent; they are, however, released at the subcutaneous level during skin flap dissection. When the subcutaneous fat is fragile, suture fixation may fail. Also plication may have a limited effect in patients with very heavy jowls and ptotic tissues in the neck.

Loop sutures (MACS lift) A variation of suture plication is the loop suture method (Fig. 9.3.21), for which the main variant is the MACS lift

165

(minimal access cranial suspension). This procedure, which itself was derived from the “S-lift”, relies on long suture loops that take multiple small bites of soft tissue in a purse-string fashion.137,138 A vertical loop (the “U” suture) and an oblique loop (the “O” suture) are used with some of the tissue bites strategically placed into platysma below the border of the mandible. Superiorly, the sutures are secured to the deep temporal fascia at a point just superior to the zygomatic arch and anterior to the ear. The theoretical explanation for the efficacy of this technique relates to the use of multiple bites of tissue, which the developers of the technique feel creates “microimbrications” of the superficial fat and SMAS.138 Anteriorly, a third suture can be placed to advance the malar fat pad, although the fat pad is not surgically released and its repositioning depends on its own intrinsic mobility. Treatment of the neck can be done with closed liposuction or with an open procedure done through a submental incision, as described in Chapter 9.8. On closure, proponents of this technique recommend a nearly vertical vector for the skin flap, with a short scar incision. This may generate bunching of skin in the temple, which is dealt with by a W-plasty. The advantages with this technique are similar to those of plication, although proponents point to the added benefit of using a firmer point of fixation (deep fascia) and the improved effect of microimbrications. Disadvantages are the same as SMAS plication: potential loss of effect if the sutures pull through, the lack of deep ligament release, and concerns about the effectiveness of sutures holding heavy jowls and ptotic neck tissues against gravity. Lastly, surgeons using this technique must address the tendency for loop sutures to cause fat to bunch up, potentially leaving bulges that can be visible through the skin.

Supraplatysmal plane facelift The supraplatysmal plane facelift (Fig. 9.3.22) involves a deep subcutaneous dissection carried out immediately superficial to the SMAS and platysma. Originally called the “extended supraplatysmal (ESP)” facelift, this procedure raises the skin and superficial fat as a single layer, leaving the SMAS layer untouched.139 The zygomatic ligaments are released as dissection of the superficial facial fat extends over the malar prominence as far forward as the nasolabial folds. The theory behind this technique is the belief that the superficial fat is ptotic, but the underlying SMAS and platysma are not.139 After the flap has been raised, the fat on the underside of the flap can be contoured and sutures can also be placed from this fat to underlying fixation points. This technique provides good mobilization because ligaments are released, and it produces a thick robust flap. Also, with no surgical penetration of the underlying SMAS, there is theoretically no risk to branches of the facial nerve. Concerns about this method are that the flap is unidirectional (the skin and fat move en bloc) and the fact that repositioning the weight of this flap depends primarily on skin tension at the suture line.

SMASectomy The SMASectomy procedure involves excision and direct closure of the SMAS and superficial fat in the midcheek (Fig. 9.3.23). After skin flap elevation, a strip of SMAS and overlying fat, angling obliquely across the cheek, is removed from the lateral malar eminence to the angle of the mandible.140

166

SECTION II

CHAPTER 9.3  • Principles and surgical approaches of facelift

Figure 9.3.19  (A,B) Subcutaneous flap dissection with no submental incision. Platysma and skin are being moved in the same direction, superolaterally, thus requiring minimal separation of skin from platysma. (C,D) Subcutaneous flap dissection with submental incision. The paired platysma muscles, when sutured together in the midline, are shifted medially. As the skin is being moved in the opposite direction, a more thorough separation of skin from platysma is required.

A

B

C

D

The resulting defect, usually 2 to 3 cm in width, is sutured directly. The procedure can be done with a conventional facelift incision or a short scar approach. If required, the neck can be treated directly with closed liposuction or with platysma plication done through a submental incision. A primary advantage of this technique is the location of traction, which is close to the ptotic lower facial tissues, such as the jowl, and therefore potentially more effective than a more superiorly placed SMAS flap. The technique allows for skin and SMAS to be moved along different vectors. By suturing two freshly cut edges, fixation may be more secure than plication alone. Compared with doing a separate SMAS flap, the procedure is less time consuming, with less theoretical risk to the facial nerve because there is no deep-plane dissection. Also, the cut edges have not been undermined, potentially making them more viable than undermined SMAS flaps. Proponents feel that fixation is effective because the mobile SMAS is advanced and anchored to the fixed SMAS. Disadvantages include

the possibility of injuring a facial nerve branch (if the SMAS removal is done too deeply) and the lack of any ligamentous release, which may limit the movement of certain tissues such as the malar fat pad.

SMAS flap with skin attached (deep-plane facelift) Tord Skoog in 1974 published his method of raising skin, subcutaneous fat, and the SMAS as a single layer, which created a thick robust flap with excellent blood supply. It also contained a stretch-resistant structure (the SMAS), giving the promise of a long-lasting result.141 In concept, this procedure is like the ESP procedure (above), except that the SMAS is also included in the flap being raised. Because the operation was devised before Furnas described the retaining ligaments, the original Skoog procedure afforded only limited improvement

Surgery

167

in the anterior face. This lack of anterior movement was later found to be due to tethering of the SMAS to the lip elevators: zygomaticus major and minor and levator labii superioris.84 In order to overcome some of these shortcomings, several variations were developed (Barton: high SMAS; Hamra: deep plane; Fig. 9.3.24).53,142–144 The skin is normally raised for only 2–3 cm anterior to the tragus, the SMAS is then incised, and the rest of the dissection is done deep to the SMAS as far as the zygomaticus major muscle from which the SMAS is released. Beyond that, dissection can become more superficial. The skin and subcutaneous fat are left attached to the SMAS, and the entire flap is then advanced and fixated. Advantages of this technique are the robustness and physical strength of the flap, and the requirement for only one plane of dissection. Ligaments can also be released. Certain variations of the technique also allow for repositioning of the malar fat pad.142,144 In the composite technique, the orbicularis oculi muscle and overlying skin were included in the dissection.142,143 The neck is treated as required with an open approach to deal with the platysma and excess fat. Disadvantages of the purely deepplane procedures include the inherent risks of dissecting under the SMAS. Also, these procedures are mostly “monobloc” techniques, where the skin, subcutaneous fat, and SMAS are generally moved in one direction.

Subcutaneous facelift with separate SMAS flap (dual plane facelift) Figure 9.3.20  Subcutaneous flap with SMAS plication.

Figure 9.3.21  Subcutaneous flap with loop sutures (minimal access cranial suspension [MACS] lift).

Surgeons wishing to move the SMAS and subcutaneous fat in a different direction than the skin arrived at the concept of two separate flaps: the random-pattern facelift skin flap and a SMAS flap carrying the superficial fat (Fig. 9.3.25). Once the skin flap has been raised, the dissection plane for the SMAS flap is like the deep-plane dissection. Multiple variations of the SMAS flap component have been described with some dissections beginning above the zygomatic arch (high SMAS), some from below the zygomatic arch (low SMAS) and some in the midcheek. There are also variations in the pattern and extent of lateral platysma mobilization in the neck. In all cases, retaining ligaments are released and the SMAS, in conjunction with the platysma, is repositioned. Terminology has been introduced by different authors depending on their SMAS flap design (extended SMAS: Stuzin; high SMAS: Connell and Marten; FAME: Aston; MAPS Lift: Warren; Extended Vertical: Jacono).47,51,55,145–151 Proponents of this method feel that that moving the skin and subcutaneous soft tissues along different vectors provides more control over the facelift result. Typically, the deep tissue flap is shifted more vertically than the skin flap, which is shifted perpendicular to the nasolabial fold. A second advantage is the ability to reposition deep facial tissues by mobilizing and fixating the SMAS flap internally without the need to rely on skin tension for support. Retaining ligaments are surgically released, resulting in excellent mobilization and advancement of the SMAS and overlying fat. Disadvantages relate to a more time-consuming procedure because two different surgical planes are developed. In addition, these two planes introduce the inherent problems of each: potential damage to deep structure when doing the SMAS flap dissection and potential problems with the skin flap if it is too thinly dissected or if it is placed on too much tension. In a thin patient, both layers can be quite thin, which increases the technical demands placed on the surgeon.

168

SECTION II

CHAPTER 9.3  • Principles and surgical approaches of facelift

SMAS/platysma

Superficial fat

ESP dissection

A

Area of skin and subcutaneous fat elevation in extended supraplatysmal plane (ESP)

SMAS/platysma B

Figure 9.3.22  (A,B) Supraplatysmal plane (extended supraplatysmal plane [ESP] lift).

Subperiosteal facelift

Lateral SMASectomy extends from tail of parotid to lateral canthus Resection is at interface of fixed and mobile SMAS. Width of resection determined by SMAS laxity and desired debulking Undermining posterior border of platysma for advancement to mastoid

Figure 9.3.23  Subcutaneous flap with SMAS excision (SMASectomy).

Paul Tessier, in 1979, first presented his concept for a subperiosteal approach using craniofacial principles to elevate facial tissue.57,152 Variations were developed,59,153 but it was not until the introduction of the endoscope that surgeons widely adopted this concept (Fig. 9.3.26 ). As with an endoscopic browlift (see Chapter 11) approaching from the temple, the midface can be dissected in either the subperiosteal58,154 or supraperiosteal plane.155,156 Added exposure can be achieved by including access through a lower eyelid or an intraoral incision. The advantages are a dissection that is deep to all vital structures, a relatively short incision, and harmonious lifting of the midface and lateral brow. There is little or no tension on the skin, thus eliminating problems from excess tension on the skin. Disadvantages include the additional technology and equipment involved, a limited effect in the lower face/neck region, and limited effect on superficial structures, particularly loose skin. The younger patient who requires midface improvement without skin tightening has been proposed as being a good candidate.157

Skin flap closure (Video 9.3.4

)

Regardless of the technique used (excepting a pure subperiosteal approach), skin flap mobilization and closure is an important part of a facelift. Errors made during closure can create some of the most obvious facelift deformities which will denigrate an otherwise well-done procedure. At all times, the

Surgery

Subgaleal dissection Subcutaneous dissection 4cm

169

Subcutaneous tunnel superior to arch Only skin expected to be removed is undermined

Subcutaneous dissection of neck from mastoid to midline superficial to platysma

Upper lateral corner of SMAS remains attached to skin

Temporal branch, facial nerve

SMAS incision Dissection from beneath SMAS over zygomaticus major thus releasing restraint of investing fascia

Marginal mandibular branch of facial nerve

Figure 9.3.24  SMAS flap with skin attached (deep-plane facelift).

skin should be considered a covering layer, not a structural one. Therefore, skin flap repositioning should be seen as a removal of redundancy rather than a method to hold up ptotic soft tissue. In dual plane techniques, the skin flap is advanced

superolaterally along an oblique vector that is less vertical than the typical vector used for repositioning deep tissues. In other techniques, such as the MACS lift, surgeons employ a nearly vertical vector to the skin flap. In a deep-plane procedure,

170

SECTION II

CHAPTER 9.3  • Principles and surgical approaches of facelift

Figure 9.3.25  Subcutaneous facelift with separate SMAS flap (dual plane facelift).

the skin and deep tissues are mobilized together. A popular way to treat the skin flap is to redrape it “where it lies”, which means moving the cheek skin flap obliquely to the position it naturally assumes when the patient is lying in the supine position on an operating table.158 Another common guide is to advance the skin flap toward the temple along a vector that is perpendicular to the nasolabial fold. This is also approximately along the long axis of the zygomaticus major muscle. Determining flap tension is a surgical judgment and a skin flap marking forceps can help to determine where the skin should be incised. The anterior anchor point is immediately adjacent to the helix of the ear at the junction of the hair-bearing scalp. It can be held in place with a half-buried mattress suture to minimize the chance of a visible suture mark (Fig. 9.3.27 ). Posteriorly, the skin flap should be drawn along a vector that roughly parallels the body of the mandible. The second anchor point will be at the superior-most extent of the postauricular sulcus at the point where the incision starts to transition posteriorly. Once again, a half-buried mattress suture can be used. At this point, trimming of the overlapping flap and suturing can be done in the temple and in the occipital region; the order is based on surgeon preference. Then excess skin around the ear is trimmed, with no tension on the closure. If a tragal edge incision is used, the tragal flap is thinned and hair follicles are removed. In the retroauricular sulcus, there is normally little or no skin to be trimmed if the posterior flap has been correctly positioned. Earlobe inset is done last and is designed to angle the lobe 15° posterior to the long access of the ear (Fig. 9.3.28).129,132 Tension on the earlobe can lead to distortions such as the pixie ear deformity and the malpositioned earlobe, both of which are difficult to correct (see Chapter 9.10).

Proper insetting of the earlobe

A

B

Figure 9.3.28  The earlobe should be inset with the long axis of the earlobe (dotted line) about 15° posterior to the long axis of the ear itself. If the earlobe is pulled forward, an unnatural appearance results.

Neck surgery In most patients, an aging-looking neck accompanies an aging face and appropriate rejuvenation involves the correction of both. Anatomic structures in the neck that contribute to aging changes include the skin, subcutaneous fat, platysma muscles, subplatysmal fat, the digastric muscles and the

Surgery

170.e1

Fronto-temporal approach Intraoral approach Submental approach

Figure 9.3.27  Diagram shows typical skin flap redraping along an oblique direction which is slightly less vertical than the vector along which deep tissues are moved. There is considerable variation in this, however. Some techniques involve a more horizontal vector (dual plane extended SMAS) while other techniques utilize a nearly vertical vector (MACS lift).

SOOF

Intraoral incision Subcutaneous dissection Buccal fat

Figure 9.3.26  Subperiosteal facelift. SOOF, Suborbicularis oculi fat.

Surgery

submandibular glands. Basic principles for dealing with these structures are covered here, with a more thorough review presented in Chapter 9.8. A proper physical examination of the neck will help delineate the underlying anatomy and determine what tissues need correction. With the patient vertical, a traction test is done by manually repositioning cheek soft tissue to simulate the effect a facelift could have on the upper neck. Asking the patient to contract the platysma helps determine the thickness of subcutaneous fat as well as the strength and configuration of the platysma muscles. Viewing the patient from the side is helpful in assessing the length of the mandibular body, the degree of chin projection, the nature of the cervicomental angle and the location of the hyoid bone. The skin of the neck is typically thinner and less elastic than facial skin. In younger patients, the only lines present may be transverse, so-called necklace lines, which may be amenable to filler injection. With age, neck skin becomes more lax, often causing vertical wrinkles and pleats. These can be corrected by tightening the skin in a posterior oblique direction. One school of thought is that the platysma and skin are embryologically formed together and should be repositioned together by using a superior/oblique vector.138,159 Conversely, when the skin and platysma are treated separately, they must be surgically separated to allow them to be mobilized in different directions. With age, subcutaneous fat is lost in the lower neck while total fat volume increases in the upper neck. Increased upper neck fat, both superficial and deep to the platysma, contributes to blunting of the cervicomental angle.80 When the presence of subcutaneous fat is the only presenting problem, closed liposuction is a good solution when the skin is young and firm.160 Non-surgical measures such as cryolipolysis or injections of deoxycholic acid can also be used in that setting.161,162 Many surgeons perform closed liposuction in patients with looser neck skin, providing the skin is simultaneously tightened as part of a facelift. An important long-term consideration with all these methods is that submental fat removal can lead to laxity of submental skin later in life (Fig. 9.3.29). In general, the removal of subcutaneous fat should be done conservatively,

leaving a layer of fat on the skin that is thick enough to hide and disguise underlying anatomic undulations. The paired platysma muscles have well-recognized variations in their anatomy. The majority (roughly 75%) of necks exhibit interdigitation of the platysma muscles in the submental region for the first 1–2  cm behind the chin.163,164 The remaining 25% either overlap extensively, or do not overlap at all (Fig. 9.3.30). With age, there is a loss of tethering of the platysma muscles to the deep cervical fascia, analogous to the loss of tethering of the orbicularis oculi along the infraorbital rim. As a result, the anterior platysma borders fall away from the cervical mandibular angle and the sharp angle of youth gives way to the obtuse angle of age. The leading edge of the paired platysma muscles may cause visible bands, but clinical experience has

Figure 9.3.29  This 55-year-old woman had submental liposuction 25 years previously. She presents with excessive skin laxity in the submental region where the liposuction was done.

Mandibular symphysis

Thyroid cartilage

Limited platysma interdigitation

Extensive platysma interdigitation

No platysma interdigitation

Figure 9.3.30 Three types of platysma anatomy: limited interdigitation, 75%; extensive interdigitation, 15%; no interdigitation, 10%.  

171

172

SECTION II

CHAPTER 9.3  • Principles and surgical approaches of facelift

demonstrated that not all visible bands in the anterior neck are muscle; they may be caused by folds of excess loose skin. The distinction between muscle redundancy or loose skin should be determined during preoperative physical examination. Anterior platysma bands are considered either passive (present at rest) or active (only present on animation). To treat anterior passive neck bands caused by the platysma, one option is to treat the platysma and overlying skin as a common layer, as previously mentioned for treatment of loose neck skin. In conjunction with the facial SMAS, the platysma muscles can be drawn in a superior/oblique direction with fixation to firm fascia such as the platysma auricular fascia.92,159 In addition to this action, the anterior platysma muscle can be divided from the posterior approach, usually with a wedge excision to help ensure separation. One modification of this technique is the lateral skin-platysma displacement (LSD) procedure which creates a transposition flap out of anterior platysma that tightens anterior neck skin as the flap is mobilized posteriorly.165 Alternatively, the paired platysma muscles can be treated independently from the overlying skin. The approach to the platysma muscles is through a 2–3 submental incision, either in the submental crease or posterior to it. The muscles can then be drawn medially and approximated in the midline.28,166 Central approximation of the platysma muscles may require removal of interplatysmal fat and fascia. In joining the paired platysma muscles together, some surgeons advocate multiple rows of sutures to aggressively advance the platysma muscles medially; this has been termed the “corset platysmaplasty”.61 The logic in suturing the platysma muscles centrally is that a hammock effect is created to help support the deeper neck tissues and the platysma bands are eliminated by converting two muscles into one. A further maneuver, transecting the platysma inferior to the plication sutures, is necessary to eliminate active bands. In patients with very strong platysma muscles with a short thick neck, it may be necessary to do a complete transection of the muscles. Deep to platysma muscles, the subplatysmal fat has been described in three components: central, medial and lateral.167 The largest portion is the central, which is fibrous fat that fills the space between and overlies the digastrics. On its deep surface it extends to the mylohyoid. Laterally the medial portion becomes less fibrous and terminates as the most lateral portion

A

overlying the submandibular gland (Fig. 9.3.31A,B). This deep fat contributes to blunting of the cervicomental angle. It is easily accessed through the submental approach and can be partially or completely removed under direct vision. Also the anterior digastric muscle bellies may contribute to the appearance of submental fullness and can be surgically thinned. When submandibular glands are visible below the mandibular border or will become so after neck tightening, they can be treated with partial excision.168–170 Conceptually, deep soft tissues in the upper neck, consisting of deep fat, digastric muscles and submandibular glands should be considered as a contiguous soft-tissue mass that adds bulk to the neck. The alteration of any one component may require the alteration of all structures to create a congruent result.171,172 (Fig. 9.3.32). In some patients, when the only concern is the neck, an isolated neck procedure can be done. In that scenario, a submental incision is used for fat removal, platysma plication, or platysma transection plus the manipulation of anatomic structures deep to the platysma.173 Skin laxity can be corrected with an isolated retroauricular incision to redrape the skin. Through

Figure 9.3.32  Subplatysmal structures that affect neck contour. (1) Anterior belly of the digastric muscle, (2) submandibular salivary gland, (3) hyoid, and (4) mylohyoid muscle. Subplatysmal fat (not depicted) is distributed around these structures. (From Auersvald A, Auersvald LA, Uebel CO. Subplatysmal necklift: a retrospective analysis of 504 patients. Aesthet Surg J. 2017;37(1):1–11.)

B

Figure 9.3.31 (A) Subplatysmal fat elevated showing pyramidal shape. (B) Subplatysmal fat reflected revealing the floor of the submental triangle made by the mylohyoid muscle and the lateral boundaries made up by the digastric muscles. (From O’Daniel TG. Understanding deep neck anatomy and its clinical reverence. Clin Plastic Surg. 2018; 45: 447–454.)  

Ancillary techniques

this incision, tightening of the posterior plastysma can also be accomplished. The limitation with isolated neck lifts is often the skin which, when mobilized posteriorly, causes pleating anterior to the ear. This may require extending the incision anterior to the ear, thus approximating a facelift incision. In some older male patients with significant neck tissue laxity, a preferred option may be a direct excision of excess neck skin using a midline incision often broken up with a zigzag pattern or with Z-plasties.174 This minimally invasive technique is easily done with local anesthetic with or without sedation and provides unparalleled access to the platysma and subplatysmal structures. It allows maximal tightening of redundant neck skin. The primary disadvantage of this approach is a midline neck scar.

Choice of procedure With so many different methods described, it is difficult for the novice to choose the appropriate approach for face and neck lift surgery. In subsequent chapters, leading proponents of the techniques described here review their methods in detail. This is a field where personal opinions are strong, and the greatest difference of opinion among facelift surgeons relates to the way they manage the deeper tissue of the face and neck. Some surgeons feel that surgery above the SMAS (SMASectomy, Plication, MACS lift) will suffice, while others feel that dissecting and repositioning the SMAS is imperative for long-lasting results. In the neck, some surgeons feel that any anterior platysma banding warrants open surgery through a submental incision, while others rely completely on posterior–superior platysma traction. Some surgeons feel that visible submandibular glands must be addressed, while others feel it should never be done. In all cases, the objective is the same: an effective procedure with a long-lasting result and a high margin of safety. Over the years, a number of studies have been done attempting to compare different facelift techniques.32,175–183 One study involved four surgeons and two pairs of identical twins. At 10 years, both sets of twins had similar results.183 A systematic review of the world literature over a 60-year period was done looking for reliable data to support the efficacy and safety of one method over another.184 No clear indication could be found that any one facelift technique was superior to any other. As a result of such studies, surgeons are left to use their own judgment based on experience with different procedures in their own hands. Furthermore, the surgical technique for face and neck must be tailored to the individual patient because no one operation will fit every situation. Regardless of technique, there is inevitably some deterioration of the facelift result over time, something that depends on the quality of tissue being manipulated as well as technique being used.181 For example, one paper documented the recurrence of skin laxity and platysma bands in the anterior neck in 50% of patients at 1 year after extensive neck surgery.185 Comparing different face and neck lift techniques has historically been difficult because of the subjective nature of the end product. Recently, there has been progress in the objective assessment of surgical results using patient satisfaction as the metric.186 Looking forward, new technologies show promise in comparing facelift results based on the objective measurement of reduced apparent age as rated by independent reviewers or with artificial intelligence software.187,188

173

Ancillary techniques Browlift surgery and blepharoplasty Facial aging is typically a pan-facial phenomenon, and a comprehensive approach is often required to achieve a harmonious result. For many patients, surgery for the brow (Chapter 11) and the eyelids (Chapter 13) are critical components of a global approach to rejuvenation. Also, a facelift may introduce an indication for lateral brow lifting because of soft-tissue recruitment in the temple region. In this area, when a considerable amount of skin has been mobilized with cheek reposition, skin bunching can occur, and the best option may be to reposition the lateral brow and temple skin.

Volume removal With radial expansion of the lower third of the face and upper neck, many patients require fat removal. Superficial fat in the jowl area can be sculpted under direct vision or with closed small cannula liposuction. Deep fat removal in the cheek involves the buccal fat pad, which can be accessed during a facelift when the dissection plane is deep to the SMAS. The buccal fat pad is found between the buccal and zygomatic branches of the facial nerve. It then can be repositioned or partially removed.189,190 (Video 9.3.5 ). An alternative method is to partially remove the buccal fat through the mouth with an upper buccal sulcus incision.191 In the neck, superficial fat can be removed under direct vision or with closed liposuction. Deep fat in the central neck can be removed under direct vision. In all cases of fat removal in the face or neck, caution is advised because of the potential defects that can be produced when too much fat is removed.

Volume augmentation As volume loss in the face is a critical component of aging, proper rejuvenation should address facial deflation as well as soft-tissue ptosis. Volume can be added to the aging face using synthetic implants (cheek implants, submalar implants, orbital rim implants), injectable synthetic fillers, hydroxyapatite granules, or fat graft. Techniques involved in harvesting, processing, and injection of micro-droplet fat grafts (lipofilling) have undergone technical improvements and as a result, this technology is reproducible and reliable.64,192 For many surgeons fat grafting is now an integral part of facelift.193 There is a high rate of fat graft take after fat injection in the middle third and upper third of the face; in fact, significant over-grafting should be avoided in the periorbital area because of the possibility of visible ridges or lumps. Fat grafting is less reliable around the vascular mobile structures such as the lips. Specific areas that are commonly fat grafted in conjunction with facelift surgery are temples, the periorbita (orbital rim, upper lid sulcus, and the tear trough), the midfacial groove, and the malar prominence.193 The depth of injection can be in the superficial fat layer (superficial to SMAS) or, more commonly, in the deep fat layer against bone. As mentioned earlier, it has been proposed that the deep medial fat compartment may play a unique role in support of soft tissue in the midface, suggesting the benefits of fat grafting these zones.66 Therefore, the suborbicularis fat compartment

174

SECTION II

CHAPTER 9.3  • Principles and surgical approaches of facelift

(SOOF) and the deep medial fat compartments are grafted to restore midface volume in the midcheek. Fat injection can be done independently or in combination with facelift surgery. When done in conjunction with facelifting, it is done at the surgeon’s preference, either at the beginning of the procedure before the facelift flap has been raised (this author’s preference) or at the end of the procedure (Video 9.3.6 ).

Midface lift In an attempt to lift the tissue immediately inferior to the infraorbital rim (the midface), an approach through the lower lid was developed.194 This involves a subciliary or a transconjunctival blepharoplasty-type incision followed by a dissection down over the face of the maxilla. This procedure can be done in the subperiosteal plane, which requires an inferior periosteal release, or it can be done in a supraperiosteal plane.195 After mobilization of the cheek mass, the soft tissue is secured superiorly, either laterally along the lateral orbital rim,194 or more vertically with anchoring to the bone of the infraorbital rim.196 Disadvantages have included the learning curve necessary for surgeons to feel comfortable with this approach and a significant incidence of revisions for malposition of the lower eyelid.197 An alternative to the blepharoplasty approach is an endoscopic approach through the temple. This involves an extension of the endoscopic temple dissection along the lateral orbital rim, across the malar prominence, into the midface. The midface soft tissue is then elevated and fixated to the deep temporal fascia with long cable sutures or with specially made fixation devices.198

Lip procedures The aging face often develops changes in the perioral region, but a facelift will not affect this region except for some minor improvement in marionette lines. Common changes include elongation of the upper lip as measured from Cupid’s bow to the base of the columella, a thinning of the vermilion, and the development of perioral rhytides. Elongation of the upper lip is highly variable, but if present, tends to hide the upper teeth when the lips are in a relaxed position. It has been estimated that the ideal distance from Cupid’s bow to the base of the columella is 15 mm.199,200 The upper lip can be shortened by performing a skin excision along the contours of the base of the nose (bullhorn pattern). Skin is excised along with underlying fibrofatty tissue, exposing the orbicularis oculi. After undermining, the skin flap is drawn superiorly, with direct approximation of skin at the nasal base. Disadvantages include a potentially visible scar and a certain degree of relapse (Fig. 9.3.33). Alternatively, a strip of skin can be removed along the vermilion border, advancing the vermilion superiorly. This has the advantage of immediately increasing the apparent width of the vermilion lip, but the disadvantages are that the white roll is eliminated, and a permanent scar will be left along the vermilion border. Women can deal with this by using lipstick, but this is usually a lifelong commitment when the scar is visible. Lip augmentation can be done with many different techniques. Commonly used methods include injectable filler, injected fat, dermal fat graft, acellular dermis, and SMAS grafts. Many different types of human tissue and many synthetic materials have been used to thicken lips. Depending on the technique used, various problems have included

A

B

Figure 9.3.33  (A) Pre- and (B) postoperative photographs of a lip-shortening procedure using a bullhorn-shaped incision along the nostril sill.

resorption and loss of effect, permanently overfilled lips, misshaped lips, immobile lips, and in some cases, tissue necrosis from vascular compromise. Attempts to augment the lip along the vermilion border can over augment the skin above the lip, causing a duck-like appearance. Augmentation along the wet–dry junction is more likely to achieve a normal-appearing lip. Perioral rhytides are a common finding in the facelift age group. They can be effectively treated at the time of surgery with resurfacing procedures. Options include chemical peel, surgical dermabrasion, or laser treatment. The most common problem with resurfacing is permanent depigmentation if the resurfacing has been overly aggressive.

Dressings and drains Most surgeons use light dressings to cover the incisions and to act as an absorbent for wound drainage, although some surgeons feel that dressings after facelift surgery are not necessary at all. If used, dressings should not be tight or constrictive, but rather soft and comfortable. The initial dressing is normally removed on the first postoperative day. Opinions vary on the use of drains. When tissue glue such as fibrin sealant is used beneath the skin flap, or when quilting sutures are used, drains may not be indicated.

Early complications

Postoperative care In the initial postoperative period, the patient is kept still and blood pressure is monitored closely. Any signs of blood pressure increase should be taken very seriously; the patient is examined for possible causes (pain, anxiety, urinary retention) and appropriate measures taken. If the increase in blood pressure is endogenous, it should be treated pharmacologically. If the surgical procedure has been long (greater than 3 hours), sequential compression devices are kept on the legs in the recovery room until the patient can ambulate normally. The patient is then encouraged to get out of bed with assistance. Patient positioning involves keeping the head slightly elevated but avoiding flexion of the neck . Avoiding the use of a pillow for 10–14 days will help keep the patient’s head in a neutral, non-flexed position. Cool packs to the face will increase comfort and help decrease swelling. Analgesics and antinauseants are used as necessary. Depending on a surgeon’s pattern of practice, some patients are discharged home while others are kept under the care of a medically trained individual for the first night after surgery. On the first postoperative day, the patient is reviewed, paying particular attention to the possibility of a hematoma, the dressings are changed or removed, and drains may be removed as indicated. After the first day, options include another light dressing, a commercially available “chin strap”, or no dressing at all. Patients are usually permitted to have a shower and wash their hair when the incisions are sealed from the environment – usually 2–4 days postoperatively. Subsequently, patients are seen for dressing changes, suture removal, and wound inspection, at intervals up to 7–9 days when the final sutures are removed. Typically, there is a return visit at 2–3 weeks and then again between 6 and 8 weeks. Photographic documentation of the surgical result should be deferred for at least 6 months to allow for all postoperative swelling to settle completely.

175

as an urgent problem and dealt with promptly. If skin flap compromise is suspected and there is a delay in returning to the operating room, a temporary solution is the removal of sutures to relieve pressure (Fig. 9.3.35 ).

Sensory nerve injury The terminal branches of sensory nerves to a facelift flap are routinely divided when the flap is raised. This leads to a self-limiting paresthesia that usually recovers completely in 6–12 months. The great auricular nerve is the major sensory nerve at greatest risk for damage during facelift surgery. Transection will lead to numbness of the lateral portion of the external ear as well as skin anterior and posterior to the ear. A painful neuroma can also develop at the site of nerve transection. If knowingly transected during facelift surgery, either partial or complete, it should be repaired intraoperatively. A portion of the zygomaticofacial nerve is often transected when the malar fat pad is lifted; this will lead to numbness of the lateral cheek, which will continue to improve for over a year. In this area, some permanent numbness is possible.

Motor nerve injury Intra-operative damage to a facial nerve branch can easily go unnoticed by the surgeon until muscle paralysis is identified postoperatively. Immediately after surgery, in the recovery room setting, facial nerve paresthesias are extremely common and are usually caused by the lingering effects of local anesthetic. Once the temporary anesthetic effects are gone (approximately 12 h for bupivacaine), persisting dysfunction may be due to surgical traction or the effect of cautery near a nerve branch; these issues can be expected to resolve spontaneously over days or weeks. If a facial nerve branch has

Early complications Hematoma Postoperative hematoma is the most common facelift complication and has a reported incidence of 2%–3% in women. The incidence in men has been reported up to 8%, although this can be decreased to 4% through meticulous surgery and postoperative blood pressure control.201,202 A positive association has been found with the following: simultaneous open neck surgery, patients taking platelet inhibitors such as aspirin and anti-inflammatories, hypertension in the postoperative period, and the rebound effect when injected epinephrine wears off postoperatively.122,123 Hematoma prevention includes the preoperative discontinuation of anti-inflammatory medications and close attention to blood pressure control both before and after surgery. Various intra-operative strategies have been explored, including dressings, drains, fibrin glue, platelet gel and the use of tranexamic acid either systemically or in the local anesthetic.110 The most effective method yet described is a netting of externally placed quilting sutures to temporarily close off the subcutaneous space (Fig. 9.3.34). One published series of 405 consecutive facelifts had no hematomas.203,204 Hematomas typically develop in the first 24 h after surgery. If an expanding hematoma is identified, it should be treated

Figure 9.3.34  This 59-year-old woman is shown 48 h after a facelift. She has a hemostatic net (quilting sutures) that was put in place at the completion of her surgery. The concept is to close the dead space where a hematoma can collect.

Early complications

Figure 9.3.35  Postoperative hematoma in a hypertensive male. Note the ineffective suction drain.

175.e1

176

SECTION II

CHAPTER 9.3  • Principles and surgical approaches of facelift

been transected or wrapped in a suture, complete functional recovery may still be possible if the target muscle receives collateral innervation. The most commonly injured branches are thought to be the buccal branches, although long-term sequelae are rare due to multiple interconnections between nerve branches. Damaged temporal or marginal mandibular branches are less likely to recover because they are terminal branches with less collateral support. Fortunately, permanent paralysis of any degree is a rare event and has been reported as being less than 1%.205

Skin necrosis Facelift dissection creates a large, relatively thin, random-pattern skin flap that is placed under some tension; it has a remarkable ability to survive. Factors contributing to skin loss include excessive tension, an overly thin flap, hematoma, constrictive dressings, and the most damaging of all – smoking. The preferred approach for smokers considering facelift surgery is to discontinue all nicotine products for 3 weeks prior to surgery. Established skin necrosis should be dealt with conservatively because the majority of such cases will eventually heal spontaneously. Scar revision can be done at a later date.

Infection Infection is reported to be rare in facelift surgery, with large series indicating an incidence of less than 1%.206–210 However, most published series have only counted cases requiring surgical drainage or hospitalization. Minor cases of cellulitis and stitch abscesses are likely more common. Should a significant infection occur, standard treatment is indicated with surgical drainage, antibiotics, and appropriate wound care (Fig. 9.3.36).

Sialocele or fistula (submandibular or parotid glands) During dissection deep to the SMAS, the parotid gland can be injured, allowing for the escape of salivary excretions and the development of a sialocele fluid collection. Theoretically, lacerated parotid tissue exposed to overlying skin could lead to Frey’s syndrome (gustatory sweating). More common is a sialocele from partial submandibular gland resection where fluid builds up adjacent to the gland deep to the platysma. If clear fluid emanates from either site, it should be collected and its amylase content analyzed. For submandibular gland resections, one prophylactic option is to insert a suction drain at the site of the gland surgery to collect salivary fluid leakage. If a collection occurs, repeated aspirations are useful. Also used are a series of botulinum toxin injections into the remaining gland in an attempt to dry up the secretions.211,212

Venous thromboembolism Of the potentially lethal complications from facelift surgery (including anesthetic misadventure and drug allergy anaphylaxis), venous embolism is the most studied and best understood. Several studies, looking at large series of patients have documented an incidence of deep venous thrombosis after facelift of between 0.1% and 0.35%.209,213,214 In these same series, a documented incidence of pulmonary embolism has been reported between 0% and 0.14%.210 Two of these studies identified a higher risk with general anesthetic as opposed to conscious sedation, although the type of general anesthetic was not specified and may not have involved spontaneous ventilation. Prolonged procedures and combined procedures are associated with a higher risk. For prophylaxis, all studies recommend the use of intermittent lower-extremity compression devices and early ambulation. Because of the risk of hematoma, the use of systemic anticoagulation for facelift patients has been controversial. One study investigated the use of low-molecular-weight heparin for facelift patients and found a 16.2% incidence of postoperative bleeding with no difference in the rate of venous thrombosis in treated patients and non-treated patients.215

Late complications Many of the late complications possible in facelifts are reviewed as secondary deformities in Chapter 9.12. The key issues are covered here.

Unsatisfactory scars

Figure 9.3.36  Abscess under cervical portion of facelift flap 1 week after a facelift. This was treated with drainage and antibiotics.

Depending on the incision chosen, scars can potentially be obvious and deforming. Improper placement of incisions can lead to distortion of the ear and unnatural shifting of the hairline. Excessive tension can lead to loss of hair, depigmentation, and widened scars. Some scars can be improved with scar revision at a later date. Hypertrophic scars can be dealt with by steroid injection and scar revision if necessary. True keloid scars are rare, but if they occur, they are usually located around the earlobe or in the retroauricular sulcus. Patients with pigmented skin are most likely to develop keloids. They should be treated with conventional treatments, the mainstay being a series of corticosteroid injections.

Facial analysis, anthropometrics and concepts of facial shape

Alopecia Loss of hair can occur along the incision line or within the hair-bearing scalp that has been raised as a flap. The usual cause is excess tension at the incision line. However, if a flap of hair-bearing skin is raised, follicles can be damaged by the dissection itself, by cautery, or by traction on the flap. Permanent hair loss can be treated in some cases by mobilization of an adjacent flap of hair-bearing scalp. However, for significant alopecia, achieving adequate coverage with hair growth in the proper direction is best achieved with micro hair grafting.

Ear deformities The ear is an excellent anatomic structure to hide facelift scars providing the ear is treated with respect, skin incisions are planned carefully placed and closing wound tension is kept to a minimum. If a retrotragal incision is used, careless use of the scalpel can result in a “chopped” tragus where some portion of the tragus is inadvertently excised. Tension on the tragus can cause the tragus to fold forward, opening the auditory canal in an unnatural fashion. In a male, drawing bearded skin up onto the tragus without removing hair follicles can cause unnatural beard growth on the tragus. At the earlobe, poor insetting of the ear, or tension on the earlobe can result in a pixie ear deformity.

Facial distortion and irregularities The lateral sweep deformity can appear postoperatively as curved lines swooping from under the jowl upward across the cheek. This problem is caused by soft-tissue elevation posteriorly in the cheek without repositioning of more anterior superficial fat that includes the jowl.216 “Joker lines” are transverse cross-cheek depressions emanating from the corner of the

177

mouth. They are thought to occur in patients who are prone to this appearance and are accentuated by mobilizing the deeper planes of the face. If they occur, treatment is difficult although fat grafting has been used successfully.217 Not infrequently, masses and bulges appear after a facelift has completely healed. These may represent small subcutaneous hematomas that were not noticed during the initial healing phase and go on to form subcutaneous scar. Alternatively, some underlying structures such as a protruding buccal fat pad in the cheek or a ptotic submandibular gland in the neck may be revealed if a facelift has successfully repositioned more superficial facial layers, without addressing these deeper structures at the time of surgery.

Facial analysis, anthropometrics and concepts of facial shape Access the Historical Perspective section, including Figs. 9.3.37 and 9.3.38, online at Elsevier eBooks+ The standardization of soft-tissue facial analysis and the application of the neoclassical canons relies on consistent facial landmarks that can be assessed with standard photography (Table 9.3.1, Box 9.3.1). The initial proportional analysis of the face begins with the division into halves, with the height of the vertex to endocanthion being equal to the endocanthion to gnathion height (Fig. 9.3.39). One of the most utilized canons is the division of the face into thirds (see Fig. 9.3.39). The distance from the trichion to the glabella equals the distance from the glabella to subnasale, which equals the subnasale to

Table 9.3.1  Soft-tissue landmarks

Landmark

Description

Vertex (v)

The highest seen point on the head with the head in Frankfort horizontal

Trichion (tr)

The junction of the hairline and the forehead in the midline

Glabella (g)

The most prominent point of the forehead in the midline between the eyebrows

Nasion (n)

The midline point of the junction of the frontonasal suture and the superior nasal bones. Externally, nasion often corresponds to the point of greatest concavity of the nasal dorsum near a line level with the upper lid lash line

Orbitale (or)

The palpable point of the lowest margin of the inferior orbital rim

Porion (po)

The most superior point of the external auditory meatus

Frankfort horizontal (FH)

The line connecting porion and orbitale. This line is parallel to the floor for anthropometric measurements. It is an approximation of neutral head position in straight gaze

Endocanthion (en)

The point of the medial canthus where the upper and lower lids join

Pronasale (prn)

The most prominent point of the nasal tip

Subnasale (sn)

The deepest point at the junction of the base of the columella and the upper lip in the midline

Stomion (sto)

The midline point where the upper lip touches the lower lip

Sublabial (sl)

The midline point at the junction of the lower border of the cutaneous lower lip and the superior border of the chin. It is the deepest point of the labiomental groove

Pogonion (pg)

The most prominent point of the chin in the midline

Gnathion (gn)

The most inferior point of the lower border of the mandible; also called menton (me). In cephalometric analysis, gnathion and menton are two different points on the mandible

Facial analysis, anthropometrics and concepts of facial shape

177.e1

Anthropometry involves the study of the human body in relation to its variations in size and proportions. While the ancient Egyptians are reported to have been the first to divide the human body into equal parts, the Greek sculptor Polykleitus is credited with the development of canons, as exemplified in his statue of Doryphoros (Fig. 9.3.37).218 During the Renaissance, artists such as da Vinci, Dürer, Pacioli, and Alberti developed the “neoclassical canons”, which divided the face into symmetric ideal proportions. The twentieth century was highlighted by the development of radiographic techniques to indirectly measure the facial skeleton. Broadbent’s concept of cephalometrics219 allowed the initial compilation of normative facial data in 5400 children over 36 years.220,221 The idea of the “golden proportion” having application to facial analysis was introduced by Seghers et  al.222 and popularized by Ricketts.223,224 The aesthetically attractive 1:1.618 ratio, indicated by the Greek letter phi (Φ), was first recorded

in the 3rd century BCE by the Pythagoreans and has applications dating back to the architecture of the Egyptians and Greeks.225 Marquardt attempted to objectify the concept of an aesthetic face with development of the golden ratio phi mask (Fig. 9.3.38). Although the validity of this concept has been supported by superimposing the mask on young, white individuals of European descent,226 there are many limitations, as Guyuron points out,227 in the use of two-dimensional photographs to define an attractive face. Modern-day anthropometrics was led by the work of Leslie Farkas. He defined and measured countless soft-tissue points and dimensions in hundreds of people of varying ethnicities and ages.228,229 His extensive work has allowed the development of a database of normative values to which subsequent facial analyses may be compared. Perhaps of equal importance, Farkas realized the limited application of the neoclassical canons and the golden ratio to only a select group of patients.230,231

Figure 9.3.37  The Greek sculptor Polykleitos’ Doryphoros.

Figure 9.3.38  Marquardt’s phi mask is based on the “golden ratio”.

178

SECTION II

CHAPTER 9.3  • Principles and surgical approaches of facelift

BOX 9.3.1  Neoclassical canons 1. The height of vertex to endocanthion is equal to the height of endocanthion to gnathion (two-section canon). 2. The heights of trichion to nasion, nasion to subnasale, and subnasale to gnathion are equal (three-section canon). 3. The heights of vertex to trichion, trichion to glabella, glabella to subnasale, and subnasale to gnathion are equal (four-section canon). 4. The width of the alae equals one-fourth the width of the distance between the zygomas (nasofacial proportion canon). 5. The length of the nose is equal to the height of the ear (nasoaural proportion canon). 6. The inclination of the nasal dorsum is equal to the inclination of the ear (nasoaural inclination canon). 7. The distance between the medial canthi is equal to the width of the eye fissure (medial to lateral canthus of the eye) (orbital proportion canon). 8. The distance between the medial canthi equals the width of the ala (orbitonasal proportion canon). 9. The width of the mouth equals the width of the ala (naso-oral proportion canon).

gnathion distance. Obviously, a limitation of this technique is the position of the hairline, which may change with age, most notably in the male patient. When examining the lower third, it can be further divided into thirds such that the distance from the subnasale to the stomion is one-third and the distance from the stomion to gnathion is two-thirds (see Fig. 9.3.39). The four-section canon states that the distances from vertex to trichion, trichion to glabella, glabella to subnasale, and subnasale to gnathion are all equal (see Fig. 9.3.39). Farkas

examined the reliability of these relationships and found that a majority of patients deviate from these proportions.230,231 The upper half of the face, especially in women, is actually greater than the lower half, and the height of the nose is typically less than the upper and lower thirds. Men typically have a larger lower third due to a more prominent mandible, while women tend to have more equal lower and middle thirds. Further consideration must be given to proportional variations due to ethnicity, and these differences must be respected when considering surgical changes. Further division of the face into five major aesthetic masses (forehead, eyes, nose, lips, and chin) allows a more detailed analysis. Anthropometry is particularly useful in the preoperative assessment of faces that will surgically undergo fundamental shape change. This is most pronounced when the underlying skeletal framework of the face is manipulated with orthognathic procedures or with facial implants. In such cases, anthropometric and cephalometric examination are an integral part of surgical planning (Video 9.3.7 ). In the arena of facial rejuvenation surgery, facial shape is an important consideration in determining the procedure of choice for a given face.78,232 While formal cephalometric examination is not normally done for facelift surgery, anthropometric principles still apply. With most facelift techniques, volume in the midface is typically enhanced while volume in the lower face is reduced as tissue is shifted superiorly in the face. However, the wide face may not benefit from volume enhancement in the midcheek, while the long, thin face would benefit from combination of soft-tissue shifting and overlap, as well as additional volume augmentation with fat grafting. Aesthetic considerations must supersede technical considerations, and facelift techniques should be selected and modified to suit the unique requirements of every individual face.

Facial analysis, anthropometrics and concepts of facial shape

A

C

179

B

D

Figure 9.3.39  (A) The division of the face into halves. The height from the vertex to endocanthion is equal to the endocanthion to gnathion height. (B) The division of the face into thirds. The distance from the trichion to glabella equals the glabella to subnasale distance, which equals the subnasale to gnathion distance. (C) The lower third of the face can be divided into thirds, with subnasale to stomion equal to one-third and stomion to gnathion equal to two-thirds. (D) The four-section canon. The distances from vertex to trichion, trichion to glabella, glabella to subnasale, and subnasale to gnathion are equal.

Bonus images for this chapter can be found online at Elsevier eBooks+ Fig. 9.3.9 Mendelson’s interpretation of soft-tissue attachments (see Chapter 9.2). The fixed posterior soft tissue is held in place by the platysma auricular fascia (large red area). The anterior face is fixed by a vertical column of attachments: orbital ligament, lateral orbital thickening (superficial canthal tendon), zygomatic ligaments, masseteric ligaments, mandibular ligament. In the midcheek, there is some mobility of these ligaments, while there is limited mobility over the platysma auricular fascia. The so-called “fixed SMAS” is that portion attached to the parotid and the posterior border of the platysma. Anterior to this, is the “mobile SMAS”. (Courtesy of Dr. Levent Efe, CMI.) Fig. 9.3.26 Subperiosteal facelift. SOOF, Suborbicularis oculi fat. Fig. 9.3.27 Diagram shows typical skin flap redraping along an oblique direction, which is slightly less vertical than the vector along which deep tissues are moved. There is considerable variation in this, however. Some techniques involve a more horizontal vector (dual plane extended SMAS) while other techniques utilize a nearly vertical vector (MACS lift). Fig. 9.3.35 Postoperative hematoma in a hypertensive male. Note the ineffective suction drain. Fig. 9.3.37 The Greek sculptor Polykleitos’ Doryphoros. Fig. 9.3.38 Marquardt’s phi mask is based on the “golden ratio”.

Access the reference list online at   Elsevier eBooks+

References

References 1. Stuzin J. Aging face and neck. In: Mathes SJ, ed. Plastic Surgery. Philadelphia, PA: Saunders Elsevier; 2006. 2. Rogers BO. A brief history of cosmetic surgery. Surg Clin North Am. 1971;51:265–288. 3. Rogers BO. The development of aesthetic plastic surgery: a history. Aesthetic Plast Surg. 1976;1:3–24. 4. Rees TD, Wood-Smith D. Cosmetic Facial Surgery. Philadelphia: WB Saunders; 1973. 5. González-Ulloa M. The history of rhytidectomy. Aesthetic Plast Surg. 1980;4:1–45. 6. Rees TD. Aesthetic Plastic Surgery. Philadelphia: WB Saunders; 1980. 7. Barton FE. Rhytidectomy. Sel Read Plast Surg. 1985:3. 8. Barton FE. The aging face/rhytidectomy. Selected Readings in Plastic Surgery. 1987:4. 9. Joseph J. Hangewangenplastik (melomioplastik). Dtsch Med Wochenschr. 1921;47:287. 10. Lexer E. Die Gesamte Wiederherstellungschirurgie. Vol. 2. Leipzig: JA Barth; 1931. 11. Hollander E. Die kosmetische chirurgie. In: Joseph M, ed. Handbuch der Kosmetik. Leipzig: Verlag von Veit; 1912:688. 12. Hollander E. Plastische (kosmetische) operation: kritische darstellung ihres gegenwartigen stands. In: Klemperer G, Klemperer F, eds. Neue Deutsche Klinik. Vol. 9. Berlin: Urban and Schwarzenberg; 1932:1–17. 13. Passot R. La chirurgie esthetique des rides du visages. Presse Med. 1919;27:258. 14. Bourguet JI. La disparition chirurgicale des rides et plis du visage. Bull Acad Med Paris. 1919;82:183. 15. Bourguet JV. Les hernies graisseuses de l’orbite. Notre traitement chirurgical. Bull Acad Med Paris. 1924;92:1270. 16. Bourguet JV. Chirurgie esthetique de la face. Les nez concaves, les rides et les “poches” sous les yeux. Arch Prov Chir. 1925;28:293. 17. Noel A. La Chirurgie Esthetique: Son Role Social. Paris: Masson et Cie; 1926. 18. Miller CC. The Correction of Featural Imperfections. Chicago: Oak Printing Company; 1907. 19. Miller CC. The excision of bag-like folds of skin from the region about the eyes. Med Brief. 1906;34:648. 20. Miller CC. Semilunar excision of the skin at the outer canthus for the eradication of crow’s feet. Am J Dermatol. 1907;11:483. 21. Miller CC. Cosmetic Surgery: The Correction of Featural Imperfections. Chicago: Oak Printing Company; 1908. 22. Miller CC. Cosmetic Surgery: The Correction of Featural Imperfections. 2nd edn. Philadelphia, PA: FA Davis; 1925. 23. Kolle FS. Plastic and Cosmetic Surgery. New York: Appleton; 1911. 24. Bettman AG. Plastic and cosmetic surgery of the face. Northwest Med. 1920;19:205. 25. Hunt HL. Plastic Surgery of the Head, Face and Neck. Philadelphia: Lea & Febiger; 1926. 26. Bames H. Truth and fallacies of face peeling and facelifting. Plast Reconstr Surg. 1927;126:86. 27. Aufricht G. Surgery for excess skin of the face and neck. In: Wallace EB, ed. Transactions of the Second International Congress of Plastic and Reconstructive Surgery. Edinburgh: E & S Livingstone; 1960:495–502. 28. Adamson JE, Horton CE, Crawford HH. The surgical correction of the “turkey gobbler” deformity. Plast Reconstr Surg. 1964;34: 598–605. 29. Millard DR, Pigott RW, Hedo A. Submandibular lipectomy. Plast Reconstr Surg. 1968;41:513–522. 30. Pennisi VR, Capozzi A. The transposition of fat in cervicofacial rhytidectomy. Plast Reconstr Surg. 1972;49:423–427. 31. Baker TJ, Gordon HL. Adjunctive aids to rhytidectomy. South Med J. 1969;62:108–112.

179.e1

32. Tipton JB. Should the subcutaneous tissue be plicated in a face lift? Plast Reconstr Surg. 1974;54:1–5. 33. Skoog T. Rhytidectomy – a personal experience and technique. Presented and demonstrated at. Miami, FL: Cedars of Lebanon Hospital; 1973. 34. Skoog T. Plastic Surgery: New Methods and Refinements. Philadelphia: WB Saunders; 1974. 35. Mitz V, Peyronie M. The superficial musculo-aponeurotic system (SMAS) in the parotid and cheek area. Plast Reconstr Surg. 1976;58:80–88. This paper is the first description of the superficial musculo-aponeurotic system. 36. Guerrero-Santos J, Espaillat L, Morales F. Muscular lift in cervical rhytidoplasty. Plast Reconstr Surg. 1974;54:127–130. 37. Peterson R. Cervical rhytidoplasty – a personal approach. Presented at the Annual Symposium on Aesthetic Plastic Surgery, Guadalajara, Mexico; October 1974. 38. Connell BF. Cervical lifts: the value of platysma muscle flaps. Ann Plast Surg. 1978;1:32–43. 39. Guerrero-Santos J. The role of the platysma muscle in rhytidoplasty. Clin Plast Surg. 1978;5:29–49. 40. Guerrerosantos J. Surgical correction of the fatty fallen neck. Ann Plast Surg. 1979;2:389–396. 41. Aston SJ. Platysma muscle in rhytidoplasty. Ann Plast Surg. 1979;3:529–539. 42. Lemmon ML, Hamra ST. Skoog rhytidectomy: a five-year experience with 577 patients. Plast Reconstr Surg. 1980;65:283–297. 43. Kaye BL. The extended neck lift: the “bottom line”. Plast Reconstr Surg. 1980;65:429–435. 44. Kaye BL. The extended face-lift with ancillary procedures. Ann Plast Surg. 1981;6:335–346. 45. Furnas DW. The retaining ligaments of the cheek. Plast Reconstr Surg. 1989;83:11–16. 46. Stuzin JM, Baker TJ, Gordon HL. The relationship of the superficial and deep facial fascias: relevance to rhytidectomy and aging. Plast Reconstr Surg. 1992;89:441–449. discussion 450–451. Anatomic dissections confirm the presence of retaining ligaments previously described by other authors as well as newly described masseteric ligaments. The authors discuss the support these structures supply between fixed bone and deep fascia and the superficial fascia. 47. Mendelson BC. Correction of the nasolabial fold: extended SMAS dissection with periosteal fixation. Plast Reconstr Surg. 1992;89: 822–833, discussion 834–835. 48. Bosse JP, Papillon J. Surgical anatomy of the SMAS at the malar region. Transactions of the 9th International Congress of Plastic and Reconstructive Surgery. New York, NY: McGraw-Hill; 1987:348. 49. Hamra ST. The deep-plane rhytidectomy. Plast Reconstr Surg. 1990;86:53–61, discussion 62–63. 50. Stuzin J.M., Baker T.J., Gordon H.L. The extended SMAS flap in the treatment of the nasolabial fold. Presented at the American Society for Aesthetic Plastic Surgery meeting, Chicago, IL; 1990. 51. Stuzin JM, Baker TJ, Gordon HL, et al. Extended SMAS dissection as an approach to midface rejuvenation. Clin Plast Surg. 1995;22:295–311. This review article outlines the authors’ understanding of facial anatomy as it pertains to facelift surgery, their understanding of facial aging, and it describes their surgical procedure in detail. The procedure is called the extended SMAS dissection because it involves raising the malar fat pad in conjunction with the SMAS flap. The authors emphasize the importance of flap fixation in order to create a long-lasting result. 52. Mendelson BC. Extended sub-SMAS dissection and cheek elevation. Clin Plast Surg. 1995;22:325–339. 53. Barton FE. Rhytidectomy and the nasolabial fold. Plast Reconstr Surg. 1992;90:601–607. 54. Owsley JQ. Lifting the malar fat pad for correction of prominent nasolabial folds. Plast Reconstr Surg. 1993;91:463–474, discussion 475–476. 55. Connell BF, Marten TJ. The trifurcated SMAS flap: three-part segmentation of the conventional flap for improved results in the midface, cheek, and neck. Aesthetic Plast Surg. 1995;19:415–420.

179.e2

SECTION II

CHAPTER 9.3  • Principles and surgical approaches of facelift

56. Aston SJ. Facelift with FAME technique. Presented at the Thirty-Second Annual Baker Gordon Symposium on Cosmetic Surgery. Miami, FL: Mercy Hospital; 1998. 57. Tessier P. Facial lifting and frontal rhytidectomy. In: Fonseca J, ed. Transactions of the VII International Congress of Plastic and Reconstructive Surgery, Rio de Janeiro. Rio de Janeiro: Cartgraf; 1979:393–396. 58. Ramirez OM, Maillard GF, Musolas A. The extended subperiosteal face lift: a definitive soft-tissue remodeling for facial rejuvenation. Plast Reconstr Surg. 1991;88:227–236. discussion 237–238. The authors’ experience with subperiosteal facelift techniques is reviewed. Pertinent points include: (1) using an interconnected subperiosteal approach that involves the entire zygomatic arch; (2) utilizing upward pull of the muscles of facial expression to elevate the mouth; (3) keeping the dissection deep in the temple to protect the temporal branch; and (4) utilizing the temporal fascia as a lifter and anchoring point. 59. Psillakis JM, Rumley TO, Camargos A. Subperiosteal approach as an improved concept for correction of the aging face. Plast Reconstr Surg. 1988;82:383–394. 60. Little JW. Three-dimensional rejuvenation of the midface: volumetric resculpture by malar imbrication. Plast Reconstr Surg. 2000;105:267–285. discussion 286–289. 61. Feldman JJ. Neck Lift. St. Louis: Quality Medical Publishing; 2007. 62. Rohrich RJ, Pessa JE, Ristow B. The youthful cheek and the deep medial fat compartment. Plast Reconstr Surg. 2008;121:2107–2112. Anatomic dissections of deep facial fat are presented (fat that is deep to the muscles of facial expression). The deep fat is compartmentalized by septae, creating the deep medial fat pad, and the suborbicularis oculi fat. 63. Lambros V. Models of facial aging and implications for treatment. Clin Plast Surg. 2008;35:319–327, discussion 317. 64. Coleman SR. Facial recontouring with lipostructure. Clin Plast Surg. 1997;24:347–367. A pioneer of facial fat grafting presents early experience with lipoinjection of the face. 65. Lambros V. Observations on periorbital and midface aging. Plast Reconstr Surg. 2007;120:1367–1376, discussion 1377. 66. Rohrich RJ, Pessa JE. The fat compartments of the face: anatomy and clinical implications for cosmetic surgery. Plast Reconstr Surg. 2007;119:2219–2227, discussion 2228–2231. Anatomic dissections are presented that demonstrate how the subcutaneous fat of the face is partitioned into multiple, independent anatomical compartments. In some locations, the septae dividing the fat compartments are aligned with retaining ligaments. 67. Fitzgerald R, Graivier MH, Kane M, et al. Update on facial aging. Aesthet Surg J. 2010(30 suppl):11S–24S. 68. Kligman LH. Photoaging. Manifestations, prevention, and treatment. Dermatol Clin. 1986;4:517–528. 69. Raskin E, Latrenta GS. Why do we age in our cheeks? Aesthet Surg J. 2007;27:19–28. 70. Surek CK,Vargo J, Lamb J. Deep pyriform space: anatomical clarifications and clinical implications. Plast Reconstr Surg. 2016;138(1):59–64. 71. Cotofana S, Gotkin RH, Frank K, et al. The functional anatomy of the deep facial fat compartments: a detailed imaging-based investigation. Plast Reconstr Surg. 2018;143(1):53–63. 72. Boehm LM, Morgan A, Hettinger P, Matloub HS. Facial aging: a quantitative analysis of midface volume changes over 11 years. Plast Reconstr Surg. 2021;147:319–327. 73. Muzaffar AR, Mendelson BC, Adams WP. Surgical anatomy of the ligamentous attachments of the lower lid and lateral canthus. Plast Reconstr Surg. 2002;110:873–884, discussion 897–911. 74. Lambros V. Facial aging: a 54-year, three-dimensional population study. Plast Reconstr Surg. 2020;145:921–928. 75. Gosain AK, Amarante MT, Hyde JS, et al. A dynamic analysis of changes in the nasolabial fold using magnetic resonance imaging: implications for facial rejuvenation and facial animation surgery. Plast Reconstr Surg. 1996;98:622–636. A comparative MRI study demonstrates the changes in subcutaneous fat that develop with age. The authors conclude that superficial fat in the cheek becomes ptotic while the underlying elevators of the lip do not elongate with age.

76. Gierloff M, Stöhring C, Buder T, et al. Aging changes of the midfacial fat compartments: a computed tomographic study. Plast Reconstr Surg. 2012;129:263–273. 77. Lambros V.S. Personal communication, 1999. 78. Stuzin JM. Restoring facial shape in face lifting: the role of skeletal support in facial analysis and midface soft-tissue repositioning (Baker Gordon Symposium Cosmetic Series). Plast Reconstr Surg. 2007;119:362–376.This review discusses the changes in facial shape that occur with aging, the surgical means we have to correct these changes, and alterations that should be made with different degrees of underlying skeletal support. 79. Mendelson BC, Freeman ME, Wu W, et al. Surgical anatomy of the lower face: the premasseter space, the jowl, and the labiomandibular fold. Aesthetic Plast Surg. 2008;32:185–195. 80. Orra S, Tadisina K, Charafeddine A, et al. The effect of age on fat distribution in the neck using volumetric computed tomography. Plast Reconstr Surg. 2021;147:49–55. 81. Little JW. Volumetric perceptions in midfacial aging with altered priorities for rejuvenation. Plast Reconstr Surg. 2000;105:252–266, discussion 286–289. 82. Gosain AK, Yousif NJ, Madiedo G, et al. Surgical anatomy of the SMAS: a reinvestigation. Plast Reconstr Surg. 1993;92:1254–1263, discussion 1264–1265. 83. Lukavsky R, Trussler A, Barton FE, Lee M. Identifying regional viscoelastic properties of the superficial muscular aponeurotic system. Aesthetic Surg Journal. 2021;41:277–283. 84. Barton FE. The SMAS and the nasolabial fold. Plast Reconstr Surg. 1992;89:1054–1057, discussion 1058–1059. 85. Saulis AS, Lautenschlager EP, Mustoe TA. Biomechanical and viscoelastic properties of skin, SMAS, and composite flaps as they pertain to rhytidectomy. Plast Reconstr Surg. 2002;110:590–598, discussion 599–600. 86. Mustoe TA, Rawlani V, Zimmerman H. Modified deep plane rhytidectomy with a lateral approach to the neck: an alternative to submental incision and dissection. Plast Reconstr Surg. 2011;127: 357–370. 87. Furnas DW. Festoons, mounds, and bags of the eyelids and cheek. Clin Plast Surg. 1993;20:367–385. 88. Lowe JB, Cohen M, Hunter DA, et al. Analysis of the nerve branches to the orbicularis oculi muscle of the lower eyelid in fresh cadavers. Plast Reconstr Surg. 2005;116:1743–1749, discussion 1750–1751. 89. Salinas NL, Jackson O, Dunham B, et al. Anatomical dissection and modified Sihler stain of the lower branches of the facial nerve. Plast Reconstr Surg. 2009;124:1905–1915. 90. Mendelson BC, Jacobson SR. Surgical anatomy of the midcheek: facial layers, spaces, and the midcheek segments. Clin Plast Surg. 2008;35:395–404. discussion 393. 91. Lore JM. Atlas of Head and Neck Surgery. Vol. 2. 2nd revised ed. Philadelphia: WB Saunders; 1973:596–597. 92. Labbé D, Franco RG, Nicolas J. Platysma suspension and platysmaplasty during neck lift: anatomical study and analysis of 30 cases. Plast Reconstr Surg. 2006;117(6):2001–2007, discussion 2008–2010. 93. Kikkawa DO, Lemke BN, Dortzbach RK. Relations of the superficial musculoaponeurotic system to the orbit and characterization of the orbitomalar ligament. Ophthal Plast Reconstr Surg. 1996;12(2):77–88. 94. Mendelson BC, Muzaffar AR, Adams WP. Surgical anatomy of the midcheek and malar mounds. Plast Reconstr Surg. 2002;110:885– 896, discussion 897–911. 95. Moss CJ, Mendelson BC, Taylor GI. Surgical anatomy of the ligamentous attachments in the temple and periorbital regions. Plast Reconstr Surg. 2000;105:1475–1490, discussion 1491–1498. 96. Jelks GW, Jelks EB. The influence of orbital and eyelid anatomy on the palpebral aperture. Clin Plast Surg. 1991;18(1):183–195. 97. Pessa JE, Desvigne LD, Lambros VS, et al. Changes in ocular globe-to-orbital rim position with age: implications for aesthetic blepharoplasty of the lower eyelids. Aesthetic Plast Surg. 1999;23:337–342.

References

98. Pessa JE, Chen Y. Curve analysis of the aging orbital aperture. Plast Reconstr Surg. 2002;109:751–755, discussion 756–760. 99. Pessa JE. An algorithm of facial aging: verification of Lambros’s theory by three-dimensional stereolithography, with reference to the pathogenesis of midfacial aging, scleral show, and the lateral suborbital trough deformity. Plast Reconstr Surg. 2000;106:479–488, discussion 489–490. 100. Bartlett SP, Grossman R, Whitaker LA. Age-related changes of the craniofacial skeleton: an anthropometric and histologic analysis. Plast Reconstr Surg. 1992;90:592–600. 101. Shaw RB, Katzel EB, Koltz PF, et al. Aging of the mandible and its aesthetic implications. Plast Reconstr Surg. 2010;125:332–342. 102. Kahn DM, Shaw RB. Aging of the bony orbit: a three-dimensional computed tomographic study. Aesthet Surg J. 2008;28:258–264. 103. Tzafetta K, Terzis JK. Essays on the facial nerve: Part I. Microanatomy. Plast Reconstr Surg. 2010;125:879–889. The authors review facial nerve anatomy and present anatomic findings that confirm extensive arborization between facial nerve branches. The discussion by Stuzin104 highlights clinically important issues. 104. Stuzin JM. Discussion. Essays on the facial nerve: Part I. Microanatomy. Plast Reconstr Surg. 2010;125:890–892. 105. Davis RA, Anson BJ, Budinger JM, et al. Surgical anatomy of the facial nerve and parotid gland based upon a study of 350 cervicofacial halves. Surg Gynecol Obstet. 1956;102:385–412. 106. Agarwal CA, Mendenhall SD, Foreman KB, et al. The course of the frontal branch of the facial nerve in relation to fascial planes: an anatomic study. Plast Reconstr Surg. 2010;125:532–537. 107. Pitanguy I, Ramos AS. The frontal branch of the facial nerve: the importance of its variations in face lifting. Plast Reconstr Surg. 1966;38:352–356. 108. Gosain AK, Sewall SR, Yousif NJ. The temporal branch of the facial nerve: how reliably can we predict its path? Plast Reconstr Surg. 1997;99:1224–1233, discussion 1234–1236. 109. Stuzin JM, Wagstrom L, Kawamoto HK, et al. The anatomy and clinical applications of the buccal fat pad. Plast Reconstr Surg. 1990;85:29–37. 110. Huettner F, Rueda S, Ozturk CN, Drake R, Langevin CJ, Zins JE. The relationship of the marginal mandibular nerve to the mandibular osseocutaneous ligament and lesser ligaments of the lower face. Aesthet Surg J. 2015;35(2):111–120. 111. Nelson DW, Gingrass RP. Anatomy of the mandibular branches of the facial nerve. Plast Reconstr Surg. 1979;64:479–482. 112. Sinno S, Thorne CH. Cervical branch of facial nerve: an explanation for recurrent platysma bands following necklift and platysmaplasty. Aesthetic Surg Journal. 2019;39:1–7. 113. Ellenbogen R. Pseudo-paralysis of the mandibular branch of the facial nerve after platysmal face-lift operation. Plast Reconstr Surg. 1979;63(3):364–368. 114. McKinney P, Katrana DJ. Prevention of injury to the great auricular nerve during rhytidectomy. Plast Reconstr Surg. 1980;66:675–679. 115. Rohrich RJ, Taylor NS, Ahmad J, et al. Great auricular nerve injury, the “subauricular band” phenomenon, and the periauricular adipose compartments. Plast Reconstr Surg. 2011;127:835–843. 116. Beer GM, Spicher I, Seifert B, Emanuel B, Kompatscher P, Meyer VE. Oral premedication for operations on the face under local anesthesia: a placebo-controlled double-blind trial. Plast Reconstr Surg. 2001;108(3):637–643. 117. Ramanadham SR, Mapula S, Costa C, Narasimhan K, Coleman JE, Rohrich RJ. Evolution of hypertension management in face lifting in 1089 patients: optimizing safety and outcomes. Plast Reconstr Surg. 2015;135(4):1037–1043. 118. Krueger JK, Rohrich RJ. Clearing the smoke: the scientific rationale for tobacco abstention with plastic surgery. Plast Reconstr Surg. 2001;108:1063–1073, discussion 1074–1077. 119. Rees TD, Liverett DM, Guy CL. The effect of cigarette smoking on skin-flap survival in the face lift patient. Plast Reconstr Surg. 1984;73:911–915.

179.e3

120. Hashem AM, Couto RA, Duraes EFR et al. Facelift Part I: history, anatomy, and clinical assessment. Aesthet Surg J. 2020;40(1):1–18. 121. Ellenbogen R, Karlin JV. Visual criteria for success in restoring the youthful neck. Plast Reconstr Surg. 1980;66(6):826–837. 122. Grover R, Jones BM, Waterhouse N. The prevention of haematoma following rhytidectomy: a review of 1078 consecutive facelifts. Br J Plast Surg. 2001;54:481–486. 123. Jones BM, Grover R. Avoiding hematoma in cervicofacial rhytidectomy: a personal 8-year quest. Reviewing 910 patients. Plast Reconstr Surg. 2004;113:381–387, discussion 388–390. The authors review a large facelift series where the most common complication of facelift surgery, hematoma, is addressed. Variables thought to influence the formation of hematoma are reviewed, including the use of dressings, drains, soft-tissue adhesives, and epinephrine. 124. Couto RA, Charafeddine A, Sinclair NR, Nayak LM, Zins JE. Local infiltration of tranexamic acid with local anesthetic reduces intraoperative facelift bleeding: a preliminary report. Aesthet Surg J. 2020;40(6):587–593. 125. Cohen JC, Glasgold RA, Alloju L, Glasgold MJ. Effects of intravenous tranexamic acid during rhytidectomy: a randomized, controlled, double-blind pilot study. Aesthet Surg J. 2021;41(2): 155–160. 126. Coleman SR. Long-term survival of fat transplants: controlled demonstrations. Aesthetic Plast Surg. 1995;19:421–425. 127. Lambros V. Fat injection for aesthetic facial rejuvenation. Aesthet Surg J. 1997;17:190–198. 128. Guyuron B, Watkins F, Totonchi A. Modified temporal incision for facial rhytidectomy: an 18-year experience. Plast Reconstr Surg. 2005;115:609–616. 129. Marten TJ. Facelift. Planning and technique. Clin Plast Surg. 1997;24:269–308. This review article covers the planning, surgical marking and technical details of two-layer facelift surgery. Details regarding the skin incisions are emphasized. 130. Camirand A, Doucet J. A comparison between parallel hairline incisions and perpendicular incisions when performing a face lift. Plast Reconstr Surg. 1997;99:10–15. 131. Tonnard PL. The Macs-Lift Short Scar Rhytidectomy. St. Louis: Quality Medical Publishing; 2004. 132. Psillakis JM, Connell BF, Marten TJ. Deep layer techniques in cervicofacial rejuvenation. Deep Face-Lifting Techniques. New York: Thieme Medical; 1994. 133. Baker DC. Minimal incision rhytidectomy (short scar face lift) with lateral SMASectomy. Aesthet Surg J. 2001;21:68–79. 134. Marchac D, Brady J, Chiou P. Face lifts with hidden scars: the vertical U incision. Plast Reconstr Surg. 2002;109:2539–2551, discussion 2552–2554. 135. Robbins LB, Brothers DB, et al. Anterior SMAS plication for the treatment of prominent nasomandibular folds and restoration of normal cheek contour. Plast Reconstr Surg. 1995;96:1279–1288. 136. Berry MG, Davies D. Platysma-SMAS plication facelift. J Plast Reconstr Aesthet Surg. 2010;63:793–800. The authors describe their logic for using soft-tissue plication and describe their particular method, called the PSP lift (platysma-SMAS plication). A series of 117 consecutive patients is reported, all of whom were followed objectively with a five-point scale. There was excellent improvement with a low complication rate: 3.4% hematoma and 3.4% transient facial nerve palsies. 137. Saylan Z. The S-lift: less is more. Aesthet Surg J. 1999;19:406–409. 138. Tonnard P, Verpaele A, Monstrey S, et al. Minimal access cranial suspension lift: a modified S-lift. Plast Reconstr Surg. 2002;109:2074–2086. The authors report that in 1999 they modified the previously described S-lift to include improved suture fixation and soft-tissue elevation, which they named the MACS lift, an acronym for minimal access cranial suspension. Two long loop sutures are used to elevate facial soft tissue with fixation to the deep temporal fascia above the zygomatic arch and a third suture is used for the malar fat pad in the extended version of the procedure. A total of 88 patients over 20 months were presented with a low complication rate. The operative technique is described in detail. 139. Hoefflin SM. The extended supraplatysmal plane (ESP) face lift. Plast Reconstr Surg. 1998;101:494–503. The author presents his logic

179.e4

SECTION II

CHAPTER 9.3  • Principles and surgical approaches of facelift

behind using a facelift flap that contains skin and all the subcutaneous fat down to, but not including, the SMAS. The technique is described in detail and the results with a series of 300 patients are presented. There was high patient satisfaction reported, no nerve injuries, and relatively rapid recovery. 140. Baker DC. Lateral SMASectomy. Plast Reconstr Surg. 1997;100: 509–513. The author presents his personal evolution in arriving at the SMASectomy technique, describing his logic in doing so, and reports a series of 1500 cases over 5-year period. One transient buccal branch injury was encountered. The author feels this technique affords a safe, effective technique, but acknowledges that other techniques also produce excellent results. 141. Skoog T. Plastic Surgery. Philadelphia: WB Saunders; 1974. In this classic text, the author describes the first technique to utilize the sub-SMAS plane to elevate ptotic facial tissue. Illustrations effectively convey the basics of this new technique. 142. Hamra ST. Composite rhytidectomy. Plast Reconstr Surg. 1992;90:1–13. 143. Hamra ST. The zygorbicular dissection in composite rhytidectomy: an ideal midface plane. Plast Reconstr Surg. 1998;102:1646–1657. 144. Barton FE, Hunt J. The high-superficial musculoaponeurotic system technique in facial rejuvenation: an update. Plast Reconstr Surg. 2003;112:1910–1917. This is a follow-up of a previous publication by Barton that described his variation for a SMAS-based facelift technique called the high SMAS technique. In this paper, 267 patient records were reviewed using the nasolabial fold as an indicator of surgical result 6 months after surgery. Using this hard endpoint, improvement was almost universally achieved with a low complication rate. Recommendations are made as to the extent of dissection required based on depth of the nasolabial fold. 145. Owsley JQ. Platysma-fascial rhytidectomy: a preliminary report. Plast Reconstr Surg. 1977;60:843–850. 146. Connell BF. Eyebrow, face, and neck lifts for males. Clin Plast Surg. 1978;5:15–28. 147. Marten TJ. High SMAS facelift: combined single flap lifting of the jawline, cheek, and midface. Clin Plast Surg. 2008;35:569–603. vi–vii. The review article outlines the author’s logic in utilizing a two-layer facelift, emphasizing that skin has a covering function, and that deep tissue manipulation is necessary for facial reshaping. The high SMAS facelift is described in detail, with emphasis on skin incisions, and the proper selection of vectors. 148. Aston SJ. The FAME technique. Presented at the Aging Face Symposium. New York: Waldorf Astoria Hotel; 1993. 149. Aston SJ, Walden J. Facelift with SMAS technique and FAME. In: Aston SJ, Steinbrech DS, Walden JL, eds. Aesthetic Plastic Surgery. Philadelphia: Saunders Elsevier; 2009. 150. Warren R. The oblique SMAS with malar fat pad elevation. Presented at the Canadian Society for Aesthetic Plastic Surgery 29th Annual Meeting, Toronto, Ontario; 2002. 151. Jacono AA, Parikh SS. The minimal access deep plane extended vertical facelift. Aesthetic Surg Journal. 2011;31(8):874–890. 152. Tessier P. [Subperiosteal face-lift]. Ann Chir Plast Esthet. 1989;34:193–197. 153. De La Plaza R, Valiente E, Arroyo JM. Supraperiosteal lifting of the upper two-thirds of the face. Br J Plast Surg. 1991;44:325–332. 154. Hinderer UT. The sub-SMAS and subperiosteal rhytidectomy of the forehead and middle third of the face: a new approach to the aging face. Facial Plast Surg. 1992;8:18–32. 155. Byrd HS, Andochick SE. The deep temporal lift: a multiplanar, lateral brow, temporal, and upper face lift. Plast Reconstr Surg. 1996;97:928–937. 156. Hunt JA, Byrd HS. The deep temporal lift: a multiplanar lateral brow, temporal, and upper face lift. Plast Reconstr Surg. 2002;110:1793–1796. 157. Saltz R, Ohana B. Thirteen years of experience with the endoscopic midface lift. Aesthet Surg J. 2012;32(8):927–936. 158. Fogli A.L. Personal communication, 2010. 159. Fogli AL. Skin and platysma muscle anchoring. Aesthetic Plast Surg. 2008;32:531–541.

160. Courtiss EH. Suction lipectomy of the neck. Plast Reconstr Surg. 1985;76:882–889. 161. Derrick CD, Shridharani SM, Broyles JM. The safety and efficiency of cryolipolysis: a systematic review of available literature. Aesthetic Surg J. 2015;35(7):830–836. 162. Jones DH, Carruthers J, Joseph JH, et al. REFINE-1, a multicenter, randomized, double-blind, placebo-controlled, phase 3 trial with ATX-101, an injectable drug for submental fat reduction. Dermatol Surg. 2016;42:38–49. 163. Vistnes LM, Souther SG. The anatomical basis for common cosmetic anterior neck deformities. Ann Plast Surg. 1979;2:381–388. 164. de Castro CC. The anatomy of the platysma muscle. Plast Reconstr Surg. 1980;66:680–683. 165. Pelle-Ceravolo M, Angelini M, Silvi E. Treatment of anterior neck aging without a submental approach: lateral skin-platysma displacement, a new and proven technique for platysma bands and skin laxity. Plast Reconstr Surg. 2017;139(2):308–321. 166. Knize DM. Limited incision submental lipectomy and platysmaplasty. Plast Reconstr Surg. 1998;101:473–481. 167. O’Daniel TG. Understanding deep neck anatomy and its clinical relevance. Clin Plastic Surg. 2018;45:447–454. 168. Sullivan PK, Freeman MB, Schmidt S. Contouring the aging neck with submandibular gland suspension. Aesthet Surg J. 2006;26:465–471. 169. Singer DP, Sullivan PK. Submandibular gland I: an anatomic evaluation and surgical approach to submandibular gland resection for facial rejuvenation. Plast Reconstr Surg. 2003;112: 1150–1154, discussion 1155–1156. 170. Benslimane F, Kleidona IA, Cintra HPL, Ghanem AM. Partial removal of the submaxillary gland for aesthetic indications: a systematic review and critical analysis of the evidence. Aesthet Plast Surg. 2020;44:339–348. 171. Auersvald A, Auersvald LA, Uebel CO. Subplatysmal necklift: a retrospective analysis of 504 patients. Aesthet Surg J. 2017;37(1):1–11. 172. Bravo FG. Reduction neck lift: the importance of the deep structures of the neck to the successful neck lift. Clin Plastic Surg. 2018;45:485–506. 173. Zins JE, Fardo D. The “anterior-only” approach to neck rejuvenation: an alternative to face lift surgery. Plast Reconstr Surg. 2005;115:1761–1768. 174. Gradinger GP. Anterior cervicoplasty in the male patient. Plast Reconstr Surg. 2000;106:1146–1154. discussion 1155. 175. Rees TD, Aston SJ. A clinical evaluation of the results of submusculo-aponeurotic dissection and fixation in face lifts. Plast Reconstr Surg. 1977;60:851–859. 176. Webster RC, Smith RC, Papsidero MJ, et al. Comparison of SMAS plication with SMAS imbrication in face lifting. Laryngoscope. 1982;92(8 Pt 1):901–912. 177. 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. 1996;98:1135–1143, discussion 1144–1147. 178. Kamer FM, Frankel AS. SMAS rhytidectomy versus deep plane rhytidectomy: an objective comparison. Plast Reconstr Surg. 1998;102:878–881. 179. Becker FF, Bassichis BA. Deep-plane face-lift vs. superficial musculoaponeurotic system plication face-lift: a comparative study. Arch Facial Plast Surg. 2004;6:8–13. 180. Zager WH, Dyer WK. Minimal incision facelift. Facial Plast Surg. 2005;21:21–27. 181. Prado A, Andrades P, Danilla S, et al. A clinical retrospective study comparing two short-scar face lifts: minimal access cranial suspension versus lateral SMASectomy. Plast Reconstr Surg. 2006;117:1413–1425. discussion 1426–1427. 182. Antell DE, Orseck MJ. A comparison of face lift techniques in eight consecutive sets of identical twins. Plast Reconstr Surg. 2007;120:1667–1673.

References

183. Alpert BS, Baker DC, Hamra ST, et al. Identical twin face lifts with differing techniques: a 10-year follow-up. Plast Reconstr Surg. 2009;123:1025–1033, discussion 1034–1036. 184. Chang S, Pusic A, Rohrich RJ. A systematic review of comparison of efficacy and complication rates among face-lift techniques. Plast Reconstr Surg. 2011;127:423–433. This paper presents the results of a systematic review that assessed all studies in the English language literature from 1950 until 2009 in which there was a comparison of facelift techniques. There were 57 studies identified; only 10 of these directly compared the efficacy of different facelift techniques. The study found there to be a lack of quality data regarding the efficacy and safety of facelift techniques and concluded that there was no evidence to support the use of any one facelift technique over another. 185. Pelle-Ceravolo M, Angelini M, Silvi E. Complete platysma transection in neck rejuvenation: a critical appraisal. Plast Reconstr Surg. 2016;138(4):781–791. 186. Sinno S, Schwiter J, Anzai L, Thorne CH. Face-lift satisfaction using the Face-Q. Plast Reconstr Surg. 2015;136(2):239–242. 187. Frautschi RS, Duraes EF, Tadisina KK, Couto RA, Zins JE. Apparent age is a reliable assessment tool in 20 facelift patients. Aesthet Surg J. 2018;38(4):347–356. 188. Gibstein AR, Chen K, Nakfoor B, et al. Facelift surgery turns back the clock: artificial intelligence and patient satisfaction quantitate value of procedure type and specific techniques. Aesthet Surg J. 2020:1–13. 189. Surek CC, Kochuba Said SA, et al. External approach to buccal fat excision in facelift: anatomy and technique. Aesthetic Plast Surg. 2020:1–8. 190. Bitik O. Sub-SMAS transposition of the buccal fat pad. Aesthet Surg J. 2020;40(4):NP114–NP122. 191. Matarasso A. Managing the buccal fat pad. Aesthet Surg J. 2006;26(3):330–336. 192. Coleman SR, ed. Structural Fat Grafting. St. Louis: Quality Medical Publishing; 2004. This text is a comprehensive review of the history, basic science, and technical details of fat harvest and fat injection. 193. Marten T, Elyassnia D. Facial fat grafting: why, where, how, and how much. Aesthetic Plast Surg. 2018;42(5):1278–1297. 194. Hester TR, Codner MA, McCord CD. Subperiosteal malar cheeklift with lower lid blepharoplasty. Eyelid Surgery: Principles and Techniques. New York: Lippincott-Raven; 1995. 195. Moelleken B. The superficial subciliary cheek lift, a technique for rejuvenating the infraorbital region and nasojugal groove: a clinical series of 71 patients. Plast Reconstr Surg. 1999;104:1863– 1874, discussion 1875–1876. 196. Le Louarn C. The concentric malar lift: malar and lower eyelid rejuvenation. Aesthetic Plast Surg. 2004;28:359–372, discussion 373–374. 197. Hester TR, Codner MA, McCord CD, et al. Evolution of technique of the direct transblepharoplasty approach for the correction of lower lid and midfacial aging: maximizing results and minimizing complications in a 5-year experience. Plast Reconstr Surg. 2000;105:393–406, discussion 407–408. 198. Anderson RD, Lo MW. endoscopic malar/midface suspension procedure. Plast Reconstr Surg. 1998;102:2196–2208. 199. Austin HW. The lip lift. Plast Reconstr Surg. 1986;77:990–994. 200. Austin HW, Weston GW. Rejuvenation of the aging mouth. Clin Plast Surg. 1992;19:511–524. 201. Baker DC, Aston SJ, Guy CL, et al. The male rhytidectomy. Plast Reconstr Surg. 1977;60:514–522. 202. Baker DC, Stefani WA, Chiu ES. Reducing the incidence of hematoma requiring surgical evacuation following male rhytidectomy: a 30-year review of 985 cases. Plast Reconstr Surg. 2005;116:1973–1985. discussion 1986–1987. 203. Auersvald A, Auersvald LA. Hemostatic net in rhytidoplasty: an efficient and safe method for preventing hematoma in 405 consecutive patients. Aesthet Plast Surg. 2014;38:1–9. 204. Ballan A, Jabbour S, Rayess YE, Jabbour K, Hachem LE, Nasr M. Quilting sutures in rhytidectomy: a systematic review of the literature. Aesthet Surg J. 2020;40(11):1157–1164.

179.e5

205. Baker DC, Conley J. Avoiding facial nerve injuries in rhytidectomy. Anatomical variations and pitfalls. Plast Reconstr Surg. 1979;64:781–795. 206. Zoumalan RA, Rosenberg DB. Methicillin-resistant Staphylococcus aureus-positive surgical site infections in face-lift surgery. Arch Facial Plast Surg. 2008;10:116–123. 207. Ullmann Y, Levy Y. Superextended facelift: our experience with 3,580 patients. Ann Plast Surg. 2004;52:8–14. 208. Matarasso A, Elkwood A, Rankin M, et al. National plastic surgery survey: face lift techniques and complications. Plast Reconstr Surg. 2000;106:1185–1195. discussion 1196. 209. Gupta V, Winocour J, Shi Hanyuan Shack RB, Grotting JC, Hidgdon KK. Preoperative risk factors and complication rates in facelift: analysis of 11,300 patients. Aesthetic Surg J. 2016;36(1):1–13. 210. Chopan M, Samant S, Mast BA. Contemporary analysis of rhytidectomy using the tracking operations and outcomes for plastic surgeons database with 13,346 patients. Plast Reconstr Surg. 2020;145(6):1402–1407. 211. Marchese Ragona R, Blotta P, Pastore A, Tugnoli V, Eleopra R, De Grandis D. Management of parotid sialocele with botulinum toxin. Laryngoscope. 1999;109(8):1344–1346. 212. Marchese-Ragona R, De Filippis C, Staffieri A, Restivo DA, Restino DA. Parotid gland fistula: treatment with botulinum toxin. Plast Reconstr Surg. 2001;107(3):886–887. 213. Reinisch JF, Bresnick SD, Walker JW, Rosso RF. Deep venous thrombosis and pulmonary embolus after face lift: a study of incidence and prophylaxis. Plast Reconstr Surg. 2001;107(6):1570–1575. 214. Abboushi N, Yezhelyev M, Symbas J, Nahai F. Facelift complications and the risk of venous thromboembolism: a single center’s experience. Aesthet Surg J. 2012;32:413–420. 215. Durnig P, Jungwirth W. Low-molecular-weight heparin and postoperative bleeding in rhytidectomy. Plast Reconstr Surg. 2006;118(2): 502–507. 216. Hamra ST. Frequent face lift sequelae: hollow eyes and the lateral sweep: cause and repair. Plast Reconstr Surg. 1998;102(5): 1658–1666. 217. Lambros V, Stuzin JM. The cross-cheek depression: surgical cause and effect in the development of the “joker line” and its treatment. Plast Reconstr Surg. 2008;122(5):1543–1552. 218. Snijder GAS. Het Onstaan van den Proportie-Kanon bij de Grieken. Utrecht: A. Oosthoek;; 1928. 219. Broadbent BH. A new X-ray technique and its application to orthodontia. Angle Orthod. 1931;1:45. 220. Broadbent BH. The face of the normal child. Angle Orthod. 1937;7:183. 221. Broadbent BH, Broadbent BH, Golden WH. Bolton Standards of Dentofacial Developmental Growth. St. Louis: Mosby; 1975. 222. Seghers MJ, Longacre JJ, deStefano GA. The golden proportion and beauty. Plast Reconstr Surg. 1964;34:382–386. 223. Ricketts RM. Esthetics, environment, and the law of lip relation. Am J Orthod. 1968;54:272–289. 224. Ricketts RM. Divine proportion in facial esthetics. Clin Plast Surg. 1982;9:401–422. 225. Vegter F, Hage JJ. Clinical anthropometry and canons of the face in historical perspective. Plast Reconstr Surg. 2000;106:1090–1096. 226. Bashour M. An objective system for measuring facial attractiveness. Plast Reconstr Surg. 2006;118:757–774. The “phi mask” is presented as a mathematical model to assess facial attractiveness. Validating this approach may lead to standardized assessment of facial aesthetic harmony. 227. Guyuron B. Discussion: an objective system for measuring facial attractiveness. Plast Reconstr Surg. 2006;118:775–776. 228. Farkas LG. Results. In: Farkas LG, Munro IR, eds. Anthropometric Facial Proportions in Medicine. Springfield: Charles C. Thomas; 1987:155–319. 229. Farkas LG. Anthropometry of the Head and Face. 2nd edn. New York: Raven Press; 1994:21–25.

179.e6

SECTION II

CHAPTER 9.3  • Principles and surgical approaches of facelift

230. Farkas LG, Hreczko TA, Kolar JC, et al. Vertical and horizontal proportions of the face in young adult North American Caucasians: revision of neoclassical canons. Plast Reconstr Surg. 1985;75:328–338. Conventional ideals of facial proportion were assessed with reference to 153 North American Caucasians at 6, 12, or 18 years of age. These standards were not found to be consistent with average facial proportions in this cohort.

231. Farkas LG, Sohm P, Kolar JC, et al. Inclinations of the facial profile: art versus reality. Plast Reconstr Surg. 1985;75:509–519. 232. Rohrich RJ, Ghavami A, Lemmon JA, et al. The individualized component face lift: developing a systematic approach to facial rejuvenation. Plast Reconstr Surg. 2009;123:1050–1063.

SECTION II  •  Aesthetic Surgery of the Face

9.4

Facelift: Facial rejuvenation with loop sutures: the MACS lift and its derivatives Patrick Tonnard, Alexis Verpaele, and Rotem Tzur

Access video and video lecture content for this chapter online at Elsevier eBooks+

Introduction A facial rejuvenation procedure attempts to restore an aging face’s lost youth, by surgical or non-surgical means. Rhytidectomy is without any doubt the most established facial rejuvenation procedure today. This procedure has evolved substantially in the past five decades, since the superficial musculoaponeurotic system (SMAS) was introduced by Mitz and Peyronie in the mid 1970s.1 Numerous methods and concepts have been proposed and practiced, such as SMAS plication, excision or suspension, deep plane, endoscopic lifting, etc. In the 1990s, short scar rhytidectomy regained popularity. The purpose of the minimal access cranial suspension (MACS) lift was to make rhytidectomy safer and simpler, while maintaining a powerful but natural-looking result. The MACS lift concept was gradually developed in the late 1990s and first published in 2002.2 Since then, this procedure has become well accepted worldwide. We (P.T., A.V.) now have more than 20 years of experience in performing this procedure, and we have made no substantial changes in the surgical technique. The real change came from the better understanding of the facial aging process, and consequently adding ancillary scientifically based procedures to our original MACS lift surgery, mainly for midface rejuvenation, such as lipofilling, and a more radical result in the lower neck in selected cases. It is a common mistake to see facial rejuvenation as an isolated procedure. Facial aging is a very complex multifactorial process that involves sagging, volume loss, and skin structural changes of different facial organs and aesthetic units. Consequently, a comprehensive facial rejuvenation procedure should address all the different aging processes in order to maintain a harmonious outcome. Failure to consider the many factors contributing to facial aging and address them in the rejuvenation process will result in the inability to restore a natural appearance of youth, and will lead to less than ideal results. Our notion of facial rejuvenation, therefore, is comprised of two key elements: We adopt a holistic approach to facial

rejuvenation, that addresses sagging, volume changes, and skin quality of all facial components, in order to restore all age-related facial deformities rather than change them. For a detailed description of the ageing process see Chapter 9.2.

Considerations of the facial aging process Aging is the result of the orchestrated interplay of changes occurring in the facial organs such as skeleton, ligaments, muscles, adipose tissue, and skin. These changes appear in each mentioned structure at a different timing and pace, and develop at a different age for each individual, and differ between ethnic backgrounds.3–5 The ability to pinpoint the changes that take place over time responsible for the apparent age-related changes, and appreciating the underlying anatomic factors responsible for them, is essential for appropriate planning of the rejuvenation procedures.6 In most patients, we consider the three main features of facial aging:   Tissue sagging, and loss of youthful facial contour   Loss of facial volume   Structural changes of the skin surface. Understanding the difference between facial sagging and facial deflation is imperative. Facial sagging occurs in the periphery of the face – lateral to the lateral canthus and mouth commissure and continues in the neck, and results in jowling and loss of jawline definition. Facial deflation takes place mainly in the center of the face, where most mimic musculature and movements are present, such as the periorbital region, the malar area, and the perioral area. Skin structural changes are the superficial changes in the face and neck skin quality (e.g. texture, wrinkles, pigmentation) and are independent of both sagging and deflation processes (Fig. 9.4.1).7,8

Considerations of the facial aging process

A

B

181

C

Figure 9.4.1  Different modalities of aging. (A) This patient has a problem with sagging, especially in the lower third of the face and neck. (B) This patient mainly has a deflation problem. (C) This patient shows marked structural changes in skin quality. (From Tonnard P, Verpaele A, Bensimon R. Centrofacial Rejuvenation. New York: Thieme; 2018:7.)

Whereas the lateral face aging process has been well understood in the last five decades, understanding of the aging process of the central face has been more elusive, and real progress was made in the past 20 years.

hinge hypothesis.18 We hypothesized that facial fat atrophy could be influenced by a mechanical factor. Repetitive movements due to mimic activity could result in long-term loss of fat tissue.

Considerations on the centrofacial aging process

Anterior midface

The center of the face consists of three main zones: forehead and periorbital area, the anterior midface, and the perioral area. While a facelift procedure mostly affects the lateral face and neck, it has only a limited influence on central face. Therefore, our ancillary centrofacial strategies (augmentation blepharoplasty, midfacial and perioral lipofilling, etc.) aim to restore the youthful appearance of this oval-shaped area of the anterior face. Gravity alone cannot explain why the midface soft tissues retrude posteriorly with age. The current perspective is that centrofacial aging is more a result of deflation then sagging.7–16 Lambros17 made observations on facial photographs taken 10–50 years apart. Careful analysis of the changes revealed that orbicularis wrinkles and midfacial scars and moles did not appear to move inferiorly to explain changes in shape, at least in the upper midface. Clinical findings reveal that the majority of deflation in the face occurs in areas that are mobile, as a result of facial muscles movement. As most of the mimic muscle activity occurs in the central part of the face and the temporal, these are the facial areas most subject to deflation. Deep facial grooves are mainly present in areas of repeated facial animation such as the frontal and glabellar grooves, crow’s feet, orbitomalar groove, the nasolabial fold, and labiomental groove. These grooves become deeper and permanent over time. Based on those observations, we introduced the

As we age, the osseous structures of the midface collapse.19 The maxilla and inferior orbital rim are subject to bony resorption.14,20–24 The anterior wall of the maxilla consistently retrudes as we age20 and the anterior cheek mass becomes less prominent with age.23 This bony structure serves as a foundation to the overlying soft tissue, and its resorption results in a loss of anterior projection. Apart from the changes in the bony structure, attenuation of facial ligaments alone would be insufficient to explain the changes in fat compartments and aging of the face.5 Volume loss in the midface soft tissue is a fundamental part of the aging process. Fat compartments in the face can change at different rates with age, hence the whole face does not age as a compound mass. Deflation of the deep midfacial fat may dramatically effect midfacial aging. This decreases support for the medial cheek compartment and results in diminished midface projection and unmasks the nasolabial fold.5 It was shown that volume loss of the deep medial cheek fat leads to pseudoptosis. Augmentation of this fat pad results in increased anterior projection that cannot be addressed by a lateral lifting procedure alone.25

Periorbital area The periorbital area and, in particular, the eyes and its close surroundings, serve as the focal point of the face and are considered the most important feature of facial expression. The

182

SECTION II

CHAPTER 9.4  • Facelift: Facial rejuvenation with loop sutures: the MACS lift and its derivatives

perception of age is focused primarily on this area, especially the brow and lower eyelid region.26 The upper eyelid undergoes three types of age-related changes: dermatochalasis, blepharoptosis, and fat atrophy.12 When analyzing patients’ pictures taken at a younger age, they nearly always reveal a certain degree of volume loss in the upper eyelid, especially in the medial part. This hollowing pattern of the upper eyelid has been described as the “A-frame” deformity.18 Even with weight gain, loss of upper periorbital fat is commonplace.17 The nasal fat pad tends to protrude in the upper eyelid with aging. The longstanding belief that the lower lid lengthens vertically over time is in fact an illusion. We now know that the soft transition of the youthful eyelid into the cheek becomes accentuated with aging. It results from the protrusion of intraorbital fat to the lower eyelid and the loss of volume in the malar area, which seems not to be accompanied by skin migration.17 The position of the lower lid might also depend on neighboring structures. The medial cheek serves as a foundation and provides support to the tear trough and lower lid. A negative vector, which means that the eye is protruding in front of the malar eminence, and which is caused by malar hypoplasia and accentuated by deflation of this fat compartment, allows excess gravitational traction on the lower eyelid that may contribute to a scleral show.5

Perioral area As previously discussed, facial bony structures of the midface resorb with aging.14,19–24 This resorption over time is most profound at the maxillary and at the alveolar ridge after loss of dentition. The maxillary arch flattens with aging, causes a widening of the piriform aperture, and a posterior shift of the nasal base and upper lip. As a result, soft-tissue envelope redundancy may appear in the perioral complex.16,24,27–30 Thinning of the skin, and the orbicularis oris muscle is also evident.31 In our study, 200 patients who underwent cranial magnetic resonance imaging were divided into two groups according to gender and age, and sagittal and parasagittal measurements were made. We found that lip length was significantly increased in the older age group in both sexes. The upper lip showed a significant decrease in thickness on all levels compared between young and old female and male subjects, with the highest thinning percentage at the vermiliocutaneous junction. There was also significantly less pouting in older women and men. The nasolabial tissue thickness as measured at the alar base was significantly thinner in the older age group in women and men. The sagittal cross-section surface area, which correlates to volume, was significantly smaller in the older age group in both sexes. Increase in length and thinning of the lip with time were demonstrated in other studies as well.28,31–38 The nasolabial fold deepens as we age. Many theories have been proposed to better understand this phenomenon. One group mentions the descent of the malar fat pad that bulges over the firmer adhered area over the orbicularis oris muscle in the upper lip.39–41 Contraction of superioris alaeque nasi and levator labii superioris accentuates the fold.31,42,43 Another mechanism proposed is the significant thinning of the soft tissue at the alar base29 and deflation of the deep medial cheek fat.5,25

The orbicularis oris muscle thins and becomes atrophic as we age, and also the perioral skin becomes thinner and loses its elastic and collagen fibers.31 Vertical wrinkles of the lips ("barcode") begin to appear during the fourth decade and become more visible over time – they are linearly related to age in both number and visibility.34

Skin aging The skin is an ever-changing organ in the human body and is also subject to aging. Aging of the skin is caused by extrinsic factors such as sun exposure, smoking, air pollution, poor nutrition, etc. and intrinsic factors that reflect the genetic background and depend on time.44 The skin undergoes loss of the natural regenerative capacity: decreased cell turnover, upregulation of metalloproteinases and downregulation of their inhibitors occurs, accelerating the aging process through the promotion of collagen breakdown.45 Aged skin has thinner dermis and thicker epidermis. It is characterized by photo damage such as change in texture, wrinkles, pigmentation and pigmented lesions, patchy hypopigmentations, and actinic keratoses.44,46

Patient evaluation Given that there are various factors influencing the facial aging process and this is different in every patient, it is impossible to accurately imagine a patient’s younger face without seeing pictures of the patient at a younger age. We routinely ask our patients to bring photographs of themselves, taken between the age of 20 and 35 years, to the first facial rejuvenation consult (Fig. 9.4.2). We then systematically analyze the patient face and age-related deformities, in comparison to the old photograph. Systematic facial analysis will focus on the following: Congenital malformations, asymmetry, scars, previous operations: Ranges from subtle deformity, like retruded chin or a small scar, to the more dramatic, like previous trauma or major illness such as Parry–Romberg syndrome. These malformations must be addressed.

Figure 9.4.2  We routinely obtain patients’ old photographs of themselves before facial surgeries. Here we see a soon-to-be-operated patient with a photograph from the third decade of her life. We consider the age-related changes that are easily revealed using the photograph in our facial rejuvenation procedure.

Surgical strategy and technique

Skin type and quality: Fitzpatrick skin type is recorded. Skin is being assessed for its quality and thickness, as well as photodamage, spots, depigmentation, skin lesions and rhytids. Forehead: Evaluate forehead and glabellar rhytids, tonus and action of frontalis muscle and position of the eyebrows. Periocular area: Evaluate the position of lateral brows and lateral hooding, presence of crow’s feet, dermatochalasis of upper eyelid skin, infrabrow hollowness and volume depletion ("A-frame" deformity), bulging of superior nasal fat pad, lower lid canthal tonus with scleral show or frank ectropion, lower lid skin redundancy and quality, bulging lower orbital fat compartments, presence and depth of orbitomalar groove (tear trough), and volume depletion of malar area. Deflation of the orbitomalar area can be recognized in many facial rejuvenation patients and can be seen with or without bulging fat from descending fat compartments and with or without dermatochalasis. The best way to evaluate volume loss of the orbit is in comparison with an old photograph of the patient. Anterior midface: Evaluate volume depletion of malar area and anterior cheek. This is best done in comparison to patients’ old photographs and in the oblique view of the patient (to assess the Ogee curve). Evaluate midcheek crease and the presence of festoons. Perioral area: Evaluate the nasolabial fold characteristics, volume of upper and lower lip, vermilion and white roll, pouting and vertical length of upper lip, upper and lower lip wrinkles ("barcode” deformity), characteristics of marionette deformity. The upper lip vermilion should be full and pouting, revealing 2–3 mm of the maxillary incisors. Mandibular incisors should not be seen. In the Caucasian face, in frontal view the lower lip is slightly fuller than the upper lip (golden proportion 1/1.618). In contrast, in the profile view, the upper lip should project a few millimeters anterior to the lower lip. Lateral face: Evaluate presence of temporal wasting, lateral cheek hollowness and sagging, the position and volume of the buccal fat pad, and the definition of the jawline and presence of jowling. Neck: Evaluate neck skin laxity and quality, horizontal neck rhytids, differentiate preplatysmal from retroplatysmal neck fat by platysma animation, evaluate submental skin laxity, skin laxity inferior to hyoid bone, presence of platysmal bands, and presence of ptotic submandibular glands and hypertrophic digastric muscles. Décolletage: Evaluate skin quality, texture, wrinkles, and pigmentation.

Matching the correct procedure to each deformity Correctly recognizing patient’s specific requests and goals is key to achieve the highest percentage of satisfied patients. We select for our patients a combination of treatments from our tool box that, in our point of view, align with as

183

many priorities mentioned by the patient, such as downtime, budget, etc., and will have the maximum impact on patient appearance. One of the most important factors in this idea is the concept of “synergy”, which means that the result of properly combined elements is greater than the mere sum of the individual elements. In other words, 1 + 1 = 3. For instance, the combination of a facelift and lipofilling is much more powerful than each of these procedures done separately. We rarely perform an isolated procedure (such as facelift alone), and it is very common in our practice to perform multiple rejuvenating procedures (sometimes more than 10) in a single operation.

Surgical strategy and technique The minimal access cranial suspension (MACS) facelift There are numerous efficient facelift surgical techniques that yield good results. It seems logical that the more invasive and radical the rejuvenation procedure is, the more dramatic and long lasting the effect would be. This might be true up to a certain point, beyond which the risk of complication47 and unnatural results increases, as the procedure becomes more invasive. Beyond this point, there is a trade-off between a modest gain in effectiveness and the risk for complications, longer recovery, and downtime. The results of short scar facelift technique are comparable with those of the traditional full facelift incision techniques, in the nasolabial fold and jawline regions over time.48 This principle has eloquently been proved in the identical twin study where invasive and noninvasive techniques were performed on two sets of identical twins and results compared in the short and long term. Although some differences were noticed in the short term (less than 1 year), the conclusion in the long term was that both types of facelift (invasive and less invasive) yielded similar outcomes.49 Ultimately, it is the delicate subjective balance between the final result and the morbidity of the procedure that will determine the level of patient happiness. The MACS lift concept was first published in 2002.50 This procedure became well accepted worldwide, as many patients prefer a simpler route to rejuvenation, with shorter scar, faster recovery, and lowered downtime. The appeal of the MACS lift lies in the right balance between natural and stable results, and a simple and safe procedure with reduced downtime, minimal complications, and no facelift stigmata. The senior authors now have more than 20 years of experience in performing this procedure, and we made no substantial changes in the basic surgical technique. When the additional deformities are present, it is easy to add complementary procedures to the basic MACS lift in order to obtain a comprehensive and harmonic rejuvenation result. We routinely associate microfat grafting to the centrofacial area. In selected cases we add more extensive neck corrections via either an extra submental incision (subplatysmal fat resection, digastric corset, platysmaplasty) or via a retroauricular extension for a lateral subplatysmal displacement with or without submandibulary gland reduction.51 The principle of the MACS lift is fourfold: 1. A limited pre-auricular and pre-sideburn skin incision 2. A limited subcutaneous dissection

184

3. 4.

SECTION II

CHAPTER 9.4  • Facelift: Facial rejuvenation with loop sutures: the MACS lift and its derivatives

No sub-SMAS dissection Vertical vector suspension of the SMAS and platysma to the deep temporal muscle fascia by two strong purse-string sutures.

In contrast, a horizontal or oblique vector of correction does not rejuvenate the face. It tends to flatten the face, puts it under tension, and yields unnatural results. With the MACS lift, the only vector applied on both the SMAS and the overlying skin is vertical. It can therefore be considered a pure vertical vector facelift technique. This results in an antigravitational repositioning of tissues in the upper neck and lateral face by suspension of the soft tissues, with limited skin undermining and no sub-SMAS delamination. The vertical vector of skin redraping and resection seals the underlying deep tissue suspension effect and avoids the retroauricular extension of the incision. Indeed in oblique vector skin redraping techniques the dog-ear created at the lobule necessitates a horizontal skin redraping and a retroauricular extension of the incision. The MACS lift uses purse-string sutures to suspend mobile facial and neck soft tissues to the non-mobile deep temporal fascia. The proximity of the suture loops close to the lax tissues in the mobile area of the face produces a very effective transmission of the traction forces of the purse-string suture. Another advantage of the purse-string technique is that it creates micro imbrications of the SMAS, that coalesce during the healing phase stabilize the lifting effect and facilitates volume restoration of the cheek. In comparison with a classic facelift, the MACS lift patients experience a shorter recovery time and a lower morbidity rate, with a final scar that is significantly shorter. The MACS lift provides a powerful correction of the jowls and restoration of a crisp jawline, volume restoration of the midcheek area, improvement of the nasolabial folds, correction of the marionette grooves, correction of submental and upper neck laxity above the hyoid bone and correction of a blunted cervicomental angle. The operation takes about 1.5 to 2 hours to perform and can be done under local anesthesia.

Preoperative markings Incision marking (Fig. 9.4.3) starts at the lower limit of the lobule, going up in the pre-auricular crease. At the level of the incisura intertragica, the marking makes a 90° turn backward to preserve this anatomic landmark. The marking then follows the posterior edge of the tragus, ascending toward the helical root. At the superior limit of the ear, the marking follows the small hairless recess between the sideburn and the auricle and then turns downward to follow the inferior implantation of the sideburn. In males, the marking descends approximately 1.5 cm before turning anteriorly to cross the sideburn. The marking runs further forward in a zigzag pattern, 2 mm within the lower and anterior implantation of the sideburn. The purpose of the zigzag pattern is to increase the length of the temporal incision for better congruence with the length of the cheek flap, thereby reducing dog-ear formation. The incision extends to the level of the lateral canthus and no higher than the level of the tail of the eyebrow. Skin dissection will take place two fingerbreadths below the mandibular angle and corresponds with the cranial border

Figure 9.4.3  MACS lift (pre-auricular) markings. Incision starts at the lower limit of the lobule, going up in the pre-auricular crease. At the level of the incisura intertragica, the marking makes a 90° turn backward to preserve this anatomic landmark. The marking then follows the posterior edge of the tragus, ascending toward the helical root. At the superior limit of the ear, the marking follows the small hairless recess between the sideburn and the auricle and then turns downward to follow the inferior implantation of the sideburn. Note that for a simple MACS lift, this marking is usually sufficient. In some cases of a simple MACS lift, incision will also follow the posterior lobule to avoid a dog-ear when skin is redraped.

of the platysma. The anterior point of the dissection is a point halfway between the tragus and the oral commissure. These two dots are then connected in an oval shape that continues towards the sideburn.

Infiltration We use an infiltration solution that contains lidocaine, ropivacaine, epinephrine (adrenaline), corticosteroids and tranexamic acid (Box 9.4.1). First the submental area is infiltrated, followed by the cheek infiltration (Fig. 9.4.4).

Incision and flap elevation Along the sideburn, the incision follows a zigzag pattern and the knife is inclined to an almost tangential angle with the skin in order to cut hair shafts perpendicularly. This maneuver will help conceal the scar as it allows hair to grow through it, and become virtually invisible (Fig. 9.4.5). The skin dissection starts with a knife for the first centimeter to determine the dissection level The rest of the dissection is done blindly with strong Gorney-type facelift scissors in a subcutaneous plane. We point the edges of the scissors toward the skin to have visual and tactile control over the thickness of the flap. Most of the dissection is done by spreading maneuvers (Figs. 9.4.6 & 9.4.7). The flap is created with sufficient thickness, usually 3-4 mm, to mask small irregularities of the underlying tissue.

Suspension sutures The first purse-string suture – the vertical loop – is fixed to the deep temporalis fascia (DTF) at a point 1 cm above the zygomatic arch and 1 cm in front of the root of helix (Fig. 9.4.8). This area of the DTF is exposed with sharp scissors and spreading motions after hydrodissection with local anesthetic. The DTF is identified as a distinct white shiny layer (Fig. 9.4.9). A 0 polydioxanone (PDS*II; Ethicon, Somerville, NJ) suture with a 23 mm C3 needle is used for suspending the sagged facial and neck soft tissues. The first needle bite is

Surgical strategy and technique

185

BOX 9.4.1  Infiltration solution Normal saline

200 mL

Lidocaine 2%

40 mL

Ropivacaine 10 mg/mL

10 mL

Epinephrine 1 mg/mL

0.8 mL

Tranexamic acid

500 mg

Triamcinolone

10 mg

Figure 9.4.7  The dissection technique.

Figure 9.4.4  Infiltration of MACS lift solution to the areas to be undermined. Figure 9.4.8  Area of the anchor point is marked (blue dot) 1 cm above the zygomatic arch (2 blue lines) and 1 cm anterior to the helix. (Courtesy of P Tonnard and A Verpaele.)

Figure 9.4.5  The first part of the dissection is done sharply with a No. 15 blade.

Figure 9.4.9  Deep temporal fascia (bright white tissue) is exposed

Figure 9.4.6  Most of the dissection is done with facelift scissors facing upwards, and a thumb hook, with cutting and spreading motions. The non-dominant hand always palpates the edge of the scissors to follow the depth of the dissection. See also Fig. 9.4.7.

done in the window where the DTF was visualized and goes down to the temporal bone. The needle is oriented toward the tragus to avoid danger zones and damage to any branch of the facial nerve. Firm bites of 1–1.5-cm long and 0.5-cm deep are taken in the SMAS tissue and platysma (Fig. 9.4.10). Every bite of the needle must take a substantial part of SMAS tissue to avoid pulling through. The suture continues down, toward the region of the mandibular angle until the lower limit of the undermining. A minimum of two to three strong bites should be taken in the platysma muscle, which is usually visible at the area of the mandibular angle. The suturing is then turned upward and continued toward the starting point, creating

186

SECTION II

CHAPTER 9.4  • Facelift: Facial rejuvenation with loop sutures: the MACS lift and its derivatives

Figure 9.4.10  The oblique loop suture is created by taking consecutive 1-cm bites of the SMAS and following the borders of the skin undermining.

Figure 9.4.13  After loop suture(s) are placed, skin dimples are corrected with facelift scissors with the tip facing downwards to protect the dermis. (Courtesy of P Tonnard and A Verpaele.)

Figure 9.4.14  Flattening the bulge with absorbable running sutures. Figure 9.4.11  The oblique loop suture is completed, and a knot is tied under maximal tension.

Figure 9.4.15  Bulging of the deep tissue after placement of loop sutures is common and addressed with direct excess fat excision. Figure 9.4.12  MACS lift oblique loop suture is illustrated on the skin. The anchor point is the deep temporal fascia above the zygomatic arch. Note that when combining MACS lift with LSD neck lift, the vertical loop suture is not indicated.

a 0.5- to 1-cm-wide U-shaped purse-string. The loop is tied under maximal tension (Fig. 9.4.11). Any skin dimples caused by this suture can be undermined with scissors. The second purse-string suture – the oblique loop – starts at the same location on the DTF as the first suture (Fig. 9.4.12). This suture forms a wider O-shaped loop, directed toward the jowls at an angle of 30° with the vertical loop. The descending limb of this loop is parallel to the first suture and turns anteriorly toward the jowl along the mandibular border. Next, it follows the anterior borders of the skin flap and is then directed

back toward the anchor point, where it is tied under strong tension. Some skin dimples may have to be freed at the borders of the undermined area using scissors (Fig. 9.4.13). The window in the SMAS is closed with 4-0 Vicryl (Ethicon) to prevent knot palpability. Sometimes a bulging of SMAS tissue is visible within this loop after tying. This bulging can be treated by upward suturing of the cranial part of the bulge with a running 4-0 Vicryl suture (Fig. 9.4.14) and trimming of the caudal part of the bulge (Fig. 9.4.15). This technique enhances the malar volume and improves the triangularization of the face. An alternative option is to imbricate the bulged tissue with 4-0 Vicryl figure-of-eight sutures when extra malar volume is not desired.

Surgical strategy and technique

Skin redraping and resection After vertical redraping of the skin without tension, the amount of skin to be resected in the temporal area is assessed with a Pitangui-d’Assumpcao forceps (Fig. 9.4.16). In the sideburn, skin resection is performed in a curvilinear fashion (Fig. 9.4.17). The edge will be sutured to the zigzag border of the temporal hairline incision, as the zigzag incision will then stretch when coopting with the linear cheek flap, compensating for the discrepancy in length of both borders and reducing possible dog-ears. Closure with interrupted 4-0 PDS buried sutures is started superiorly and downward, to avoid dog-ears (Fig. 9.4.18). Pre-auricular skin excision is then performed (Fig. 9.4.19). This excision is minimal due to the vertical redraping and the absence of lateral traction. The earlobe is set back without any tension by excising a small triangle of skin (Fig. 9.4.20). Skin suturing is performed with running 5-0 nylon sutures in the temporal and sideburn part of the incision, running 6-0 nylon suture for the vertical part of the incision.

187

maneuver eliminates the potential space between the two tissue layers, and prevents hematoma. Moreover, this technique allows for redraping and fixation of the skin beyond what the surgical lifting has achieved, thus eliminating the chances of bothersome folds and areas of lax skin (Fig. 9.4.21). The hemostatic net is removed typically after 48 hours to prevent stitch marks. This technique has obviated our need for suction drains and any dressing.

Ancillary lifting procedures Neck lift When concerning the neck in facial rejuvenation patients, two of the most important questions are whether to perform a

The Auersvald hemostatic net Originally described by Andre Auersvald,52 the hemostatic net is a technique that uses quilting 5-0 nylon sutures, connecting the undermined skin flap with underlying deep tissue. This

Figure 9.4.18  A few deep dermal sutures are placed and the skin is closed with no tension. (Courtesy of P Tonnard and A Verpaele.)

Figure 9.4.16  Vertical skin redraping. Excess skin excision is done after accurate marking using a Pitangui demarcator. Figure 9.4.19  Excess pre-auricular skin is marked and excised.

Figure 9.4.17  Vertical skin excess to be excised. The dog-ear will be corrected by a mild conservative extension of the incision and a temporal lift. The incision extension will should not reach higher than the lateral eyebrow.

Figure 9.4.20  Excess posterior auricular and nape skin is marked and excised.

188

SECTION II

CHAPTER 9.4  • Facelift: Facial rejuvenation with loop sutures: the MACS lift and its derivatives

Figure 9.4.21  Auersvald hemostatic net (A-net) is placed over the temporal area as a part of a gliding brow lift, but also over all other areas of facial and neck skin undermining to prevent hematoma and swelling.

supplementary neck surgery, and whether to open the neck or not. To answer those questions, we take various factors into consideration. When evaluating the patients, we evaluate the presence of retro- or pre-platysmal neck fat, ptosis and/or hypertrophy of the digastric muscles and submandibulary glands, the presence of platysmal bands and neck skin laxity, and neck skin quality. For patients between the ages of 45 and 55 with pre-platysmal fat, no ptosis or hypertrophy of the digastric muscles or submandibulary glands, and no prominent platysmal bands or skin laxity inferior to the hyoid bone, it is mostly unnecessary to perform supplementary neck surgery on top of the MACS lift. For those cases we perform a liposculpture to remove the subcutaneous fat in the submental area before performing a simple MACS lift to restore a pleasing cervicomental angle. In this group of patients, during the initial consultation, when simulating the MACS lift effect with three fingers on each pre-auricular area, simulating a vertical lifting of the facial tissues, a sufficient improvement of submental laxity is most often observed. For liposuction of the neck and sometimes also the inferior part of the jowls, we ask the patient to flex the neck and produce a double chin. The area of fat excess is then marked between the visible skin folds, usually from earlobe to earlobe, and vertically from the submental crease to the thyroid cartilage. Heavy jowls are also marked for liposuction as needed. We most often use a 3-mm spatula cannula with one opening, directed away from the skin to avoid dermal damage. A 3-mm submental incision is used, and sometimes an additional access from the prelobular incision is made to optimally address and criss-cross the area for preplatysmal liposuction. The uniformity of lipoaspiration is assessed by a thumb/ index pinch test. Usually a layer of 3-4 mm is preserved for a soft contour. The indications for an anterior cervicoplasty through a submental incision are the presence of large amounts of subplatysmal fat and/or a ptosis or hypertrophy of the digastric muscles and submandibulary glands. After direct excision of the subplatysmal fat, and partial resection of hypertrophic digastric muscles and/or submandibular gland, a digastric corset is performed, with deep sutures than include the mylohyoid muscle and reinforced with platysmorrhaphy.53

Figure 9.4.22  MACS lift and LSD (lateral skin platysma displacement) neck lift markings. Note that the incision markings are extended behind the ear to the mastoid area and back to the nape hairline where it follows it downwards. This represents a full facelift incision. Note that the oblique red line in the neck, going obliquely downward and anterior from the inferior nape hairline mark, represents the border of skin undermining. The most medial vertical red line represents the medial platysmal band. The most lateral vertical red line in the neck is a line, 4 cm medial to the platysmal band, and 1 cm inferior to the mandibular border. This line represents the most anterior border of neck skin dissection. At this line, the dissection becomes subplatysmal. The platysma is then incised all the way to the platysmal band.

In case of prominent platysmal bands, especially in thinskinned patients and/or a neck laxity below the hyoid bone which needs a horizontal redraping, we adopted the LSD neck lift (lateral subplatysmal displacement) technique.51 The neck skin is undermined from a posterior auricular approach incision, which in combination with a MACS lift results in a full facelift incision. Also the posterior incision is precapillary for preservation of the natural hairline. The skin dissection is limited, and carried only to a vertical line, marked 4 cm lateral to the medial platysmal bands (Fig. 9.4.22). The skin marking is transferred onto the deeper layers by inserting two needles (Fig. 9.4.23A,B), between which the line is marked. The platysma is incised vertically at this line, and the dissection then continues subplatysmally, leaving the skin attached to platysma muscle. The subplatysmal dissection is carried on until beyond to the medial platysmal band. The anterior segment of the platysma is then transected through a subcutaneous tunnel, thus creating two skin–muscle composite flaps (Figs. 9.4.24 & 9.4.25). These myocutaneous flaps are then suspended, the superior one towards the mastoid, and the inferior one posteriorly towards the sternocleidomastoid muscle (Fig. 9.4.26). This procedure results in a very efficient correction and good definition of the cervicomental angle and also a powerful lateral suspension of the lower neck region. Resection of a ptotic or hypertrophied submandibular gland can be easily done through this lateral approach if needed, making the need for an additional submental incision unnecessary.

Temporal lift/gliding brow lift The MACS lift is a pure vertical vector facelift procedure. As a consequence of cranial shifting of facial soft tissues a paracanthal skin excess can occur, which may accentuate a pre-existing temporal hooding. If temporal hooding is detected when evaluating the patient for facial rejuvenation, or a paracanthal

Surgical strategy and technique

A

189

B

Figure 9.4.23  (A) The line from which the subplatysmal dissection will take place is marked intraoperatively with two needles. This line is located 4-5 cm lateral to the medial platysma band. The superior needle at the most superior point of this line is placed at least 1 cm inferior to the mandibular border. The second needle is placed in the most inferior point of this line. (B) Subplatysmal dissection between the two needles. The dissection proceeds all the way to the medial platysmal bands.

Figure 9.4.24  Once the medial platysmal band is reached, a subcutaneous tunnel is made to facilitate complete transection of the platysma muscle. The result is two myocutaneous flaps.

Figure 9.4.27  Temporal dissection for a gliding brow lift/temporal lift is done in a subcutaneous plane, often concomitantly with MACS lift.

Figure 9.4.25  Two myocutaneous flaps. (Courtesy of P Tonnard and A Verpaele.) Figure 9.4.28  Forehead skin dissection border markings for temporal lift.

Figure 9.4.26  Suspension of the myocutaneous flaps with PDS-0 suture. The superior flap is suspended in the mastoid direction and the second in the lateral neck direction.

bulging of skin is detected during the MACS lift procedure, the addition of a temporal lifting procedure is needed (Fig. 9.4.27). The paracanthal and temporal skin is undermined in continuity with the MACS lift dissection (Fig. 9.4.28) in order to redrape the skin and eliminate any folds. This method also allows an effective lifting of the lateral brow to its ideal position. The skin and brow is then fixated in its new position by the Auersvald hemostatic net (A-net) described above. This procedure is actually a modification of a gliding brow lift technique, described by Fausto Viterbo54 (see section Internal browpexy and temporal lift, below).

190

SECTION II

CHAPTER 9.4  • Facelift: Facial rejuvenation with loop sutures: the MACS lift and its derivatives

Periorbital rejuvenation The periorbital area together with the perioral area are the source of facial emotional expression. Eye tracking studies have proven that when observing a face the eyes and the mouth of the subject are scanned in a triangular pattern, mostly skipping the peripheral areas of the face and neck.26

Augmentation blepharoplasty As described in Chapter 9.2, the periorbital aging process involves substantial volume loss in the upper orbital and in the malar area. Even in case of weight gain, volume loss of the periorbital area is common with aging. Classical resection upper eyelid blepharoplasty corrects the dermatochalasis component of upper lid aging by removing the excessive eyelid skin and orbicularis muscle, along with fat resection from medial and lateral fat compartments. This results, however, in a hollowing of the upper orbital area in the majority of cases, especially over the long term. Often the postoperative results do not resemble the full upper eyelids most patients have in their 20 s and 30 s. A classical lower eyelid blepharoplasty involves fat removal from the medial, median, and lateral compartments with or without trimming of the lower eyelid skin. This method temporarily corrects the bulging of the lower lid but fails to improve the blending of the eyelid–cheek junction These classic resection blepharoplasties (i.e., skin and fat resection) will seldom restore the parameters of the youthful periorbital area, as volume loss is not addressed. Augmentation blepharoplasty18 refers to the addition of volume along with the skin resection. In the upper eyelid, orbicularis muscle is never excised along with the skin. We perform a conservative skin resection when needed, and preserve a maximal amount of the pre-existing volume, and replace any volume loss of the periorbital area by means of microfat grafting.

infrabrow area. After marking, the area is infiltrated with a lidocaine/epinephrine solution in a plane deep to the orbicularis oculi muscle. A 19-gauge needle is used to make a puncture hole in the lateral part of the eyebrow and 0.5–2.5 cc of microfat graft (MFG) is deposited using the typical multistroke Coleman technique with a micro-cannula 0.7 mm, in a deep plane hugging the superior orbital rim periosteum (Figs. 9.4.30 & 9.4.31). Microfat should never be injected into the eyelid proper, so the term “eyelid fat grafting” is confusing and actually a misnomer. The fat is harvested and prepared in the manner described below (see section Facial volume restoration). Care should be taken not to graft the lateral part of the eyelid. This can result in a kind of “ape-like” deformity in the lateral eyebrow region. MFG of the superior orbital rim is frequently accompanied by resection of skin excess in the upper eyelid. We perform muscle preserving resection, and occasionally excise fat from nasal fat compartment. MFG can be done before or after skin excision, and can be combined with canthopexy/plasty, internal browpexy or temporal lifting.

Internal browpexy and temporal lift Temporal lift For our temporal and lateral brow lift cases that are not involving a concomitant MACS lift, we have recently adopted Fausto Viterbo’s gliding brow lift technique. With the help of a set of blunt dissectors it is possible to undermine the skin of the brow and temporal region above the frontalis muscle, galea and temporoparietal fascia. The dissection takes place through a 3-mm incision in the scalp. The new position of the

Augmentation upper blepharoplasty For upper eyelid augmentation, the area to be augmented is marked preoperatively (Fig. 9.4.29) with the patient in an upright position. The exact area to be grafted is dependent on the hollowness of the upper eyelid in comparison with the patient’s appearance at a younger age, and is typically located in the medial half to two-thirds of the medial Figure 9.4.30  Markings of infrabrow fat graft areas as part of an augmentation blepharoplasty procedure.

Figure 9.4.29  For upper eyelid augmentation, the area to be augmented is marked preoperatively (green markings). The marking is done with the patient in the upright position.

Figure 9.4.31  Infrabrow microfat injection using a 0.7-mm microcanula on a supraperiosteal plane. (Courtesy of P Tonnard and A Verpaele.)

Surgical strategy and technique

brow is then fixated to the underlying layer with the A-net technique while upwardly displacing the skin flap (see also p. 187 above) (Fig. 9.4.32). The sutures are removed after 2–3 days. The position of the eyebrow is then stabilized. We recommend an overcorrection of 20%–30% as the position of the lateral brow somewhat attenuates in the first 4–6 weeks. When a mild temporal hooding is present, with no concomitant MACS lift surgery, we usually perform internal browpexy through an upper blepharoplasty incision, for about 2–3 mm elevation of the tail of the brow and effacing of the temporal skin hooding.

Figure 9.4.32  The A-net is placed using a 4-0 nylon suture with a rounded needle, while the skin is pulled cephalad by the assistant. (Courtesy of P Tonnard and A Verpaele.)

191

Lower augmentation blepharoplasty The malar area is the foundation of the lower eyelid. The demarcation of the eyelid–cheek junction is due to lack of soft tissue between these two areas, which can be congenital or due to fat atrophy through aging. The depth of the tear trough deformity is noted, as well as the degree of deflation of the malar area. The extent of the fat herniation in the lower lid is evaluated as well as the existence of an orbitomalar groove deformity. Fat grafting to the tear trough and malar area can be performed to correct the groove deformity. If the fat herniation to the lower lid is extensive (Fig. 9.4.33), an orbital fat transposition over the inferior orbital rim via a subciliary incision can be combined with malar fat grafting. Alternatively, a transconjunctival fat resection can be combined with malar and tear trough fat grafting. In both procedures, skin redundancy can also be addressed by skin excision. An important advantage of the combination of a transconjunctival fat resection with an isolated skin excision is that the middle lamella is untouched, avoiding the risk of postoperative lower lid weakness or even retraction. If lower lid laxity is detected by a lower lid snapback test and lower lid distraction test, a canthopexy is added to the surgical procedure. During the MACS lift procedure and due to the vertical vector skin redraping, it is very common to encounter skin bunching in the lower lid area. It can be easily addressed by a simple lower lid pinch blepharoplasty (Fig. 9.4.34A,B).

The lower lid augmentation procedure

Figure 9.4.33  Markings of lower lid fat bulge to be resected in a transconjunctival lower blepharoplasty.

A

The malar area is marked preoperatively with the patient in the upright position (Fig. 9.4.35). The malar and tear trough lipofilling is marked as a triangular area extending from the prezygomatic zone into the lower portion of the lower eyelid. The lateral extension of the marking is decided according to the need for bizygomatic widening or not. Infiltration of the marked areas is performed using the lidocaine/epinephrin solution. The infiltration is in the deep plane. The microfat is harvested and prepared as described below in the section Microfat graft lipofilling. Fat grafting is done through two 18-gauge needle puncture holes (lateral and inferior) as access points for the malar area and lid–cheek junction. Fat is deposited in a multistroke Coleman technique with a 1-mL syringe and 0.7-mm cannula (Fig. 9.4.36A,B). For both areas, the syringe is moved back and

B

Figure 9.4.34 (A) Pinch blepharoplasty is often needed after MACS lift and vertical skin redraping. Excess skin of the lower lid is pinched using two Ahadson forceps. (B) Excess skin is excised using sharp scissores.  

SECTION II

192

CHAPTER 9.4  • Facelift: Facial rejuvenation with loop sutures: the MACS lift and its derivatives

forth rapidly with a steady plunger pressure. In the malar area, the fat is deposited in a deep plane to avoid possible graft visibility. Criss-cross grafting is done to prevent a sausage-like deposit of MFG. When grafting the lid–cheek junction area, the nondominant hand index finger is placed on the border on the inferior orbital rim, to provide tactile information of the location of the cannula tip and facilitate fat grafting precision to this delicate area. The cannula edge should be felt over the inferior orbital rim and just beyond it. In the malar area, most of the fat is grafted to the anterior part (about two-thirds of the total volume), where most of volume loss takes place. The amount of fat injected in the lid– cheek junction is usually 0.5–2 cc for each side with no overcorrection, whereas the amount of fat injected to the malar area is dependent on the loss of volume in the midface and the desired amount of anterior projection, taking into consideration volume loss of about 20%–30%. On average, between 3 and 10 cc of fat is injected per malar area, but in some cases of severe midface hypoplasia, the volume can be as high as 25 cc of MFG per side.

Resurfacing procedures of the periocular area Some patients present very thin and low-quality skin, especially of the lower eyelids but also below the lid–cheek junction and lateral to the orbit (crow’s feet area). Clinically, the skin looks paper-thin, photodamaged, hyperpigmented, and

Figure 9.4.35  Markings of malar area to be fat grafted, with the patient in the upright position. Note that the superior border of this area is in the level of the inferior orbital rim.

in the lower eyelid, skin laxity with numerous fine wrinkles can be observed, covering the entire lower lid from the lash line to the lid–cheek crease. For these cases, resection of redundant skin alone will not improve the quality of the skin and will not produce ideal results. The best treatment will include also a resurfacing procedure.

Laser resurfacing For laser resurfacing, we use the erbium:YAG laser or deep croton oil peel. Laser skin resurfacing is a safe, effective, and affordable treatment.55 We use the erbium:YAG laser, which is superior to the CO2 since it produces a substancially smaller coagulation zone around the ablation points56 and it is equally effective with a trend towards a faster recovery.57 The erythema resulting after erbium:YAG laser treatment is half the intensity of a CO2 lasers, and less than half the duration (1–3 months).58 For the treatment of the periocular skin, we perform 1–2 passes at 1000 mJ with a 5-mm spot size), with 50% overlap.

Croton oil peel In the past, many practitioners of classic Baker–Gordon phenol/croton peels were reluctant to treat lower eyelid skin for the fear of scarring. Today, thanks to the work of Gregory Hetter and Richard Bensimon, we have the ability of using modulated concentrations (from 0.05% to 0.8% croton oil) in order to treat specifically from the delicate eyelid skin to the thicker skin of the chin, upper lip, and glabella. The Baker–Gordon formula typically contained 2.1% of croton oil. We use a lower concentration formula (0.05%–0.1%) to treat the lower eyelids. The solution is applied by an cotton tip applicator. The applicator should be wet but not soaked, and is then applied to deliver the solution to the skin from the lower part of the lid, up to the lash line. Like in treating other areas of the face, the dampness of the applicator and the number of passes, and the pressure applied on the applicator will determine the depth of the peel. It is best to evenly stretch the skin and its folds and wrinkles for uniform application. Epidermal sliding and a pinkinsh to slightly white dermal frost will appear. This is the treatment endpoint for the lower eyelid. One can expect improvement in the skin surface texture and skin tightening of the entire resurfaced area. The advantage of tightening the skin with a croton oil peeling over a mere resection of a strip of skin is that the whole resurfaced area undergoes a true rejuvenation of the skin architecture. A resection blepharoplasty leaves tight, but still aged skin behind.

B

A

Figure 9.4.36 (A,B) Malar area microfat graft. We use two access points: inferior cheek and laterally from the zygomatic arch area. The tear trough area is filled only from the inferior cheek access point. (A, Courtesy of P Tonnard and A Verpaele.)  

Surgical strategy and technique

193

Dark circles Apart from the tear trough deformity, which is due to loss of volume around the orbital rim, the dark color of the lower eyelids, commonly known as “dark circles”, is caused by two different mechanisms: dermal hyperpigmentation and translucency due to extreme dermal thinness.59 Injection of nanofat with a fine 27 G needle in the immediate subdermal layer (technique detailed in section Nanofat needling, below) can address these two causal factors. Both mechanisms of decrease of melanin pigmentation and dermal thickening have been studied and scientifically proven.60–63

Perioral rejuvenation The perioral area limits are defined superiorly by the columella and alar base, laterally by the nasolabial folds and marionette lines, and inferiorly by the inferior aspect of the mental symphysis.43 The perioral region is the most dynamic anatomic area of the face and is subjected to dynamic strains that perhaps result in the complex and dramatic changes of this area during aging.64 This area, along with the periorbital area, play a major role in facial expression of emotions and in aging perception.26,30 As detailed in Chapter 9.2, the main attributes of perioral aging are elongation and thinning of the upper lip, volume loss in several areas and structural changes of the skin. The perioral rejuvenation procedure(s) should ideally address all of the above.

Lip lift The upper lip elongates with age28,29,31–38 and it is actually the only organ that elongates and sags in the anterior face. In the sagittal plane the upper lip elongates on average by approximately 19.7% in women and 18.39% in men, and less in the parasagittal plane (11.59% in women, 12.14% in men).29 Our preoperative markings for lip lift reflect on these findings. The superior resection line traverses the columella exactly at the interface between the columella and upper lip skin, the line then continues 3–5 mm inside the nostril and curves around the alar rim, again, exactly between this two aesthetic units: the ala and the pyriform fossa. The incision then continues on the outer ala border, and curves upwards. It ascends to approximately 75% of the vertical height of the ala – high enough to ensure sufficient lifting of the lateral parts of the upper lip. The lower resection line is a straight line, connecting the two lateral ends of the incision in a bow-shaped pattern30 (Fig. 9.4.37). The amount of skin to be resected and the extent of lip lift is dependent on the position of the lower incision, which mostly relies on analysis of the patient’s old photographs: with a good frontal view photograph (such as a passport photo), the proportions between the vertical height of the upper lip and nose width can be calculated and the amount of resection can be deduced. This procedure can be done under local anesthesia, or general anesthesia if combined with other facial rejuvenation procedures.

Surgical technique The area to be excised is infiltrated with local anesthetic and epinephrine solution. If made under local anesthesia, inferior orbital nerve and subnasal blocks precede the local infiltration.

Figure 9.4.37  Lip lift markings. Note the upper makings go inside the nostrils and around the nasal ala. The lower incision marking is straight.

Figure 9.4.38  Lip lift. Skin is excised to the level of the muscle using pinpoint cautery and suction. (Courtesy of P Tonnard and A Verpaele.)

Figure 9.4.39  Lip lift. Lower incision edge skin undermining.

The excision starts with the cranial incision, and with the aid of a fine-tip suction. The marked skin is then resected in the plane above the orbicularis oris muscle (Fig. 9.4.38). The caudal skin edge is undermined for 2 mm (Fig. 9.4.39). This maneuver promotes skin edge eversion on closure. Excision skin edges must be aligned with high precision. We use five buried subcutaneous polydioxanone 5-0 (Maxon or Ethicon) sutures followed by a running horizontal mattress suture of 5-0 monofilament nylon suture. This suture promotes everted skin closure, and is removed on postoperative day 6.

194

SECTION II

CHAPTER 9.4  • Facelift: Facial rejuvenation with loop sutures: the MACS lift and its derivatives

Volume restoration of the lips The lip volume can be restored with hyaluronic acid (HA) fillers or with MFGs. Microfat grafting has the advantage of being permanent, but suffers some initial resorption due to lip mobility, and also a longer downtime.

Lip volume loss Lip volume loss is restored by delivery of MFG to the upper and lower lips with 0.7-mm blunt microcannulas (Tulip Medical, San Diego, CA) through two puncture holes made with an 18 G needle in both oral commissures. The fat is delivered in all layers, with most of the volume deposited in the orbicularis muscle. Homogeneity of the distributed injected fat is secured by bidigital palpation, and any irregularities can be corrected by gentle massage. Average injected volumes are 1–3 cc per lip. This volume might be considered large, but from our experience, about 50%–60% of the injected MFG to the lips will be absorbed in the 4 months after surgery, due to high mobility of this area. On the other hand, care should be taken not to violate the proportion between the upper lip and lower lip height, that is 1:1.618, and to prevent unnatural results. To achieve this, often the lower lip needs also to addressed when the upper lip is augmented.

Figure 9.4.40  SNIF (sharp needle intradermal fat grafting) to vertical upper lip lines. Note that SNIF can be performed with 23 G and 25 G needles. All neck and face fine lines are addressed with using this method as well as lips’ white roll and philtral columns. (Courtesy of P Tonnard and A Verpaele.)

Loss of lip definition With age, the sharp defined edges of the upper and lower lips (white roll and philtrum) are lost. These can be restored by using sharp needle intradermal fat grafting (SNIF) (the procedure is described in detail later in the chapter). The MFGs are injected using a 21G needle, and the white roll is "skewered" to its whole length, in a strict subdermal plane to avoid the deeper labial artery. The MFG is then injected upon withdrawal. A volume of up to 1 cc is injected in both white rolls (upper and lower) on average. The philtral columns can be enhanced in the same manner, with an average volume of 0.25 cc per column.

Vertical rhytids Vertical rhytids can be improved also by SNIF technique, using a 23 G needle and after prior marking of the rhytids and infiltration with an epinephrine-containing solution(1:200,000). Microfat injection is performed while the wrinkle is squeezed between the index finger and thumb of the nondominant hand. We inject upon withdrawal at low pressure and in an intradermal level to avoid vascular embolization (Fig. 9.4.40).

Nasolabial fold and marionette grooves As discussed earlier in the chapter, volume loss plays an important role in the deepening and appearance of the nasolabial fold (NLF). This area shows a significantly greater volume loss in comparison with the rest of the lip.29 We perform deep MFG filling of the NLF, using a 0.7-mm microcannula through an an 18 G needle puncture hole. The area to be filled is triangular in shape, with the base of the triangle at the inferior alar rim, and the tip at the oral commissure. Indeed, most of the volume loss is in the area of the canine fossa (Ristow space) (Fig. 9.4.41). Deep filling is done perpendicular to the NLF to prevent sausage-like deformity (Fig. 9.4.42A). Superficial filling parallel to the fold can be added as needed (Fig. 9.4.42B).

Figure 9.4.41  Markings around the nasolabial fold represent areas to be fat grafted with microfat.

In a case of deep and pronounced NLFs, we often perform surgical subcision with a 18 G needle, releasing the ligamentous attachments between the NLF skin and the underlying tissue (Fig. 9.4.43). When this procedure is performed, it is suggested to add an additional layer of MFG after the subcision, to prevent reformation of the ligaments and reattachment between the NLF skin and the deeper structures. Marionette grooves can also be corrected with MFG as needed. We inject an average volume of 1–2 cc to each marionette groove, in a perpendicular fashion using a 0.7-mm microcannula (Fig. 9.4.44A,B).

Lip resurfacing procedures For photodamaged perioral skin and/or perioral vertical rhytids (“barcode” deformity) we offer some kind of resurfacing procedure, usually as an addition to the perioral rejuvenation procedures elaborated in this chapter. The lip vertical rhytids are very bothersome to most of our patients, and their correction is often very resistant to conservative measures such as fillers and botulinum toxin. We strongly believe that the best results will be attained with a combined treatment of the "valleys and hills" formed by the rhytids: the valleys are made less deep by filling them using SNIF (as detailed above) and the hills are reduced by either croton oil peel or laser resurfacing.

Surgical strategy and technique

A

195

B

Figure 9.4.42  Microfat injection to the nasolabial fold area: deep, perpendicular injection to the pyriform aperture and more superficial, parallel injection. (A, Courtesy of P Tonnard and A Verpaele.)

The choice between croton oil peel and laser as a resurfacing procedure is dependent on the depth of the wrinkles and the thickness of the skin. The depth of erbium:YAG laser treatment is limited by the oozing one gets when reaching the papillary dermis. The water content of the blood blocks the laser beam, which has H2O as a target. Deep wrinkles and furrows in thick elastotic skin can be treated more effectively by a croton oil peel, which does not have this limitation.

Facial volume restoration and skin rejuvenation Figure 9.4.43  Nasolabial fold subscision, done when indicated. A large-bore needle is used for subcision in the subcutaneous plane.

Laser resurfacing Erbium:Yag laser is a powerful tool for the correction of perioral rhytids. It is safe, predictable, and effective as an isolated procedure or in combination with other facial rejuvenation technique.56 For the treatment of perioral rhytids (upper and lower lip skin, chin), we perform 3-4 passes of 1000 mJoules each, with a 5-mm beam, criss-cross patterns, and 50% overlap. For the deeper rhytids, we perform another selective pass to flatten it (Fig. 9.4.45).

Croton oil peel The depth of the peel is decided according to the clinical needs and the estimated skin thickness. Peeling of the perioral area is done with a folded gauze, dipped in the peeling solution. We use concentrations of 0.1%–0.8%. We start the procedure with a moist but not dripping gauze, at the upper lip. One pass is performed followed by examination of the skin. A light frost appears, and becomes more intense as more passes are made. When the frost is still translucent with a pink color in its background the papillary dermis has been reached. When this pink background is lost and the frost becomes more solid white, the upper reticular dermis has been reached. Epidermal sliding is not a good clinical sign in the thick perioral skin and should not be searched for. The peeling is halted when the desired depth has been reached. The experienced surgeon can speed up the depth of the peeling by rubbing faster and harder with the soaked gauze, using a wetter gauze or higher croton oil concentrations.

Our understanding of facial layered anatomy has been dramatically improved in the past 50 years. Although it has resulted in substantial improvement of rhytidectomy procedures and more complex pulling vectors, it corrected only the laxity and apparent skin excess of the lateral face, disregarding volume losses. It remained a two-dimensional repair. However, facial structure does not present a flat, two-dimensional plane. The youthful face is composed of graceful curves and long radii.7,8 The understanding of the effects of facial volume loss on the facial aging process produced a paradigm shift in the analysis and treatment processes of the aging face. The addition of lost volume has been the single greatest improvement in the rehabilitation of the aging face since the facelift.6,65 Nowadays, failing to restore lost facial volume during a facelift procedure can almost be considered as a flaw in the rejuvenation process planning. Facelifts and volume restoration can be considered as inseparable. Fat grafting is the most versatile, safe, stable, and effective treatment for restoring facial volume and the soft appearance that is associated with youth.66 Fat can be found in virtually all patients, and it is cheap. In our practice, over 95% of facial rejuvenation procedures, to patients older than 40 years, involves some modality of lipofilling, as a standalone procedure (for younger patients), or in combination with other surgical procedure (in older patients). The deflation process is most pronounced in the centrofacial area, and specifically in the periorbital and perioral areas. In these areas, as explained at length in the discussion of the aging process earlier in this chapter, it is nowadays understood that volume loss has a major role in the aging process, rather than sagging.

SECTION II

196

CHAPTER 9.4  • Facelift: Facial rejuvenation with loop sutures: the MACS lift and its derivatives

A

B

Figure 9.4.44  (A,B) Marionette groove microfat grafting.

Figure 9.4.46  Liposuction of microfat from the anterior thigh to be grafted with a barbed-holes cannula. (Courtesy of P Tonnard and A Verpaele.) Figure 9.4.45  Erbium laser resurfacing in the perioral area.

Microfat graft lipofilling In our way of preparation, microfat grafts typically have a particle size smaller than 2 mm which is within the limits that Yoshimura determined for fat particle survival. According to his research, particles that are larger than 2 mm, will undergo a certain degree of central necrosis because of the inability of the nutrients to diffuse from the edges of the fat particle into its core, hence fat necrosis, cyst formation and decreased graft volume survival may occur.67,68 Smaller fat particles enhance the predictability of the graft survival, thus overcorrection is not needed, in contrast to larger particle fat grafts. Also, smaller fat graft particles are associated with a lower incidence of fat necrosis and hence reduced inflammation and edema. This in turn reduces downtime for the patient, and the risk of palpable or visible subcutaneous lumps and irregularities. This is especially important when applied under the delicate lower eyelid skin. We do not centrifugate as a part of our MFG preparation. We believe that centrifugation makes the graft more compact, which makes it harder to work with and less easy to precisely deliver through microcannulas of 0.7 mm, and the 21 G and 23 G needles that we use for the SNIF procedure. Also, the non-centrifugated MFG is more uniform in terms of graft density, which makes its survival more predictable. Finally, our clinical results are predictable and consistent: in our experience, it delivers a graft volume retention of between 70% and 95% in facial lipofilling, depending on the mobility of the grafted area. The only exception is in the lips, which has a graft survival capacity of no more than 50%, sometimes even

less due to the high mobility of this area. As a result, touch-up procedures are exceptional (less than 5%).

Surgical technique The liposuction areas preferred are the flanks, lower abdomen, saddle bag, inner thighs, and for thin patients, the anterior thighs. When the procedure is performed under local anesthesia the donor areas are infiltrated with Klein’s solution with an infiltration cannula. The areas to be grafted are anesthetized with regional blocks (supraorbital, infraorbital, and mental nerves are blocked as needed), and are also locally infiltrated with a solution containing 0.3% lidocaine, 1:650,000 epinephrine, and 0.15% ropivacaine. We also add 8.4% sodium bicarbonate, as a less acidic solution infiltration results in less pain during the injection. Also, an acidic pH is suspected to increase adipocytes apoptosis. The epinephrine reduces bleeding but also reduces the chances of intravascular fat embolization. We produce an MFG by harvesting fat with a standard vacuum, using a 2.4-mm cannula with 12–20, 1-mm-diameter ports with sharpened edges and small barbs (Fig. 9.4.46). Harvested fat is then washed with vitamin C in a saline or Ringer’s lactate mixture (1.5  mL ampule of 500  mg/5  mL vitamin C added to 1000 mL of saline/Ringer’s lactate) and strained through a nylon filter with a pore size of 500 µm. The fat is washed and apparent fibers are removed manually with a mosquito clamp (Fig. 9.4.47). At the end of the process, a clean uniform graft with a gel-like consistency is obtained. Typically the graft volume will be between 20% and 12% of the lipoaspirate obtained. We then aspirate the MFG to 10-mL

Surgical strategy and technique

Figure 9.4.47  Microfat process. Fat is placed on sterile nylon cloth, and washed with saline and vitamin C. Fibers are divided and removed from the fat. The fat is then aspirated and transferred into 1-mL syringes.

Table 9.4.1  Typical volumes of fat grafted and degree of resorption per area for facial rejuvenation

Facial area

Volume of fat grafted (cc)

Degree of fat resorption

Upper eyelid sulcus

0.5–3

None to very low

Tear trough

1–2

None to very low

Malar

3–10

Low to moderate

Sunken midcheek

4–15

Moderate to high

Nasolabial fold

1–4

Moderate

Lip vermilion

2–4

High

Marionette groove

2–4

Moderate

Chin

6–20

Low

Temple

2–6

Moderate

From Tonnard P, Verpaele A, Bensimon R. Centrofacial Rejuvenation. New York: Theime; 2018: Table 2.1.

197

Figure 9.4.48  Fine lines are marked with (green) fine marker and represent areas to be grafted with SNIF (sharp needle intradermal fat) graft.

office-based procedure, with high patient satisfaction rate. The most widespread dermal filler in use is cross-linked HA filler. Although HA fillers are generally safe and, in experienced hands, can produce good aesthetic results, their main disadvantages are their temporary effect and cost. Permanent, artificial dermal filling materials have high rates of sometimes serious complications and are therefore not to be recommended. Based on our experience with microfat particles, we began performing microfat grafting as a dermal filler with the technique of sharp needle intradermal fat grafting69 to address facial wrinkles. We have performed this procedure since 2008. MFG is the ideal filling material using the SNIF technique; it is a long-lasting, biocompatible tissue material that can be harvested in a cheap, straightforward technique with minimal or no morbidity. The main indication for the SNIF procedure is dermal wrinkle filling. SNIF is used for the correction of facial and neck and décolletage rhytids, acne scars, and atrophic scars.

Surgical technique

In the SNIF procedure we use MFG obtained by the technique described in the section on MFG lipofilling. The MFG is placed syringes, and 1-mL syringes are filled using a female-to-­ in a 1-mL Luer-Lok syringe connected to a 23 G needle. female connector. At the recipient site, the skin is marked when the patient is “Cold ischemia time” of the MFG is kept to a minimum by in an upright position and making facial expressions to reveal injecting it to the recipient site as soon as possible. subtle rhytids (Fig. 9.4.48). The area is then infiltrated with MFG injection is facilitated by an 18 G needle puncture hole local anesthetic solution containing epinephrine, regardless of and the introduction of a 0.7-mm microcannula connected to whether the patient is scheduled under local or general anesa 1-mL syringe. We deliver the MFG in a multistroke deliv- thesia, to promote vasoconstriction as a precautionary meaery fashion. We make 30–50 strokes per 1 cc of injected fat on sure. The injection is then made in a superficial dermal plane. average. With this method of delivery, very small volumes of The skin around the area to be injected is pinched between fat are deposited with every passage, maximizing the "take" the thumb and index finger of the nondominant hand. This rate of the graft. pinching will enhance accuracy and occlude any adjacent vesFor facial fat grafting, we always inject the fat in a deep, sel. Linear thread injection of the fat is performed under low supraperiosteal plane. The only exceptions are the lips and the plunger pressure, while withdrawing the needle. cheeks, were we inject in a intramuscular plane. Table 9.4.1 Common indications for SNIF in the facial rejuvenation shows the average volumes injected per specific area and the patient are the upper and lower lip vertical rhytids, nasolaexpected degree of resorption. Resorption of fat graft in the bial wrinkles, static glabellar wrinkles, static forehead wrinface is higher in areas with high mobility (e.g., lips). kles, fine wrinkles in the cheek area, horizontal wrinkles in the neck, and vertical wrinkles in the décolletage area. The endpoint of the injection is the blanching of the skin Sharp needle intradermal fat grafting (SNIF) over the injected wrinkle and a slight overcorrection. This In recent years, dermal filling has become a popular way overcorrection will normalize within a few hours, after the of correcting the effects of facial skin aging, as an easy and interstitial fluid is resorbed.

198

SECTION II

CHAPTER 9.4  • Facelift: Facial rejuvenation with loop sutures: the MACS lift and its derivatives

SNIF can be performed on its own, or as a supplementary procedure after classic deep lipofilling with blunt-tip cannulas to correct the fine superficial skin lines overlying the contour defects (e.g., nasolabial fold). It can also be combined with a resurfacing technique such as laser or chemical peel. The advantage of combining SNIF with resurfacing techniques is that the SNIF fills up the “valley” portion of the wrinkle, whereas the resurfacing takes down the “hill”. This allows the resurfacing procedure to be less aggressive, resulting in a shorter recovery time and a reduced incidence of hypopigmentation. The effect of those treatments is synergistic as opposed to the effect laser resurfacing might have on recently injected heterologous dermal filler which may cause degradation or liquefaction of the underlying filler.70

Complications of SNIF Based on our series of 250 patients treated with the SNIF technique,69 bruising of the treated area occurs in 38% of patients, and redness with some swelling occurs in 9% of patients. This bruising, swelling, and redness resolves 4 days after the procedure, on average. We did not encounter any serious complications such as skin necrosis or fat emboli due to intravascular injection, nor indurations, cysts, infections, surface irregularities or hypertrophy of the SNIF graft due to weight gain.

Nanofat injection and needling As lipofilling procedures became popular in the last two decades, it became clear that the skin overlying the lipofilled areas underwent a significant improvement in its quality, and in 2001 adipose-derived stem cells (ADSCs) were first discovered.71 Consequently, it was assumed that these ADSCs might be responsible for the regenerative changes of the skin.72,73 In fatty tissue, 80%–90% of the volume is attributed to adipocytes. However, they represent only about 25% of the cell count within this tissue. The remaining 75% of cells consist of ADSCs, monocytes, endothelial cells, macrophages, granulocytes, and lymphocytes74–76 but also other cells that exhibit multipotent differentiation ability such as hematopoietic stem cell progenitors, pericytes, and adventitial cells.77,78 This fraction of fat tissue is known as the stromal vascular fraction (SVF). Today, numerous studies have shown the possible regenerative implications of ADSCs and/or the SVF: in aesthetic surgery79 enhancement of autologous fat graft survival (cell-assisted lipo-transfer, CAL),80 in aging skin rejuvenation,81 atrophic scars,82 alopecia,83,84 regeneration of critical-size bone defects,85–88 and the repair and regeneration of neural defects.89 After extensive use of fine-particle fat grafts (microfat) for facial volume restoration, and the development of the SNIF procedure to deliver fat to the deep dermis (see above), the search was on for a modality to deliver fat into an even more superficial dermal plane with finer needles. To that purpose the fat needed to be even more liquid. We started emulsifying the microfat by shuffling it between two syringes through a Luer-to-Luer connector. We called the product of this emulsification “nanofat”.90 The resulting product can be injected through a 27 G needle. However, analysis of this emulsified “fat” showed the destruction of adipocytes, with the preservation of the SVF and its cells. Therefore, nanofat is not a

filler material, but a mixture of adipocyte shrapnel, SVF, and intracellular hormones and cytokines. Nanofat is not used for volumization, but solely for regenerative purposes. Since its description in 2013, nanofat as well as other mechanical methods of ADSC and SVF isolation, have been extensively studied in the field of regenerative medicine.91 Compared to the enzymatic digestion method of producing ADSCs and SVF, mechanical isolation as in nanofat production results in more vital cells and a 10 times higher cell yield than with enzymatic digestion for the same volume of basic lipoaspirate.92 Mechanically isolated SVF has proved to be useful in skin-quality regeneration,93–98 treatment of wounds,99–102 improvement of scars,103–107 treatment of knee osteoarthritis,108–113 treatment of Achilles tendinopathy,114,115 treatment of temporomandibular joint disorders,116 treatment of perianal fistula,117,118 treatment of vocal cord scars,119 and improvement of androgenic alopecia.120 Skin histology following injection of mechanically isolated SVF showed changes in collagen fibers and elastin content, formation of new blood vessels, tissue remodeling, thickening of the dermis and epidermis, and downregulation of melanogenic activity.93,104,106 The precise mechanism leading to those histological and clinically evident changes is still not entirely understood. The presence of stem cells within the adipose SVF appears to be only one of many factors. Other factors may be secreted factors promoting regeneration121 or other cell types composing the SVF. The trauma involving the preparation process of nanofat results in an upregulation of several progenitor cell populations.122 Perhaps we should look at trauma in a more positive light, inasmuch as every trauma in the human body is followed by a regenerative process, mediated by various cells and signaling factors.

Clinical indications for nanofat delivery Indications include: 1. Trophic skin changes associated with age and photodamage: a. Thin dermis b. Fine wrinkles c. Craquelé surface (i.e., neck, décolletage, upper arms, thighs) d. Mucosal aging (i.e., dry lips, genital) 2. Pigmentary conditions: a. Pigmentary changes (i.e., face, hands, décolletage) b. Dark circles under the eye in cases of thin dermis associated with increased melanin pigment deposits 3. Scarring and atrophy a. Scars b. Radiodermatitis.

Surgical technique Injection and donor sites preparation and fat harvesting technique is similar to microfat harvesting described earlier in this chapter. Nanofat processing is done by intersyringe shuffling. This is a fast and simple mechanical procedure, consisting of two consecutive micronization/emulsification steps that can be done by an assistant or scrub nurse. In the first step the microfat in a 10-mL syringe is pushed into an empty 10-mL syringe

Surgical strategy and technique

through a 2.4-mm female-to-female Luer-Lok connector (Fig. 9.4.49). After 30 passes with one pass per second, this process is repeated with a 1.2-mm female-to-female LuerLok connector for another 30 vigorous passes (Fig. 9.4.50). At the end of this process, the content of the syringes will have become more liquid, with a more whitish color than the original microfat (Fig. 9.4.51). Finally, the emulsified fat is passed through a double 400–600-micron filter (disposable filter or permanent strainer cartridge, Tulip Medical, San Diego, CA) (Fig. 9.4.52) to remove connective tissue remnants that may block a fine 27 G

199

injection needle. This end product is now called “nanofat”, ready to be delivered to the skin or other target tissue.

Nanofat delivery methods Fine needle injection A superficial delivery of nanofat can be performed using a 27G needle and a 1-mL syringe. This method of nanofat delivery is ideal for small surface area injection (e.g., lower eyelids, scars, upper lip, etc.). The injection is directed intradermally to immediately subdermally. The endpoint of the injection is a blanching-to-yellow discoloration of the injected area, which typically disappears in the next few days after the treatment. For dark circles in lower eyelids, where the skin is so thin, we inject in a subdermal plane, superficial to the orbicularis oculi muscle, also until yellowish discoloration. In mucosal injections of nanofat, the plane of injection is the submucosa. In all cases, injection is performed upon withdrawal of the needle in a fan-shaped pattern. Typically, 1 cc of nanofat can cover an area at least 1 cm by 1 cm (1 cm²).

Microneedling

Figure 9.4.49  Nanofat production: after processing the microfat and isolating it from infiltration solution, oil, and fibers, the microfat is placed in a 10-mL syringe and passed 30 times through a 2.4-mm connector.

Figure 9.4.50  Using the same syringes, the fat is then passed 30 additional times through a 1.2-mm connector.

Figure 9.4.51  Nanofat (emulsified fat, right syringe) is lighter in color than microfat (left syringe). (Courtesy Tonnard and Verpaele.)

Microneedling is a safe and effective skin rejuvenation method, achieved by performing countless small needle pricks to the papillary dermis, which stimulates percutaneous collagen induction in a mechanical way.123 Each needle puncture is considered by the skin as a microinjury. Nevertheless, the epidermis is minimally disrupted, hence scarless wound healing will occur.124 The maximal rejuvenating skin effect of microneedling is seen 3–6 months after the procedure. On top of the mechanically induced rejuvenating effect of the microneedling process, it enhances the penetration of topical products through the micro-channels produced. These channels remain open for 30–45 minutes125 and, moreover, an enhanced skin permeability for up to 40 hours after the process has been observed.126 For the treatment of large skin areas (e.g. full face, neck, décolletage), delivery of nanofat with a 27 G needle is time-consuming. It is also difficult to ascertain a uniform depth of delivery, as small variations in the needle inclination will result in a substantial difference in injection level. For those cases, we combine the microneedling and nanofat delivery in the same procedure, using the Hydra Needle 20 device (Guangzhou Ekai Electronic Technology Co. Ltd, Q16Guangzhou, China). This device allows uniform delivery of nanofat to the depth of the papillary dermis, while performing microneedling for a synergistic rejuvenating effect.

Figure 9.4.52  In order to be able to inject the nanofat through a 27G needle, a filter is used through which the nanofat is passed to be relieved of its remaining fibers. (Courtesy of P Tonnard and A Verpaele.)

200

SECTION II

CHAPTER 9.4  • Facelift: Facial rejuvenation with loop sutures: the MACS lift and its derivatives

The device features 20 gold-plated titanium needles, a reservoir of 8 mL in which the nanofat mixture is placed, and a pump system designed to dispense a small amount of nanofat mixture from the reservoir. The nanofat is introduced into the skin through the microchannels made by the needles by passive diffusion and absorption. The device is used by repetitive tapping motions, about 3 taps per seconds, on the skin for 20 minutes, the time to empty the 8-mL vial. Therefore we can assume that about 72,000 microchannels are created during this process. Since 2022 we have adopted microneedling with the Dermapen 4 (DermapenWorld, Sydney, NSW) device, set to 2.5 mm, which allows a faster and more comfortable coverage of the surface, while also reaching the papillary dermis. The nanofat is applied on the skin surface together with the needling, and massaged into the microperforations. We usually use one 8-mL vial for face/neck/décolettage area. At the end of the procedure, a diffuse punctate bleeding of the treated area is evident, indicating that the papillary dermis was reached (Fig. 9.4.53). The nanofat is then gently massaged into the skin and microchannels, and left on for another 10 minutes, washed with saline, and nanofat cream (see below) is applied (Fig. 9.4.54).

The addition of BT results in a "microbotox" effect,127 the addition of a liquid HA results in a "skin booster" effect,128 and the addition of vitamin C increases the survival and regenerative potential of ADSC129 and also has antioxidant and collagen stimulation properties and can protect the skin from hyperpigmentation.130 This effect wears off after 4–6 months, simultaneously with the appearance of the nanofat and mechanical microneedling rejuvenating effect (Fig. 9.4.55). Nanofat needling can be done as a standalone procedure to improve skin quality and superficial rhytids in areas that are not amenable to aggressive resurfacing, such as the neck, décolletage or hands. For deeper wrinkles in those areas it can be combined with the SNIF procedure. In the face, nanofat needling can be done safely on facelift skin flaps, and in the central face it can be added after erbium:YAG laser resurfacing. We often perform a nanofat needling procedure for a preventive anti-aging indication. We believe that the clinically proven rejuvenating effect of this procedure can serve to slow down the facial aging process. The preventive indication of nanofat needling is directed towards a younger age group (30–45 years), and it is done at intervals of 2–3 years.

Nanofat mixture

To benefit to the maximum from the fact that the microchannels stay open for 30 minutes and the skin permeability increases for up to 40 hours after microneedling, we developed the nanofat cream. This is composed of 50% emulsifying cream (Fig. 9.4.56) that serves as a carrier and 50% nanofat. It is applied on the treated skin surfaces (see Fig. 9.4.54). It is stored in the patient’s refrigerator, and used 5–6 times a day for up to 1 week after surgery.

From our experience, the clinical result of the nanofat regenerative effect on the skin becomes evident only after a minimum of 6–8 months. To achieve an earlier clinical improvement we enrich the nanofat with botulinum toxin (BT), vitamin C, and hyaluronic acid (HA) (Box 9.4.2).

Nanofat cream

BOX 9.4.2  Composition of nanofat microneedling mixture Nanofat

5.5 cc/mL

Botulinum toxin 100 IU/mL

0.5 cc/mL

Hyaluronic acid*

1.0 cc/mL

Ascorbic acid 500 mg/mL

1.0 cc/mL

TOTAL

8.0 cc/mL

*

Belotero Revive, Merz Aesthetics, Greensboro, NC.

Figure 9.4.53  Microneedling and the introduction with the nanofat mixture is done by rapid tapping of the entire skin of the anterior face and neck with the hydra needle. Note the punctate bleeding indicating the reaching of the papillary dermis. The undermined skin can also be treated using this method.

Nanofat needling + microbotox + HA 100

near full nanofat effect

90

80% of nanofat effect

80 %-age effect

70

Microbtx + HAeffect

60 50

HA/btx disappearing

40 30 20 10 0 0

Figure 9.4.54  Nanofat cream is rubbed onto the entire microneedled area. (Courtesy of P Tonnard and A Verpaele.)

Day 0: Treatment

2

4 Time (months)

6

8

Figure 9.4.55  Phases of nanofat mixture microneedling effect on skin quality.

10

Postoperative care and complications

201

Figure 9.4.56  Producing the nanofat cream: mixture of remaining nanofat (50%) and a base cream (cetomacrogol cream, 50%). (Courtesy of P Tonnard and A Verpaele.)

Postoperative care and complications MACS lift/neck lift After MACS lift and placement of the A-net we do not use any drains or apply any dressing. A 16–18°C cooling mask is applied (Hilotherm, Hilotherm GmbH, Germany) for 4–6 hours to reduce formation of edema. Often these patients spend the night in our facility and are monitored by the night nurse. Blood pressure is monitored and lowered if needed. On the day after surgery the patient‘s hair is washed before discharge. We prescribe corticosteroid treatment for our patients, in a tapered-down fashion: oral prednisolone, 50 mg postoperative on day 1, 2 25 mg on day 2. The A-net is removed on postoperative day 2, and skin sutures are removed on postoperative day 5–6. Complications are generally rare. Cases of ischemia are rare and with a possible higher likelihood in heavy smokers. In a case of pending skin ischemia in the early postoperative hours we use a nitroglycerine patch. If hypertrophic scarring occurs, it can be managed with scar surgical revision, intralesional injection of triamcinolone-5FU, or nanofat grafting (see section on nanofat above). Other rare complications are segmental facial paresis, which always resolves within 2 months as no nerves are interrupted during a MACS procedure. Hematomas formerly occurred in 1%, but have now been eradicated since the use of the A-net procedure (3 years in our practice). Infection and abscesses, hypertrophic scarring, suture granuloma, and sialoma in submandibular gland resection patients are extremely rare and treated conservatively. To date we have never observed a complication that did not resolve spontaneously or could not be corrected by simple measures.

Perioral rejuvenation The techniques described in this chapter focus on patient safety to minimize possible complications. We always suggest conservatism because overcorrection in some of the procedures described might result in very hard to treat complications, and sometimes impossible (e.g., lip lift or resurfacing procedures).

For perioral grafting, possible complications are underfilling, overfilling, mispositioning of fat, skin irregularities, fat necrosis, and cyst formation. Meticulous technique with regards to the area, plane, amount, and volume of aliquots grafted can prevent all of these possible complications. For the lip lift procedure, failure to excise skin lateral to the ala will result in unnatural pouting of the central lip, and insufficient lift of the lateral lip. An excision pattern that is not extending into the nostril sill might result in a visible, low scar. Overcorrection in this procedure might result in an overlifted upper lip and a difficulty in closing the mouth. This complication is virtually irreparable. Perioral resurfacing complications can be undercorrection due to shallow resurfacing, scarring due to overcorrection, hypopigmentation and hyperpigmentation. We do not recommend resurfacing treatment for dark-skinned patients (Fitzpatrick scale 4 and above), and always promise our patients an "improvement" and not "disappearance" of the rhytids. Infections are also a possible complication of all procedures described in this chapter and can also induce scar formation. Herpes simplex prophylaxis is routinely administered until complete reepithelialization. Any indurations that may lead to hypertrophic scars are recognized early and intradermal injection with 50/50 triamcinolone (10 mg/mL) and 5FU (50 mg/mL) is performed. When lip lift is correctly performed, complications are very limited. In our (P.T./A.V.) series of 500 cases of perioral rejuvenation30 self-limiting bruising and moderate swelling were seen in all patients. All patients experienced a temporary loss of sensation at the nostril margin that was spontaneously resolved approximately 4 months postoperatively. Scar widening leading to scar revision occurred in two cases (0.5%) of the 393 lip lift patients of this series. Five patients (1%) had an asymmetry of the augmented lip (n = 3) or nasolabial fold (n = 2).

Microfat grafting Puncture holes do not need closure. No dressing is used to prevent excessive pressure and impair lymphatic drainage. We cool the grafted areas for 1 hour with a cooling mask (Hilotherm) to 16–18°C. One day after surgery skin and hair washing is permited. Antibiotic treatment with amoxicillin (500 mg, three times a day) is prescribed for 3 days. Smoking is not allowed until 3 months after the lipofilling to maximize chances of fat graft take, and we encourage patients not to

202

SECTION II

CHAPTER 9.4  • Facelift: Facial rejuvenation with loop sutures: the MACS lift and its derivatives

lose weight in the 6 months following surgery to prevent a catabolic pathway of fat metabolism. Complications associated with microfat grafting are usually surgeon-related and conceptual. The most common mistakes are under- or overcorrection. There is a learning curve in assessing the right amount of fat to be grafted, taking into account the resorption to be expected. A touch-up filling procedure is easier and more acceptable by the patient than any attempt to remove excessive grafted fat. Fat necrosis, cyst formation, and subcutaneous lumps/skin irregularity are mostly prevented by the use of microfat grafts and the application of meticulous injection technique as described above. Infections are theoretically possible, but rarely encountered. Donor site irregularities are a result of over-aspirated areas and should be avoided at all cost.

Periorbital rejuvenation Compared to classic blepharoplasty, less excessive bruising or swelling is seen with augmentation blepharoplasty. Antibiotic treatment with amoxicillin (500 mg, three times a day) is prescribed for 3 days. Smoking is prohibited 3 weeks before and 3 months after surgery, and weight loss is avoided in the 6 months following surgery to avoid a catabolic state. In our series of 500 augmentation blepharoplasty cases18 no expanding hematomas or other major complications occurred. Prolonged edema (lasting >1 month postoperatively) of the malar area occurred in 35 patients (7%) and 5 patients after a lower fat redraping blepharoplasty (1%) had a degree of postoperative scleral show that was resolved within 2 months following conservative treatment. There were no reports of

Access the reference list online at   Elsevier eBooks+

sensory or motor nerve lesions, infection, asymmetries, or overfilling, and a few cases of undercorrection.

Skin resurfacing At the end of the operation, areas resurfaced with erbium:YAG laser are covered with nanofat cream. This cream replaces the earlier used ointment of 50/50 vaseline and paraffin. Clinically, a speeding up of the healing time by 1–2 days is observed. This clinical observation is currently under investigation. In the first 24 hours, we recommend local treatment with vinegar soaks (1 teaspoon of vinegar and 1 cup of warm water), 3–4 times a day for 10–15 minutes. Nanofat cream is applied abundantly until complete re-epithelialization, on the average within a week. From then on a neutral hydrating cream can be applied.

Nanofat delivery Yellow discoloration of the skin is always seen to some degree after nanofat needle injection and resolves within 7 days. It can persist if the adipocytes are not properly destroyed by a dual sequential emulsification as described above. Some erythema can occur and last for several weeks. It can easily be concealed with make-up. Petechiae and ecchymoses are commonly present after nanofat needling and resolve within 7–10 days. It can be camouflaged by make-up, starting on day 3 after the procedure. As opposed to laser or peeling procedures, no post-inflammatory hyperpigmentation in seen with nanofat microneedling and no sun exposure restriction is needed.

References

References 1. Mitz V, Peyronie M. The superficial musculo-aponeurotic system (SMAS) in the parotid and cheek area. Plast Reconstr Surg. 1976;58(1):80–88. 2. Tonnard P, Verpaele A, Monstrey S, et al. Minimal access cranial suspension lift: a modified S-lift. Plast Reconstr Surg. 2002;109(6): 2074–2086. 3. Cotofana S, Fratila AAM, Schenck TL, Redka-Swoboda W, Zilinsky I, Pavicic T. The anatomy of the aging face: a review. Facial Plast Surg. 2016;32(3):253–260. 4. Kim SJ, Kim SJ, Park JS, Byun SW, Bae JH. Analysis of age-related changes in Asian facial skeletons using 3D vector mathematics on picture archiving and communication system computed tomography. Yonsei Med J. 2015;56(5):1395–1400. 5. Rohrich RJ, Pessa JE. The fat compartments of the face: anatomy and clinical implications for cosmetic surgery. Plast Reconstr Surg. 2007;119(7):2219–2227. 6. Marten TJ, Elyassnia D. Fat grafting in facial rejuvenation. Clin Plast Surg. 2015;42(2):219–252. 7. Tonnard PL, Verpaele AM, Bensimon RH. CentroFacial Rejuvenation. New York: Thieme Medical Publishers; 2018. 8. Little JW. Volumetric perceptions in midfacial aging with altered priorities for rejuvenation. Plast Reconstr Surg. 2000;105(1):252–259. 9. Coleman S, Saboeiro A, Sengelmann R. A comparison of lipoatrophy and aging: volume deficits in the face. Aesthetic Plast Surg. 2009;33(1):14–21. 10. Fedok FG. The rejuvenation of the aged central lower face: a contemporary perspective. Facial Plast Surg. 2019;35(2):121–128. 11. Gerth DJ. Structural and volumetric changes in the aging face. Facial Plast Surg. 2015;31(1):3–9. 12. Ko AC, Korn BS, Kikkawa DO. The aging face. Surv Ophthalmol. 2017;62(2):190–202. 13. Lambros V. Models of facial aging and implications for treatment. Clin Plast Surg. 2008;35(3):319–327. 14. Pessa JE. An algorithm of facial aging: verification of Lambros’s theory by three-dimensional stereolithography, with reference to the pathogenesis of midfacial aging, scleral show, and the lateral suborbital trough deformity. Plast Reconstr Surg. 2000;106(2): 479–490. 15. Wong CH, Mendelson B. Newer understanding of specific anatomic targets in the aging face as applied to injectables: aging changes in the craniofacial skeleton and facial ligaments. Plast Reconstr Surg. 2015;136(5):44S–48S. 16. Zadoo VP, Pessa JE. Biological arches and changes to the curvilinear form of the aging maxilla. Plast Reconstr Surg. 2000;106(2):460–466. 17. Lambros V. Observations on periorbital and midface aging. Plast Reconstr Surg. 2007;120(5):1367–1376. 18. Tonnard PL, Verpaele AM, Zeltzer AA. Augmentation blepharoplasty: a review of 500 consecutive patients. Aesthetic Surg J. 2013;33(3):341–352. 19. Lipp M, Weiss E. Nonsurgical treatments for infraorbital rejuvenation: a review. Dermatol Surg. 2019;45(5):700–710. 20. Karunanayake M, To F, Efanov JI, Doumit G. Analysis of craniofacial remodeling in the aging midface using reconstructed three-dimensional models in paired individuals. Plast Reconstr Surg. 2017;140(3):448E–454E. 21. Levine RA, Garza JR, Wang PTH, Hurst CL, Dev VR. Adult facial growth: applications to aesthetic surgery. Aesthetic Plast Surg. 2003;27(4):265–268. 22. Pessa JE, Zadoo VP, Yuan C, et al. Concertina effect and facial aging: nonlinear aspects of youthfulness and skeletal remodeling, and why, perhaps, infants have jowls. Plast Reconstr Surg. 1999;103(2):635–644. 23. Richard MJ, Morris C, Deen BF, Gray L, Woodward JA. Analysis of the anatomic changes of the aging facial skeleton using computer-assisted tomography. Ophthalmic Plast Reconstr Surg. 2009;25(5):382–386.

202.e1

24. Shaw RBJ, Kahn DM. Aging of the midface bony elements: a three-dimensional computed tomographic study. Plast Reconstr Surg. 2007;119(2):673–675. 25. Rohrich RJ, Pessa JE, Ristow B. The youthful cheek and the deep medial fat compartment. Plast Reconstr Surg. 2008;121(6): 2107–2112. 26. Nguyen HT, Isaacowitz DM, Rubin PAD. Age- and fatigue-related markers of human faces: an eye-tracking study. Ophthalmology. 2009;116(2):355–360. 27. Bartlett SP, Grossman R, Whitaker LA. Age-related changes of the craniofacial skeleton: an anthropometric and histologic analysis. Plast Reconstr Surg. 1992;90(4):592–600. 28. Lambros V. Facial Aging: a 54-year, three-dimensional population study. Plast Reconstr Surg. 2020:921–928. 29. Ramaut L, Tonnard P, Verpaele A, Verstraete K, Blondeel P. Aging of the upper lip: Part I. A retrospective analysis of metric changes in soft tissue on magnetic resonance imaging. Plast Reconstr Surg. 2019;143(2):440–446. 30. Tonnard PL, Verpaele AM, Ramaut LE, Blondeel PN. Aging of the upper lip: Part II. Evidence-based rejuvenation of the upper lip – a review of 500 consecutive cases. Plast Reconstr Surg. 2019;143(5): 1333–1342. 31. Penna V, Stark GB, Eisenhardt SU, Bannasch H, Iblher N. The aging lip: a comparative histological analysis of age-related changes in the upper lip complex. Plast Reconstr Surg. 2009;124(2):624–628. 32. Guerrissi JO, Sanchez LI. An approach to the senile upper lip. Plast Reconstr Surg. 1983;92(6):1187–1191. 33. Iblher N, Kloepper J, Penna V, Bartholomae J-P, Stark GB. Changes in the aging upper lip – a photomorphometric and MRI-based study (on a quest to find the right rejuvenation approach). J Plast Reconstr Aesthet Surg. 2008;61(10):1170–1176. 34. Lévêque JL, Goubanova E. Influence of age on the lips and perioral skin. Dermatology. 2004;208(4):307–313. 35. Penna V, Fricke A, Iblher N, Eisenhardt SU, Stark GB. The attractive lip: a photomorphometric analysis. J Plast Reconstr Aesthet Surg. 2015;68(7):920–929. 36. Penna V, Stark GB, Voigt M, Mehlhorn A, Iblher N. Classification of the aging lips: a foundation for an integrated approach to perioral rejuvenation. Aesthet Plast Surg. 2015;39(1):1–7. 37. Raphael P, Harris R, Harris SW. Analysis and classification of the upper lip aesthetic unit. Plast Reconstr Surg. 2013;132(3):543–551. 38. Raschke GF, Rieger UM, Bader R-D, et al. Perioral aging--an anthropometric appraisal. J Craniomaxillofac Surg. 2014;42(5): e312–e317. 39. Karsan N, Ellis DAF. The lip–cheek groove: a new analysis with treatment options. Arch Facial Plast Surg. 2006;8(5):324–328. 40. Perkins SW, Sandel 4th HD. Anatomic considerations, analysis, and the aging process of the perioral region. Facial Plast Surg Clin North Am. 2007;15(4):403–407, v. 41. Yousif NJ, Gosain A, Matloub HS, Sanger JR, Madiedo G, Larson DL. The nasolabial fold: an anatomic and histologic reappraisal. Plast Reconstr Surg. 1994;93(1):60–69. 42. de Maio M, DeBoulle K, Braz A, Rohrich RJ. Facial assessment and injection guide for botulinum toxin and injectable hyaluronic acid fillers: focus on the midface. Plast Reconstr Surg. 2017;140(4): 540e–550e. 43. Wollina U. Perioral rejuvenation: restoration of attractiveness in aging females by minimally invasive procedures. Clin Intervent Aging. 2013;8:1149–1155. 44. Puizina-Ivic N. Skin aging. Acta Dermatovenerol Alp Pannonica Adriat. 2008;17(2):47–53. 45. Jenkins G. Molecular mechanisms of skin ageing. Mechan Ageing Dev. 2002;123(7):801–810. 46. Khavkin J, Ellis DAF. Aging skin: histology, physiology, and pathology. Facial Plast Surg Clin North Am. 2011;19(2):229–234. 47. Jacono AA, Alemi AS, Russell JL. A meta-analysis of complication rates among different SMAS facelift techniques. Aesthtic Surg J. 2019;39(9):927–942.

202.e2

SECTION II

CHAPTER 9.4  • Facelift: Facial rejuvenation with loop sutures: the MACS lift and its derivatives

48. Antell DE, May JM, Bonnano MJ, Lee NY. A comparison of the full and short-scar face-lift incision techniques in multiple sets of identical twins. Plast Reconstr Surg. 2016;137(6):1707–1714. 49. Alpert B, Baker DC, Hamra ST, Owsley JQ, Ramirez O. Identical twin face lifts with differing techniques: a 10 year follow-up. Plast Reconstr Surg. 2009;123:1025. 50. Tonnard P, Verpaele A, Monstrey S, et al. Minimal access cranial suspension lift: a modified S-lift. Plast Reconstr Surg. 2002;109(6): 2074–2086. 51. Pelle-Ceravolo M, Angelini M, Silvi E. Treatment of anterior neck aging without a submental approach: lateral skin-platysma displacement, a new and proven technique for platysma bands and skin laxity. Plast Reconstr Surg. 2017;139(2):308–321. 52. Auersvald A, Auersvald LA. Hemostatic net in rhytidoplasty: an efficient and safe method for preventing hematoma in 405 consecutive patients. Aesthet Plast Surg. 2014;38(1):1–9. 53. Giot J, Labbe D, Kaluzinski E. Submental area rejuvenation by digastric corset : anatomical study and clinical application in 20 cases. Aesthetic Plast Surg. 2013;37:222–231. 54. Viterbo F, Auersvald A, O’Daniel TG. Gliding brow lift (GBL): a new concept. Aesthetic Plast Surg. 2019;43(6):1536–1546. 55. Khatri KA, Machado A, Magro C, et al. Laser peel : facial rejuvenation with a superficial erbium : YAG laser treatment. J Cutan Laser Ther. [online]. 2009, 12 Jul https://doi.org/10.1080/ 14628830050516353. 56. Sanniec K, Afrooz PN, Burns AJ. Long-term assessment of perioral rhytide correction with erbium: YAG laser resurfacing. Plast Reconstr Surg. 2019;143(1):64–74. 57. Khatri KA, Ross V, Grevelink JM, Magro CM, Anderson RR. Comparison of erbium:YAG and carbon dioxide lasers in resurfacing of facial rhytides. Arch Dermatol. 1999;135(4):391–397. 58. Tonnard PL, Verpaele AM. Short-Scar Face Lift: Operative Startegies and Techniques. St. Louis, MO: Quality Medical Publishers; 2007. 59. Friedmann DP, Goldman MP. Dark circles etiology and management options. Clin Plast Surg. 2020;42(1):33–50. 60. Kim DW, Jeon BJ, Hwang NH, et al. Adipose-derived stem cells inhibit epidermal melanocytes through an interleukin-6-mediated mechanism. Plast Reconstr Surg. 2014;134(3):470–480. 61. Xu Peng, Yu Qian, Huang Huizhen, Zhang Wen Jie, Li Wei. Nanofat increases dermis thickness and neovascularization in photoaged nude mouse skin. Aesthetic Plast Surg. 2018;42: 343–351. 62. Rigotti G, Charles-de-Sá L, et al. Expanded stem cells, stromalvascular fraction, and platelet-rich plasma enriched fat: comparing results of different facial rejuvenation approaches in a clinical trial. Aesthet Surg J. 2016;36:261–270. 63. Amirkhani MA, Shoae-Hassani Soleimani M, et al. Rejuvenation of facial skin and improvement in the dermal architecture by transplantation of autologous stromal vascular fraction: a clinical study. Bioimpacts. 2016;6(3):149–154. 64. Hsu VM, Wes AM, Tahiri Y, Cornman-Homonoff J, Percec I. Quantified facial soft-tissue strain in animation measured by real-time dynamic 3-dimensional imaging. Plast Reconstr Surg Glob Open. 2014;2(9):e211. 65. Mowlds DS, Lambros V. Cheek volumization and the nasolabial fold. Plast Reconstr Surg. 2018;141(5):1124–1129. 66. Coleman SR. Structural fat grafts: the ideal filler? Clin Plast Surg. 2001;28(1):111–119. 67. 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. 2012;129(5): 1081–1092. 68. Kato H, Mineda K, Eto H, et al. Degeneration, regeneration, and cicatrization after fat grafting: dynamic total tissue remodeling during the first 3 months. Plast Reconstr Surg. 2014;133(3): 303e–313e. 69. Zeltzer AA, Tonnard PL, Verpaele AM. Sharp-needle intradermal fat grafting (SNIF). Aesthetic Surg J. 2012;32(5):554–561. 70. Alam M, Levy R, Pajvani U, et al. Safety of radiofrequency treatment over human skin previously injected with medium-term

injectable soft-tissue augmentation materials: a controlled pilot trial. Lasers Surg Med. 2006;38(3):205–210. 71. Zuk PA, Zhu M, Mizuno H, et al. Multilineage cells from human adipose tissue: implications for cell-based therapies. Tissue Eng. 2001;7(2):211–228. 72. Coleman SR. Structural fat grafting: more than a permanent filler. Plast Reconstr Surg. 2006;118(3 Suppl):108S–120S. 73. Rigotti G, Marchi A, Galiè M, et al. Clinical treatment of radiotherapy tissue damage by lipoaspirate transplant: a healing process mediated by adipose-derived adult stem cells. Plast Reconstr Surg. 2007;119(5):1404–1409. 74. Eto H, Suga H, Matsumoto D, et al. Characterization of structure and cellular components of aspirated and excised adipose tissue. Plast Reconstr Surg. 2009;124(4):1087–1097. 75. Suga H, Matsumoto D, Inoue K, et al. Numerical measurement of viable and nonviable adipocytes and other cellular components in aspirated fat tissue. Plast Reconstr Surg. 2008;122(1):103–114. 76. 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. 2006;208(1):64–76. 77. James AW, Zara JN, Zhang X, et al. Perivascular stem cells: a prospectively purified mesenchymal stem cell population for bone tissue engineering. Stem Cells Transl Med. 2012;1(6):510–519. 78. Kilinc MO, Santidrian A, Minev I, et al. The ratio of ADSCs to HSC-progenitors in adipose tissue derived SVF may provide the key to predict the outcome of stem-cell therapy. Clin Transl Med. 2018;7(1):5. 79. Glass GE, Ferretti P. Adipose-derived stem cells in aesthetic surgery. Aesthetic Surg J. 2019;39(4):423–438. 80. Matsumoto D, Sato K, Gonda K, et al. Cell-assisted lipotransfer: supportive use of human adipose-derived cells for soft tissue augmentation with lipoinjection. Tissue Eng. 2006;12(12):3375–3382. 81. Park B-S, Jang KA, Sung J-H, et al. Adipose-derived stem cells and their secretory factors as a promising therapy for skin aging. Dermatol Surg. 2008;34(10):1323–1326. 82. Zhou B-R, Zhang T, Bin Jameel AA, et al. The efficacy of conditioned media of adipose-derived stem cells combined with ablative carbon dioxide fractional resurfacing for atrophic acne scars and skin rejuvenation. J Cosmetic Laser Ther. 2016;18(3): 138–148. 2016. 83. Anderi R, Makdissy N, Azar A, Rizk F, Hamade A. Cellular therapy with human autologous adipose-derived adult cells of stromal vascular fraction for alopecia areata. Stem Cell Res Ther. 2018;9(1):141. 84. Shin H, Ryu HH, Kwon O, Park B-S, Jo SJ. Clinical use of conditioned media of adipose tissue-derived stem cells in female pattern hair loss: a retrospective case series study. Int J Dermatol. 2015;54(6):730–735. 85. Sándor GK, Tuovinen VJ, Wolff J, et al. Adipose stem cell tissue-engineered construct used to treat large anterior mandibular defect: a case report and review of the clinical application of good manufacturing practice-level adipose stem cells for bone regeneration. J Oral Maxillofac Surg. 2013;71(5):938–950. 86. Taylor JA. Bilateral orbitozygomatic reconstruction with tissueengineered bone. J Craniofac Surg. 2010;21(5):1612–1614. 87. Thesleff T, Lehtimäki K, Niskakangas T, et al. Cranioplasty with adipose-derived stem cells and biomaterial: a novel method for cranial reconstruction. Neurosurgery. 2011;68(6):1535–1540. 88. Yoon E, Dhar S, Chun DE, Gharibjanian NA, Evans GRD. In vivo osteogenic potential of human adipose-derived stem cells/poly lactide-co-glycolic acid constructs for bone regeneration in a rat critical-sized calvarial defect model. Tissue Eng. 2007;13(3):619–627. 89. Zack-Williams SD, Butler PE, Kalaskar DM. Current progress in use of adipose derived stem cells in peripheral nerve regeneration. World J Stem Cells. 2015;7(1):51–64. 90. Tonnard P, Verpaele A, Peeters G, Hamdi M, Cornelissen M, Declercq H. Nanofat grafting: basic research and clinical applications. Plast Reconstr Surg. 2013;132(4):1017–1026. 91. Ghiasloo M, Lobato RC, Díaz JM, Singh K, Verpaele A, Tonnard P. Expanding clinical indications of mechanically isolated stromal

References

vascular fraction: a systematic review. Aesthetic Surg J. 2020;40(9):NP546–NP560. 92. Sesé B, Sanmartín JM, Ortega B, Matas-Palau A, Llull R. Nanofat cell aggregates: a nearly constitutive stromal cell inoculum for regenerative site-specific therapies. Plast Reconstr Surg. 2019;144(5): 1079–1088. 93. Charles-de-Sá L, Gontijo-de-Amorim NF, Maeda Takiya C, et al. Antiaging treatment of the facial skin by fat graft and adiposederived stem cells. Plast Reconstr Surg. 2015;135(4):999–1009. 94. Cohen SR, Goodacre AK, Womack H, et al. Topical nanofat biocrème improves aesthetic outcomes of nonablative fractionated laser treatment: a preliminary report. Aesthetic Surg J. 2020;40(8): 892–899. 95. Liang Z-J, Lu X, Li D-Q, et al. Precise intradermal injection of nanofat-derived stromal cells combined with platelet-rich fibrin improves the efficacy of facial skin rejuvenation. Int J Exp Cell Physiol Biochem Pharmacol. 2018;47(1):316–329. 96. Rigotti G, Charles-de-Sá L, Gontijo-de-Amorim NF, et al. Expanded stem cells, stromal-vascular fraction, and platelet-rich plasma enriched fat: comparing results of different facial rejuvenation approaches in a clinical trial. Aesthetic Surg J. 2016;36(3):261–270. 97. Uyulmaz S, Sanchez Macedo N, Rezaeian F, Giovanoli P, Lindenblatt N. Nanofat grafting for scar treatment and skin quality improvement. Aesthetic Surg J. 2018;38(4):421–428. 98. Wei H, Gu S-X, Liang Y-D, et al. Nanofat-derived stem cells with platelet-rich fibrin improve facial contour remodeling and skin rejuvenation after autologous structural fat transplantation. Oncotarget. 2017;8(40):68542–68556. 99. Del Papa N, Di Luca G, Sambataro D, et al. Regional implantation of autologous adipose tissue-derived cells induces a prompt healing of long-lasting indolent digital ulcers in patients with systemic sclerosis. Cell Transplant. 2015;24(11):2297–2305. 100. Lonardi R, Leone N, Gennai S, Trevisi Borsari G, Covic T, Silingardi R. Autologous micro-fragmented adipose tissue for the treatment of diabetic foot minor amputations: a randomized controlled single-center clinical trial (MiFrAADiF). Stem Cell Res Ther. 2019;10(1):223. 101. Raposio E, Bertozzi N, Bonomini S, et al. Adipose-derived stem cells added to platelet-rich plasma for chronic skin ulcer therapy. Wounds. 2016;28(4):126–131. 102. Tarallo M, Fino P, Ribuffo D, et al. Liposuction aspirate fluid adipose-derived stem cell injection and secondary healing in fingertip injury: a pilot study. Plast Reconstr Surg. 2018;142(1): 136–147. 103. Bhooshan LS, Devi MG, Aniraj R, Binod P, Lekshmi M. Autologous emulsified fat injection for rejuvenation of scars: a prospective observational study. Ind J Plast Surg. 2018;51(1):77–83. 104. Gentile P, Scioli MG, Bielli A, Orlandi A, Cervelli V. Comparing different nanofat procedures on scars: role of the stromal vascular fraction and its clinical implications. Regen Med. 2017;12(8): 939–952. 105. Gu Z, Li Y, Li H. Use of condensed nanofat combined with fat grafts to treat atrophic scars. JAMA Facial Plast Surg. 2018;20(2): 128–135. 106. Jan SN, Bashir MM, Khan FA, et al. Unfiltered nanofat injections rejuvenate postburn scars of face. Ann Plast Surg. 2019;82(1):28–33. 107. Tenna S, Cogliandro A, Barone M, et al. Comparative study using autologous fat grafts plus platelet-rich plasma with or without fractional CO(2) laser resurfacing in treatment of acne scars: analysis of outcomes and satisfaction with FACE-Q. Aesthetic Plast Surg. 2017;41(3):661–666. 108. Barfod KW, Blønd L. Treatment of osteoarthritis with autologous and microfragmented adipose tissue. Danish Med J. 2019;66(10):A5565. 109. Bisicchia S, Bernardi G, Pagnotta SM, Tudisco C. Microfragmented stromal-vascular fraction plus microfractures provides better clinical results than microfractures alone in symptomatic focal chondral lesions of the knee. Knee Surg Sports Traumatol Arthrosc. 2020;28(6):876–1884. 110. Cattaneo G, De Caro A, Napoli F, Chiapale D, Trada P, Camera A. Micro-fragmented adipose tissue injection associated with

202.e3

arthroscopic procedures in patients with symptomatic knee osteoarthritis. BMC Musculoskelet Disord. 2018;19(1):176. 111. Hudetz D, Borić I, Rod E, et al. The effect of intra-articular injection of autologous microfragmented fat tissue on proteoglycan synthesis in patients with knee osteoarthritis. Genes. 2017;8(10):270. 112. Mautner K, Bowers R, Easley K, Fausel Z, Robinson R. Functional outcomes following microfragmented adipose tissue versus bone marrow aspirate concentrate injections for symptomatic knee osteoarthritis. Stem Cells Transl Med. 2019;8(11):1149–1156. 113. Panchal J, Malanga G, Sheinkop M. Safety and efficacy of percutaneous injection of lipogems micro-fractured adipose tissue for osteoarthritic knees. Am J Orthop (Belle Mead N). 2018;47(11). https://doi.org/10.12788/ajo.2018.0098. 114. Albano D, Messina C, Usuelli FG, et al. Magnetic resonance and ultrasound in Achilles tendinopathy: predictive role and response assessment to platelet-rich plasma and adipose-derived stromal vascular fraction injection. Eur J Radiol. 2017;95:130–135. 115. Usuelli FG, Grassi M, Maccario C, et al. Intratendinous adiposederived stromal vascular fraction (SVF) injection provides a safe, efficacious treatment for Achilles tendinopathy: results of a randomized controlled clinical trial at a 6-month follow-up. Knee Surg Sports Traumatol Arthrosc. 2018;26(7):2000–2010. 116. Mahmmood VH, Shihab SM. Assessment of therapeutic effect of intra-articular nanofat injection for temporomandibular disorders. J Craniofac Surg. 2019;30(3):659–662. 117. Laureti S, Gionchetti P, Cappelli A, et al. Refractory complex Crohn’s perianal fistulas: a role for autologous microfragmented adipose tissue injection. Inflamm Bowel Dis. 2020;26(2):321–330. 118. Naldini G, Sturiale A, Fabiani B, Giani I, Menconi C. Microfragmented adipose tissue injection for the treatment of complex anal fistula: a pilot study accessing safety and feasibility. Techn Coloproctol. 2018;22(2):107–113. 119. Cantarella G, Mazzola RF. Management of vocal fold scars by concurrent nanofat and microfat grafting. J Craniofac Surg. 2019;30(3):692–695. 120. Stevens HP, Donners S, de Bruijn J. Introducing platelet-rich stroma: platelet-rich plasma (PRP) and stromal vascular fraction (SVF) combined for the treatment of androgenetic alopecia. Aesthetic Surg J. 2018;38(8):811–822. 121. Daneshmandi L, Shah S, Jafari T, et al. Emergence of the stem cell secretome in regenerative engineering. Trends Biotechnol. 2020;38(12):1373–1384. 122. Banyard DA, Sarantopoulos CN, Borovikova AA, et al. Phenotypic analysis of stromal vascular fraction after mechanical shear reveals stress-induced progenitor populations. Plast Reconstr Surg. 2016;138(2):237e–247e. 123. Ramaut L, Hoeksema H, Pirayesh A, Stillaert F, Monstrey S. Microneedling: where do we stand now? A systematic review of the literature. J Plast Reconstr Aesthet Surg. 2018;71(1):1–14. 124. Aust MC, Reimers K, Kaplan HM, et al. Percutaneous collagen induction-regeneration in place of cicatrisation? J Plast Reconstr Aesthet Surg. 2011;64(1):97–107. 125. Sasaki GH. Micro-needling depth penetration, presence of pigment particles, and fluorescein-stained platelets: clinical usage for aesthetic concerns. Aesthetic Surg J. 2017;37(1):71–83. 126. Gupta J, Gill HS, Andrews SN, Prausnitz MR. Kinetics of skin resealing after insertion of microneedles in human subjects. J Controlled Release. 2011;154(2):148–155. 127. Wu WTL. Microbotox of the lower face and neck: evolution of a personal technique and its clinical effects. Plast Reconstr Surg. 2015;136(5 Suppl):92S–100S. 128. Ayatollahi A, Firooz A, Samadi A. Evaluation of safety and efficacy of booster injections of hyaluronic acid in improving the facial skin quality. J Cosmet Dermatol. 2020;19(9):2267–2272. 129. Al-Niaimi F, Chiang NYZ. Topical vitamin C and the skin: mechanisms of action and clinical applications. J Clin Aesthet Dermatol. 2017;10(7):14–17. 130. De Dormael R, Bastien P, Sextius P, et al. Vitamin C prevents ultraviolet-induced pigmentation in healthy volunteers: Bayesian meta-analysis results from 31 randomized controlled versus vehicle clinical studies. J Clin Aesthet Dermatol. 2019;12(2):E53–E59.

SECTION II  •  Aesthetic Surgery of the Face

9.5 Facelift: Platysma-SMAS plication Miles G. Berry, James D. Frame III, and Dai M. Davies

Access video content and video lecture content for this chapter online at Elsevier eBooks+

SYNOPSIS

ƒ Predominantly oblique, but allows multivector traction to individualize the facelift. ƒ Sutures placed closer to the point of lift have the best effect. ƒ Delivers a good malar auto-augmentation. ƒ Offers reduced downtime. ƒ Safe and ideal for thin, attenuated SMAS layers or repeat facelifts.

Introduction As summarized in Chapter 9.3, facelifting has made great developmental strides from the skin-only procedures of the early twentieth century. Today, surgeons are faced with an almost bewildering array of techniques and tissue planes from which to choose. Whilst each technique will be strongly supported by its proponent, most will be based on the superficial musculo-aponeurotic system (SMAS), originally highlighted by Skoog in the 1970s1 and detailed in Mitz and Peyronie’s now classic treatise.2 The question remains precisely what to do with the SMAS in order to balance invasiveness, and thus tissue trauma from which the patient must recover, with risk and longevity. Options for SMAS manipulation include elevation and advancement,3 dissection at various planes,4,5 combination with mesh to augment malar projection,6 excision,7 or plication.8 The multiplicity of techniques bears testament to the fact that the universal procedure continues to elude us. There is also evidence of little practical difference, in either short9 or long term, between techniques of varying aggressivity;10,11 therefore, procedures with lower inherent risk to important structures, such as the facial nerve, may well be safer. Limitations noted include inconsistent results, a less-than-impressive effect on the nasolabial folds and jowls, and lengthy operations with extended periods of careful surgery,

particularly with anterior SMAS dissection. Furthermore, the SMAS is relatively avascular,12 perhaps behaving more as a graft in certain circumstances, and may be thin and attenuated, thus providing poor anchorage for sutures. In revision or secondary surgery, the poverty of vascular supply to the undermined SMAS may present the surgeon with little more than a mass of scar tissue. Given the inexorable drive towards minimally invasive techniques, primarily to reduce recovery time but also to limit facial nerve complications, the minimal access cranial suspension (MACS) lift was initially enthusiastically promoted.13 It has proven effective in younger patients with early jowling, minimal neck ptosis, and the desire for rapid recovery. Itself a derivation of Saylan’s “S-lift”,14 the MACS lift has, however, shown certain limitations with time and experience. First, the relative lack of malar augmentation, was addressed by the addition of a third suture and quickly became routine.15 Precise purse-string suture placement, however, can be challenging, and subcutaneous irregularities may not always settle as well as described. The authors feel it does not always have a sufficiently potent effect on the lateral neck of older patients and is rather painful initially, with the added limitation of constrained mouth opening.13 Finally, there are two areas of tissue excess, or dog-ears, in pure vertical-vector lifts, which may fail to settle satisfactorily. The first lies inferior to the lobule. Second, cutaneous bunching at the lateral canthus is particularly pronounced with the powerful suture of the extended MACS15 and frequently needs a lower lid blepharoplasty incision; however, not all patients wish for either this additional procedure or its attendant scar. Moreover, restricting tension to the SMAS rather than the skin, both cutaneous dog-ears and scar stretch3 are minimized. Experience with these limitations led the authors to the use of sutures to plicate the SMAS, a procedure termed the “platysma-SMAS plication” (PSP) lift. Its advantages (Table 9.5.1) include an oblique posterosuperior, as opposed to purely vertical, vector, which allows a lift tailored to each individual. The vertically extended skin incision permits

204

SECTION II

CHAPTER 9.5  • Facelift: Platysma-SMAS plication

Table 9.5.1  Comparison of chief features for the PSP and MACS facelifts

Feature

PSP

MACS

Incision

Vertical temporal (± postauricular extension)

Inverted L (anterior only)

Skin flap

As required

Limited to 5 cm oval

Dissection into neck

Yes

No

Platysmaplasty

Direct (infralobular excision)

Indirect

SMAS fixation

SMAS–SMAS

SMAS–deep temporal fascia

Malar augmentation

Yes

No

Vector

Cephaloposterior

Predominantly vertical

Skin excision

Tailored, no tension

Tailored, high tension

Neck

Multiple procedures

Liposuction in >95%

Ancillary procedures

Yes

No

MACS, Minimal access cranial suspension; PSP, platysma-SMAS plication.

synchronous temporal lift and reduces sideburn elevation and a visible scar.16,17 Concealing the scar within temporal hair allows greater flexibility with no risk of highly visible alopecia between the helical root and hairline. A postauricular extension, not required in all cases, may be employed to ameliorate the postauricular skin dog-ear, which adds to downtime and has been similarly reported with the MACS.9 Actually, many patients do not appreciate that scar length is not based on surgical whim, rather the quantity of excess skin after tightening. With no sub-SMAS dissection, the PSP lift is safer, particularly with respect to the facial nerve, and quicker. It is also beneficial with poorly vascularized SMAS. Large bites of SMAS allow greater security and, therefore, potential longevity. A second layer of finer imbrication sutures produces both a smooth finish and perhaps additional strength. The PSP lift does produce two dog-ears in the subcutaneous layer. Fortunately, the first, overlying the malar prominence, has the effect of auto-augmentation and assists with the overall rejuvenation by square-to-triangular facial shape reversion. The second, in the infralobular region, is less beneficial but is easily excised; a maneuver common to both Baker’s7 and Waterhouse’s modified SMASectomy procedures.18

Technique (Video 9.5.1 and Video lecture 9.5.1) The surgical procedure is as follows. Patients are prepared as for a standard facelift with tumescent subcutaneous infiltration (20 mL 0.5% bupivacaine and 1 mL 1 : 1000 adrenaline

in 200 mL normal saline). The standard retrotragal incision extends vertically in the temporal scalp and on occasion into the postauricular sulcus as required (Fig. 9.5.1). A postauricular extension is used where required and subcutaneous dissection tailored to each patient. The anterior SMAS is grasped in a posterosuperior direction to provide a satisfactory effect on the jowl (Fig. 9.5.2). The key suture, using 2-0 polydioxanone (PDS) (Johnson & Johnson Medical Ltd, Wokingham, UK), is then inserted to attach this SMAS to the relatively immobile preauricular parotid-masseteric fascia. Similar platysma-mastoid sutures (Fig. 9.5.3) serve to tighten cervical platysma, enhance mandibular angle definition, and help prevent pixie ear deformity.19 Any surface irregularities are addressed by suture imbrication with 3-0 Vicryl (Johnson & Johnson). Excess SMAS in the infralobular region is excised, following hydrodissection, and closed with 2-0 PDS. Following meticulous hemostasis, excess skin is trimmed and closed without tension over a small suction drain with 4-0 and 6-0 nylon. A light, compressive facelift dressing remains overnight and is removed with the drain the following morning. These can be similarly removed immediately prior to discharge in day-case patients. Sutures are removed at 4–6 days.

Evaluation Patients and methods The PSP lift was initiated over a decade ago and a consecutive cohort of 122 patients reported.20 Pusic et al.’s FACE-Q21 evaluation system was not yet available, so a simple Likert scale allowed both patient and surgeon to contribute to the assessment. Kappa’s correlation provided the statistical analysis.

Results Of the original cohort, five were lost to follow-up or had insufficient data for analysis. Of the remaining 117, the mean age was 55 years (range 29–79) and all bar 8 were women (3 male-to-female transgender patients were analyzed as biologically male). General anesthesia was employed in the majority, with only 3 undergoing sedation–local anesthesia. Additional aesthetic procedures were performed in 104 patients (Table 9.5.2). The neck was addressed with a variety of procedures in 92 (78.6%) (Table 9.5.3). Overall, correlation was high (r = 0.76) between patient and surgeon. Mean scores of 4.45 (range 2–5) and 4.49 (3–5) were obtained for patients and surgeon respectively initially, and 4.43 (2–5) and 4.45 (3–5) finally. The same score was given at both stages in 42.9%, improved with time in 39.3%, and deteriorated in 17.8%.

Complications The most common complication was hematoma, which occurred in 4 patients (3.4%), one following drain removal. All underwent evacuation under local anesthesia without apparent adverse effect on outcome (mean score 4.75). Some degree of nerve dysfunction was noted in 5 patients. Of the 4 with motor symptoms, only one lasted more than 6 weeks and was associated with ipsilateral infection. One with unilateral dysesthesia was referred to a chronic pain clinic after 3 months.

Discussion

205

Figure 9.5.1  Incision and area of subcutaneous dissection employed with the platysma-SMAS plication (PSP) lift. Note that the posterior extension is not always required but is useful where excess skin remains in the neck after SMAS plication. SMAS, Superficial musculo-aponeurotic system.

The rate of temporary nerve injury overall was therefore 4.3%, motor 3.4%, and sensory 0.85%. Five patients experienced delayed wound healing, all settling conservatively, with oral antibiotics being required in a single case. Two received intra­ lesional steroid therapy for mild scar hypertrophy. A small area of alopecia in the temporal incision, not visible socially, improved spontaneously, and a single patient underwent corrective fat transfer for persistent surface irregularity. There was no statistically significant relationship between any complication and hypertension, smoking, or secondary surgery.

Discussion Facial rejuvenation is increasingly viewed by patients as a suitable recourse in a more ageist society where people live longer and with better health. Interestingly, studies have shown no significant differences between highly invasive and less aggressive procedures,10,11 and more affluent, younger patients are requesting procedures with as little downtime as possible. The PSP facelift was designed to address these issues.

It must be remembered that SMAS advancement, whether composite or independent, exerts uniform traction, much like braces on trousers. Elegant studies by Rohrich et al. revealed discrete subcutaneous facial partitions that go a long way to explaining why simple SMAS elevation–advancements often provide only partial correction.22 The PSP lift exploits the fact that the optimal effect from a suture derives from its proximity to the point of lift, and plication sutures can be placed wherever they are required. This addresses one of the major drawbacks of SMASectomies and conventional SMAS flaps, where excision is remote from both jowl and nasolabial fold (NLF). With the PSP lift, SMAS is sutured directly, rather than the MACS lift’s purse-string, and has the potential for an infinite multiplicity of vectors, to obtain a precise individual tailoring. This differs from Robbins’ anterior plication, which employs a vertical row of SMAS sutures lateral to the NLF.8 While addressing the NLF, this approach obliges anteroinferior traction on both lateral SMAS and malar fat, thus counterbalancing malar augmentation. Many have reported that the SMAS progressively thins anteriorly,3,7,10 particularly in secondary surgery.17 Saulis et al. demonstrated both the weakness and reduced suture retention

206

SECTION II

CHAPTER 9.5  • Facelift: Platysma-SMAS plication

Figure 9.5.2  Placement of the key suture, which takes a generous bite of anterior musculo-aponeurotic system (SMAS), tractioning it posterosuperiorly onto the parotidomasseteric fascia. It can be trialed and its effect easily measured by external observation of jowl reduction and nasolabial fold effacement.

Table 9.5.2  Number of synchronous procedures

Procedure

N

Face alone

13

Face + 1 additional

40

Face + 2 additional

41

Face + 3 additional

12

Face + 4 additional

5

Face + non-face additional

6

Total

117

Source: Berry MG, Davies DM. Platysma SMAS plication facelift. J Plast Reconstr Aesthet Surg. 2010;63:793–800.

of the SMAS when raised alone,23 as compared to a SMAS flap raised in continuity with the skin, a feature cited by composite flap enthusiasts. However, they also demonstrated reduced tissue creep and stress relaxation in the SMAS flap, lending credence to SMAS-tightening procedures such as plication, in the pursuit of surgical longevity. The degree of skin flap

undermining is also greater in the PSP than with procedures such as the MACS in observance of Baker’s philosophy that SMAS vectoring to give maximal anatomic improvement is not adversely affected by employing a separate vector for skin redraping.24 Minimal access supporters stress the importance of vertical vectors13; however, facial aging occurs in multiple directions, according to gravity, the locations of retaining ligaments, and local muscular forces.16 With gravitational senescence characterized by anteroinferior descent,7 it seems counterintuitive to disregard some vectors at the expense of others.10 Additionally, traditional SMAS techniques with no specific malar fat dissection have a limited effect on malar ptosis and the NLF.3 As shown in Fig. 9.5.4, PSP can exert a powerful effect on the malar prominence and NLF due to individualized plication. Another advantage is that after initial plication, any residual SMAS irregularities are addressed with secondary imbrication to leave a smooth surface – this second layer further contributing to the integrity of the SMAS fixation. Personal experience has shown that the purse-string technique may lead to irregularities, which do not always resolve as well as claimed, leading to patient dissatisfaction.

Discussion

207

Figure 9.5.3  Tying the key suture produces a “dog-ear” of musculo-aponeurotic system (SMAS) that produces a convenient malar auto-augmentation. A second suture passes between the posterior platysma and the mastoid fascia to complete the effect on the jowl and commence the necklift.

Debate continues regarding where the anchorage point of the advanced SMAS should be.25 Deep fixation often leaves the patient with “marked pain and restricted mouth opening”,13 and the success of SMASectomy procedures attests to the strength of SMAS–SMAS fixation.7,18 Furthermore, there is the added benefit of autologous malar augmentation as originally proposed by Baker.7 The infralobular platysma-SMAS excess is excised (Fig. 9.5.5) and closed to remove the lateral swelling beneath the ear lobe, a giveaway feature of more minimal techniques. Nerve dysfunction, particularly motor, remains the most feared complication of any facelift, and in our series, none were permanently affected. Of note, half underwent synchronous endoscopic browlifts that more likely caused the frontal branch palsies. Interestingly, all nerve complications occurred in the first third of the study, indicating a learning curve. That all motor function in this series recovered fully and rapidly indicates the inherent safety of PSP, and assuages critics’ fears that blind needle insertion into the premasseteric SMAS is dangerous. Patient satisfaction in our series was high (4.45 of 5) within the limitations of the scoring system. High inter-observer

correlation lent further credence to what is effectively a subjective assessment. Of those few who downgraded their scores, three-quarters had experienced some problem, including persistent dysesthesia, postoperative hematoma, and skin flap telangiectasia, although all were considered by the surgeon to have achieved at least a grade 4 surgical outcome.

The neck The neck continues to be a challenging area for several reasons: swelling and scarring seem to settle slowly, and platysmal band correction is often incomplete. In addition, aggressive submental lipectomy can leave irregularities in thinner skin and may exacerbate residual jowling. Finally, seroma and excess skin are a frequent source of complaint and secondary surgery. The neck is a defining feature, as small remnant imperfections can spoil an otherwise excellent result in the face. Management of the neck, therefore, remains controversial, with supporters at both minimal and aggressive ends of the spectrum. That such a range and difference of opinion exists

208

SECTION II

CHAPTER 9.5  • Facelift: Platysma-SMAS plication

Table 9.5.3  Type and number of options employed in management of the neck

Management of the neck

N

Liposuction alone

54

Band division + platysmaplasty

11

Liposuction + band division + platysmaplasty

9

Lipectomy + band division + platysmaplasty

6

Liposuction + platysmaplasty

3

Liposuction + lipectomy + band division + platysmaplasty

2

Lipectomy + platysmaplasty

2

Band division alone

2

Liposuction + lipectomy

1

Liposuction + lipectomy + platysmaplasty

1

Liposuction + lipectomy + band division

1

Platysmaplasty alone

1

Total

92

Source: Berry MG, Davies DM. Platysma SMAS plication facelift. J Plast Reconstr Aesthet Surg. 2010;63:793–800.

indicates the universal procedure remains elusive, although the pendulum has swung towards minimalism due to the limited margin for technical error and healing irregularities.11,13 The viscoelastic properties of cervical flaps are inherently different to facial flaps, with greater creep and stress–relaxation allowing increased relapse, although the reason for this remains unclear.23 The importance of the posterosuperior part of the neck’s anterior triangle has been highlighted recently with demonstration of a gliding plane between the platysma and the sternocleidomastoid such that superolateral traction exerts a powerful effect on both lateral and anterior platysma.26 Waterhouse emphasized a similar concept18 for optimal results in the neck, which we fully endorse. It is worth reiterating the advantage of infralobular dissection, with or without a posterior incision, which allows SMAS anchoring to the mastoid fascia for a strong lateral platysmaplasty. A little over three-quarters of our patient cohort underwent some additional management of the neck, the majority (54 of 92) receiving liposuction alone. Following assessment, 9 (7.7%) were felt to have suboptimal neck outcomes. Distribution was equal in the first and second halves of the study, with no obvious features to assist in the preoperative selection of such patients. It is recognized that the follow-up period is short and that the outcome score used did not specifically address

Figure 9.5.4  Completion of the face and necklift, leaving the beneficial malar dog-ear and excision of the undesirable inferoposterior lobule dog-ear.

Discussion

A

209

B

Figure 9.5.5  Following tying of the platysma-mastoid suture, the infralobular excess is (A) marked and (B) excised prior to being sutured.

the neck. Jones and Lo27 looked specifically at neck skin laxity after facelift procedures and were generally disappointed with long-term results. Conversely, they found the midface remained in a good position, suggesting that facelift per se had limited influence in dealing with the hanging or banding neck over time. Of course, there are different opinions on how best to elevate a slackening neck, and the general principle applied to lifting the SMAS from the point of most laxity to give a satisfactory result in facelift holds equally in the neck. Anatomically, the ribbon-like structure of the platysma muscle is initially elevated by traction on the SMAS during vertical vector SMAS facelift. With conventional sutures being above the jawline, it may be of little surprise that neck laxity recurs, often within a few weeks after facelift, unless additional consideration to this area is applied (Fig. 9.5.6). The surgical options for correction of neck laxity depend upon the underlying anatomical structures. The foundation upon which all soft tissues are based is the skeleton and the retruded or projecting mandible with malocclusion critically impacts neck definition. Soft-tissue variables such as the congenitally variable platysma midline raphe position, sub- and/or supraplatysmal fat pad volume, and skin laxity contribute to the picture of the hanging “turkey neck” (Fig. 9.5.7) or platysmal banding associated with aging skin. The surgical options are best understood according to a skeletal and soft-tissue assessment. Most commonly, at the time of facelift the neck skin is redraped after a vector pull of SMAS following lipocutaneous mobilization of the skin from platysma. At this stage, there are those that benefit from a suture suspension platysmaplasty, as with the I-Guide,28 which may include a neck-defining suture as described by Mueller29 (Fig. 9.5.8). Where platysmal bands are apparent, they can be released using a “Gigli” technique (Fig. 9.5.9A–E) or via open release with or without platysmaplasty, but in all cases it is important to prevent vertical dislocation of the submandibular gland. Digastric bands may need releasing and relocating, but this is a rare necessity. Finally, when all else fails, the best, and most direct, option is for open excision of the redundant tissue. Access to the muscles after skin removal is amazingly clear and allows very precise redraping and neckline definition. In the aging skin, the scars are usually excellent.

Figure 9.5.6  The 3-month postoperative lateral view in a female having undergone vector-pull facelift.

Figure 9.5.7 The classical “turkey neck” seen on profile view in a 63-year-old male.  

210

CHAPTER 9.5  • Facelift: Platysma-SMAS plication

SECTION II

A

B

C

D

Figure 9.5.8  (A,B) Preoperative images of a 53-year-old woman undergoing I-Guide platysmaplasty. (C,D) Postoperative views 1 year after surgery.

A

B

D

C

E

Figure 9.5.9  (A–E) Operative series in a middle-aged woman showing the stages involved in platysmal band release using the Gigli technique. This series demonstrates the use of a straight needle and 3-0 Vicryl (Ethicon) to divide preoperatively marked platysmal bands. The skin and platysma are pinched free from the comparatively immobile deeper structures, and the straight needle is passed behind the platysma. Just before complete exit, the blunt end of the needle is re-passed in front of the platysma to exit from the same entry point and thus encircles the muscle. By using a saw-like action of the two suture ends, as when using an orthopedic Gigli saw to divide bone, the platysmal band is safely and easily divided.

Conclusion

A

B

C

D

E

F

G

H

I

211

Figure 9.5.10  (A–C) A 54-year-old female former heavy smoker prior to platysma-SMAS plication (PSP) facelift with synchronous endoscopic browlift and perioral CO2 laser. (D–F) Same patient 1-year postoperatively demonstrating the dual effects on jowl and cervicomental angle improvement. In this instance, malar auto-augmentation is modest but present. (G–I) Now over 10 years after the original surgery, she remains delighted by both the durability and natural appearance of her PSP facelift.

Conclusion The use of suture plication of the SMAS has been encouraging for aesthetic outcome, complication rate, and – with 10-year follow-up in the early patients now available – durability (Fig. 9.5.10). The PSP facelift seeks to combine the advantages of SMAS advancement with those of plication whilst minimizing complications and maximizing outcome. It has a sound anatomical basis, allowing individual, and

Access the reference list online at   Elsevier eBooks+

differential, SMAS and skin vectoring for specific anatomical correction and to help ameliorate asymmetry. Moreover, the technique is safe to perform and readily learned by the less experienced. The PSP facelift is suitable for either day-case surgery as a single procedure or combined with other procedures, and is particularly good for autologous malar augmentation. It works particularly well where the facial ptosis is concentrated in the midface and the jowl and has been noted by our patients to settle rapidly, thereby minimizing downtime.

References

References 1. Skoog T. Plastic Surgery. Philadelphia, PA: W.B. Saunders; 1974:300–330. 2. Mitz V, Peyronie M. The superficial musculo-aponeurotic system (SMAS) in the parotid and cheek area. Plast Reconstr Surg. 1976;58: 80–88. A classic facelift paper in which the SMAS was described. It

opened up a new field for surgery and study in addition to the benefits of much improved longevity over skin-only lifts.

3. Owsley JQ. Platysma-fascial rhytidectomy: a preliminary report. Plast Reconstr Surg. 1977;59:843–850. 4. Hamra ST. The deep plane rhytidectomy. Plast Reconstr Surg. 1990;86:53–61. 5. Hamra ST. The zygorbicular dissection in composite rhytidectomy: an ideal midface plane. Plast Reconstr Surg. 1998;102:1646–1657. 6. Stuzin JM, Baker TJ, Baker TM. Refinements in face lifting: enhanced facial contour using Vicryl mesh incorporated into SMAS fixation. Plast Reconstr Surg. 2000;105:290–301. Describes the use of

Vicryl mesh to both improve the fixation and enhance overall contour. This technique excises no SMAS but utilizes the excess to augment the malar area.

7. Baker DC. Lateral SMASectomy. Plast Reconstr Surg. 1997;100:509–513. 8. Robbins LB, Brothers DB, Marshall DM. Anterior SMAS plication for the treatment of prominent nasomandibular folds and restoration of normal cheek contour. Plast Reconstr Surg. 1995;96:1279–1287. 9. Prado A, Andrades P, Danilla S, et al. A clinical retrospective study comparing two short-scar face lifts: minimal access cranial suspension versus lateral SMASectomy. Plast Reconstr Surg. 2006;117:1413–1425. 10. Ivy EJ, Lorenc PZ, Aston SJ. Is there a difference? A prospective study comparing lateral and standard SMAS facelifts with extended SMAS and composite rhytidectomies. Plast Reconstr Surg. 1996;98:1135–1143. A study with the dual interest of both being able

to undertake different procedures on opposite sides, in addition to the finding that significant differences were hard to detect.

11. Alpert BS, Baker DC, Hamra ST, et al. Identical twin face lifts with differing techniques: a 10-year follow-up. Plast Reconstr Surg. 2009;123:1025–1033. 12. Whetzel TP, Stevenson TR. The contribution of the SMAS to the blood supply in the lateral face lift flap. Plast Reconstr Surg. 1997;100:1011–1018. 13. Tonnard P, Verpaele A, Monstrey S, et al. Minimal access cranial suspension lift: a modified S-lift. Plast Reconstr Surg. 2002;109:2074–2086.

211.e1

14. Saylan Z. Purse string-formed plication of the SMAS with fixation to the zygomatic bone. Plast Reconstr Surg. 2002;110:667–671. 15. Verpaele A, Tonnard P, Guerao FP, et al. The third suture in MACS-lifting: making midface-lifting simple and safe. J Plast Reconstr Aesthet Surg. 2007;60:1287–1295. 16. Mendelson BC. Surgery of the superficial musculoaponeurotic system: principles of release, vectors, and fixation. Plast Reconstr Surg. 2001;107:1545–1552. The scholarly treatise of anatomy and

vectors now accepted as one of the benchmarks of principles underpinning facelifting.

17. Guyuron B. Secondary rhytidectomy. Plast Reconstr Surg. 2004;114:797–800. 18. Waterhouse N, Vesely M, Bulstrode NW. Modified lateral SMASectomy. Plast Reconstr Surg. 2007;119:1021–1026. 19. Stanek JJ, Berry MG. Platysma-mastoid suture to prevent ear lobule deformity following facelift. J Plast Reconstr Aesthet Surg. 2009;62:e615–e616. 20. Berry MG, Davies DM. Platysma SMAS plication facelift. J Plast Reconstr Aesthet Surg. 2010;63:793–800. 21. Klassen AF, Cano SJ, Scott A, et al. Measuring patient-reported outcomes in facial aesthetic patients: development of the FACE-Q. Facial Plast Surg. 2010;26:303–309. 22. Rohrich RJ, Pesa JE. The fat compartments of the face: anatomy and clinical implications for cosmetic surgery. Plast Reconstr Surg. 2007;119:2219–2227. 23. Saulis AS, Lautenschlanger EP, Mustoe TA. Biomechanical and viscoelastic properties of skin, SMAS and composite flaps as they pertain to rhytidectomy. Plast Reconstr Surg. 2002;110:590–598. 24. Baker TJ. Rhytidectomy: a look back and a look forward. Ann Plast Surg. 2005;55:565–570. 25. Baker TJ, Stuzin JM. Personal technique of face lifting. Plast Reconstr Surg. 1997;100:502–508. 26. Labbé D, Franco RG, Nicolas J. Platysma suspension and platysmaplasty during neck lift: anatomical study and analysis of 30 cases. Plast Reconstr Surg. 2006;117:2001–2007. An elegant study

that goes a long way to explaining why the neck is frequently the most disappointing part of a facelift.

27. Jones BM, Lo SJ. How long does a face lift last? Objective and subjective measurements over a 5-year period. Plast Reconstr Surg. 2012;130:1317–1327. 28. Mueller GP, Leaf N, Aston SJ, et al. The percutaneous trampoline platysmaplasty: technique and experience with 105 consecutive patients. Aesthet Surg J. 2012;32:11–24. 29. Mueller GP, et al. Personal communication. 2015.

SECTION II  •  Aesthetic Surgery of the Face

9.6 Facelift: Lateral SMASectomy facelift Daniel C. Baker and Steven M. Levine

Access video lecture content for this chapter online at Elsevier eBooks+

SYNOPSIS

ƒ Because the procedure does not require traditional SMAS flap elevation, there is less concern about tearing of the superficial fascia. ƒ The potential for facial nerve injury is lower because most of the deep dissection is over the parotid gland. ƒ Because SMAS flaps have not been elevated, they tend to hold suture fixation more strongly, and the potential for postoperative dehiscence and relapse of contour is decreased. ƒ SMASectomy is not suitable in every rhytidectomy. Patients with thin faces and minimal subcutaneous fat should undergo simple plication or imbrication (Video lecture 9.6.1 ).

Access the Historical Perspective section online at Elsevier eBooks+

Senior author’s personal philosophy For many years I have listened to panels and presentations and have read articles about the “super-SMAS”, “deep plane”, “subperiosteal”, and various other extended rhytidectomy procedures. In their search for the penultimate facelift, these pioneering surgeons demonstrate superb anatomic studies, beautiful illustrations, and impeccable photographs. Their presentations are well organized, stimulating, and seductive. I have always considered myself to be a bold and aggressive surgeon, and the temptation to utilize these new, deeper dissections is extremely appealing. However, I am reluctant to employ them, and I keep asking myself why? The explanation is partly that I am not convinced that the results are superior to those obtained by the standard SMAS-platysma techniques. More important, I do not yet believe that the implied “benefits” outweigh the increased morbidity and risks, especially to the facial nerve. The presentations on deep dissection and subperiosteal rhytidectomies recall the period between 1976 and 1980 when

virtually all panels and courses were advocating complete platysma muscle transactions and a multitude of platysma flaps. As a plastic surgeon just completing residency, I was highly impressed; I became a believer and a convert: The only way to get the “best result” in rhytidectomy was with these techniques. However, many years of patient complaints, complications, and overoperated necks occurred before most of these techniques were abandoned. I can only speculate on whether the deep plane rhytidectomy techniques will have a similar evolution. In the twenty-first century, the consumer’s preference has been for minimally invasive and noninvasive techniques: fillers, Botox, endoscopy, and limited-incision aesthetic surgery. The rationale for any minimal-incision surgery is evident: less invasiveness, less bleeding, presumably less pain, faster healing, and less scarring. The primary advantages of minimal-incision rhytidectomy, however, are that it preserves the posterior hairline and avoids retroauricular scars, which are particularly important for a woman with a pulled-up or swept-back hairstyle. It is a ponytail-friendly facelift. The primary goal of any surgeon performing rhytidectomy should be to utilize a technique giving consistently good results with minimal risk, complications, morbidity, and a speedy postoperative recovery. My intention is not to discredit these deep dissection techniques, nor to deplete the splendor of creative surgery. Their contribution is already evident: an increased and clearer knowledge of facial anatomy, muscle function, and human expression. I am certain that some aspect of these techniques will be incorporated by many plastic surgeons. The questions that remain to be answered are (1) What are the indications for these newer techniques? (2) How great are the risks and complications? and, most important, (3) Do the benefits significantly outweigh the risks to justify using these techniques routinely? There are several advantages of lateral SMASectomy in comparison with traditional SMAS elevation. First, because the procedure does not require traditional SMAS flap elevation, there is less concern about tearing of the superficial

Historical perspective

Historical perspective The senior author’s first experience with rhytidectomy was during residency in the late 1970s. At that time, the emphasis was on extensive defatting of the neck with complete platysma muscle transection, plicating medial borders, and pulling laterally. However, several years of patient complaints, complications, and overoperated necks led to a modification of this technique. With the advent of liposuction in the 1980s, he found that he could obtain excellent neck contouring in many patients utilizing liposuction combined with strong lateral platysmal suturing. When superficial musculo-aponeurotic system (SMAS) dissection first became popularized in 1976, it became fashionable to include a dissection of the lateral SMAS directly overlying the parotid gland. The senior author initially utilized this form of SMAS dissection beginning in the late 1970s and continued using it into mid-1980s, but overall was disappointed with the effects of a simple elevation and tightening of the lateral superficial fascia. Specifically, he saw little difference in overall facial contour, whether he had performed a lateral SMAS dissection or had omitted it. As he gained greater experience with SMAS dissection, it became obvious that for the superficial fascia to produce any

212.e1

effective contour change in facelifting, it was necessary to elevate the SMAS anterior to the parotid gland. The problem of more extensive SMAS dissection is that facial nerve branches are placed in greater jeopardy. He also noted that the superficial fascia tends to thin out as it is dissected more anteriorly, making the SMAS easy to tear. A SMAS dissection that is not raised as a continuous fascial sheet but rather is raised with several tears in it is a poor substrate for holding the tension of contouring the face. For these reasons, he felt that an extensive SMAS dissection was not warranted in most patients and offered little long-term benefit when compared with SMAS plication. In 1992, Dr. Baker realized that an alternative to formal elevation of the superficial fascia was a “lateral SMASectomy”, removing a strip of SMAS in the region directly overlying the anterior edge of the parotid gland and extending to the lateral canthus. Excision of the superficial fascia in this region secures mobile anterior SMAS to the fixed portion of the superficial fascia overlying the parotid. The direction in which the SMASectomy is performed is oriented so that the vectors of elevation following SMAS closure lie perpendicular to the nasolabial fold, thereby producing improvement not only of the nasolabial fold but also of the jowl and jawline. In 2001, this technique was further developed and refined into the minimal-incision rhytidectomy (short scar facelift).

Surgical technique

213

fascia. Second, the potential for facial nerve injury is lower because most of the deep dissection is over the parotid gland. If the SMASectomy is performed anterior to the parotid, the deep fascia will similarly provide protection for the facial nerve branches as long as the resection of the superficial fascia is done precisely and the deep fascia is not violated. Third, because SMAS flaps have not been elevated, they tend to hold suture fixation more strongly, and the potential for postoperative dehiscence and relapse of contour is decreased. There are certainly other rhytidectomy techniques that produce excellent results. Each surgeon must adopt a technique that serves his or her patients best. Ideally, the technique should be safe, consistent, easily reproducible, and applicable to a variety of anatomic problems. The surgeon also must have the versatility to adapt and modify his or her technique to the needs and desires of each patient. At present, the lateral SMASectomy provides this for most of my patients. In the future, as endoscopy and fixation techniques advance, I will seek to modify and further improve my present rhytidectomy operation. It must be emphasized that I do not perform SMASectomy in every rhytidectomy. Patients with thin faces and minimal subcutaneous fat undergo simple plication or imbrication.

The temporal hairline incision allows for the more vertical elevation of the facial flap that is usually required in a short scar rhytidectomy. Other indications for this incision are a receding hairline from previous facelifts and a fine, fragile hairline. The choice of preauricular incision is up to the surgeon. When executed properly, all these incisions heal well and are imperceptible. We usually prefer a curved incision anterior to the helix and continue inferiorly anterior to the tragus in a natural skinfold. This preserves the thin, pale, hairless tragal skin and its demarcation from the usual coarser, thicker, darker cheek skin with its lanugo hairs. We perform intratragal incisions in patients in whom the cheek and tragal skin are similar and the tragal cartilage is not sharp or prominent. All of these incision choices can yield excellent results. It is important to recognize no one incision pattern will work best for everyone and it is important to customize this decision based on the patient’s anatomy. As always, closure must be without tension and the flap overlying the tragus should be defatted to dermis. In minimal-incision rhytidectomy, efforts are made to end the incision at the base of the ear lobe. This is usually possible in young patients, but sometimes a short retroauricular incision is necessary to correct a dog-ear after the facial flap rotation.

Surgical technique

Skin flap elevation

Anesthesia

All skin flap undermining is carried out under direct vision (with scissors dissection) to minimize trauma to the subdermal plexus and preserve a significant layer of subcutaneous fat on the undersurface of the flap (see Fig. 9.6.2). We usually perform some subcutaneous dissection in the temporal region to allow the skin to redrape better. (We believe that hair loss results primarily from tension rather than superficial undermining.) Subcutaneous dissection in the temporal region must be performed carefully to avoid penetrating the superficial temporal fascia that protects the frontal branch of the facial nerve. All dermal attachments between the orbicularis oculi muscle and the skin are separated up to the lateral canthus. Dissection extends across the zygoma to release the zygomatic ligaments but stops several centimeters short of the nasolabial fold. In our opinion, further dissection provides little benefit; on the contrary, the only result is increased bleeding. In the cheek, dissection releases the masseteric-cutaneous ligaments and, if necessary, the mandibular ligaments. Subcutaneous dissection continues over the angle of the mandible and sternocleidomastoid for 5–6 cm into the neck. This exposes the posterior half of the platysma muscle. If a submental incision has been made, the facial and lateral neck dissection is connected through and through to the submental dissection.

Virtually all of our facelifts are performed with the patient under monitored intravenous propofol sedation. Patients are given oral clonidine, 0.1–0.2 mg, 30 min before surgery to control their blood pressure. The face and neck are infiltrated with local anesthesia, 0.5% lidocaine with 1 : 200 000 epinephrine, through use of a 22-gauge spinal needle. The face is injected before we scrub to provide the requisite 10 minutes for vasoconstriction.

Incisions When the temporal hairline shift is assessed as minimal, the preferred incision is well within the temporal hair. With this incision, it is often necessary to excise a triangle of skin below the temporal sideburn at the level of the superior root of the helix. Keep in mind that this incision will move the natural hairline. This may be acceptable if the shift is minimal or if the hairline is low. However, when larger skin shift is anticipated (frequently the lift is more vertical with minimal-incision rhytidectomy) or the distance between the lateral canthus and temporal hairline is greater than 5 cm, we prefer an incision a few millimeters within the temporal hairline (Figs. ­9.6.1–9.6.3). Although this is a compromise, the alternative of a receding temporal hairline is never acceptable to a female patient. When the incisions are executed properly, these scars heal well and are easy to revise or camouflage. The only exception might be in a patient with deeply pigmented skin in whom the scar will contrast and appear as a white line. The temporal hairline incision should be made parallel to the hair follicle and no higher than the frontotemporal hairline.

Defatting the neck and jowls Whenever possible, we prefer closed suction-assisted lipoplasty in the neck and jowls. We use a 2.4-mm Mercedestip cannula, keeping it under constant, steady motion in the subcutaneous space. We attempt to leave a layer of subcutaneous fat on the undersurface of the cervical skin. If we suction the jowls, this is always done conservatively.

SECTION II

214

CHAPTER 9.6  • Facelift: Lateral SMASectomy facelift

Preferred incision

Optional preauricular or intratragal incision

Optional temporal incision for recessed hairlines

Usual extent of subcutaneous undermining to lateral canthus and release of malar ligaments

Subcutaneous undermining into neck allows for exposure of platysma and skin redraping Usual lower border of undermining

Submental incision in normal skin crease. Undermining connects laterally

Figure 9.6.1  Lateral SMASectomy dissection. The temporal hairline incision allows for a more vertical elevation of the facial flap than is usually required in a short scar rhytidectomy. Subcutaneous dissection is performed extending across the zygoma to release the zygomatic ligaments but stops several centimeters short of the nasolabial fold. The SMAS resection is performed on a tangent from the lateral malar eminence to the angle of the mandible in the region along the anterior edge of the parotid gland. The width depends on the laxity of the tissues and the desired elevation. Vectors are perpendicular to the nasolabial fold. A platysma flap is elevated and secured to the mastoid periosteum.

SMAS and platysma approximation suspension. Suture is just beneath SMAS

Suture from submandibular platysma SMAS to anterior tympano-parotid fascia (vertical vector) Platysma flap sutured to mastoid periosteum (lateral oblique vector)

Malar fat pad vector Facial vectors

Submandibular vertical vector

Medial and lateral platysma vectors create a muscular hammock support and define the jawline

Wedge resection of 4–5cm medial platysma border to interrupt bands

Figure 9.6.2 The incision and area of dissection in lateral SMASectomy. The temporal hairline incision is utilized to allow a more vertical elevation of the facial flap. A curved incision anterior to the helix is utilized, continuing inferiorly anterior to the tragus in a natural skinfold. Facial subcutaneous dissection is performed, extending across the zygoma to release the zygomatic ligaments but stopping short of the nasolabial fold. Subcutaneous dissection continues over the angle of the mandible and sternocleidomastoid for 5–6 cm into the neck. This exposes the posterior half of the platysma muscle. If a submental incision has been made, the facial and lateral neck dissections are connected through and through to the submental dissection.  

 

Surgical technique

215

We rarely suction or remove subplatysmal fat because (1) the facial nerves run just beneath the platysma and (2) any patient with significant subplatysmal fat probably has a fat, round face, so removing subplatysmal fat could create an overoperated look. We usually perform lipoplasty before elevating the skin flaps. In doing so, we are careful not to oversuction the portion of the SMAS-platysma that will be elevated over the mandible with the lateral SMASectomy. It is better to be conservative with liposuction at the beginning of the case as you can always remove more fat at the end of the case. Lateral SMASectomy extends from tail of parotid to lateral canthus Resection is at interface of fixed and mobile SMAS. Width of resection determined by SMAS laxity and desired debulking Undermining posterior border of platysma for advancement to mastoid

Figure 9.6.3  Outline of the SMAS excision. The SMAS resection is performed on a tangent from the lateral malar eminence to the angle of the mandible in the region along the anterior edge of the parotid gland. Continuous with the lateral SMASectomy is the resection of a strip of posterior platysma muscle several centimeters long over the tail of the parotid and anterior border of the sternocleidomastoid.

Temporalis fascia Zygomatic arch

Open submental incision with medial platysma approximation For many patients, excellent results can be achieved with closed lipoplasty and strong lateral platysma pull. However, with short scar rhytidectomy there is limited access to the platysma and the lateral vector has changed. Therefore, in these patients as well as patients with significant active platysma bands on animation, the medial approximation provides another vector to enhance the cervicomental recontouring (Fig. 9.6.4). The submental incision is made either in the submental crease or just anterior to it. The subcutaneous dissection is performed with the neck hyperextended, and undermining is usually to the level of the thyroid cartilage and angle of the mandible. Suction-assisted lipoplasty is then performed with a large, single-hole cannula under direct vision. Direct fat excision is carried out if necessary, but to avoid depressions, subplatysmal fat is rarely removed. The medial borders of the platysma muscle are identified and elevated for several centimeters. To break the continuity

Last suture lifts malar fat pad

Plication of mobile to fixed SMAS

Figure 9.6.4  Medial platysma approximation. Subcutaneous dissection through a submental incision is performed with the neck hyperextended. The dissection usually extends to the level of the thyroid cartilage and angle of the mandible. Suction-assisted lipoplasty is then performed. The medial borders of the platysma muscle are elevated for several centimeters. To break the continuity of the bands, a wedge of muscle is removed at the level of the hyoid. The medial borders of the muscle are then sutured together.

SECTION II

216

CHAPTER 9.6  • Facelift: Lateral SMASectomy facelift

of the bands, a wedge of muscle is removed at the level of the hyoid. The medial borders of the muscle are then sutured together with interrupted buried 4-0 polydioxanone (PDS) (Ethicon, Inc., Somerville, NJ). The submental incision is left open to allow for final hemostasis and recontouring after communication with the facial dissection and completion of the lateral SMASectomy.

Lateral SMASectomy including platysma resection The outline of SMASectomy is marked on a tangent from the lateral malar eminence to the angle of the mandible, essentially in the region along the anterior edge of the parotid gland (see Figs. 9.6.1 & 9.6.3). In most patients, this involves a line of resection extending from the lateral aspect of the malar eminence toward the tail of the parotid gland. Usually, a 2- to 3-cm segment of superficial fascia is excised, depending on the degree of SMAS-platysma laxity. In SMAS resection, we like to pick up the superficial fascia in the region of the tail of the parotid, extending the resection from inferior to superior in a controlled fashion. When SMAS resection is being performed, it is important to keep the dissection superficial to the deep fascia and avoid dissection into the parotid parenchyma. Note that the size of the parotid gland varies from patient to patient; consequently, the amount of protection for the underlying facial nerve branches will also vary. Despite this, as long as one carries the dissection superficial to the deep facial fascia, ensuring that only the superficial fascia is resected, facial nerve injury as well as parotid gland injury will be prevented. In essence, this is a resection of the superficial fascia in the same plane of dissection in which one would normally raise the SMAS flap. Continuous with the lateral SMASectomy is the resection of a strip of posterior platysma muscle several centimeters long over the tail of the parotid and anterior border of the sternocleidomastoid. The facial nerves are protected here.

Vectors The various vectors accomplish correction of the anterior neck, the cervicomental angle, the jowls, and the nasolabial fold. The first key suture grasps the platysma at the angle of

A

B

the mandible and advances it in a posterosuperior direction; it is secured with 2-0 Maxon (United States Surgical Corp., Norwalk, CT) to the fixed lateral SMAS (see Figs. 9.6.3–9.6.5). This lifts the cervical platysma and cervical skin. Interrupted 3-0 PDS buried sutures are used to close the SMASectomy, the fixed lateral SMAS being evenly sutured to more mobile anterior superficial fascia (see Fig. 9.6.5). Vectors are perpendicular to the nasolabial fold. The last suture lifts the malar fat pad, securing it to the malar fascia. It is important to obtain a secure fixation to prevent postoperative dehiscence and relapse of facial contour. If firm monofilament sutures are used, such as PDS or Maxon (Covidien/Medtronic, Minneapolis, MN), the sutures should be buried and sharp ends on the knot trimmed. Final contouring of any SMAS or fat irregularities along the suture line is completed with scissors. Fat can also be trimmed at the sternomandibular trough, final contouring being accomplished with lipoplasty. For the neck, a flap of the lateral platysma is developed in the region inferior to the mandibular border. After this lateral platysma flap is raised, the platysma is secured to the mastoid periosteum with figure-of-eight 2-0 Maxon sutures to help define the jawline and improve contouring in the submandibular region. This is the basic rhytidectomy operation that the senior author has performed since July 1992.

Skin closure, temporal and earlobe dog-ears After SMAS and platysma approximation, some tethering of the skin might appear at the anterior extent of the subcutaneous dissection because of the pull of the underlying SMAS. This can also occur in the lower eyelid with elevation of the malar fat pad. Further subcutaneous undermining is necessary to free these tethers, allowing the skin to redrape. The first key skin suture rotates the facial flap vertically and posteriorly to lift the midface, jowls, and submandibular skin. Suture fixation is at the level of the insertion of the superior helix. We like to use a buried 3-0 PDS through the temporal fascia with a generous bite of dermis on the skin flap. Closure is under minimal-to-moderate tension. Staples are used to close any incisions in the hair. A wedge is usually removed at the level of the sideburn to preserve the hairline. If an anterior hairline incision has been made, we like to close

C

Figure 9.6.5 Pre- and 1 year postoperative views of patient who underwent lateral SMASectomy.  

D

Postoperative care

A

B

217

D

C

Figure 9.6.6  Preoperative (A,C) and 2-year postoperative views (B,D) after lateral SMASectomy, perioral dermabrasion, advanced fluorescence technology (AFT) to face, and chin implant.

A

B

C

D

Figure 9.6.7  Preoperative (A,C) and 1-year postoperative views (B,D) after lateral SMASectomy, advanced fluorescence technology (AFT) to face, and perioral dermabrasion.

it with buried 4-0 PDS sutures and 5-0 nylon sutures on the skin. Extra time and attention must be spent on this closure to eliminate any dog-ears and obtain the finest scar. Excess skin is then trimmed from the facial flap so that there is no tension on the preauricular closure. Wound edges should be “kissing” without sutures. In short scar rhytidectomy, trimming at the earlobe must be without tension, and the skin flap is tucked under the lobe with 4-0 PDS sutures, taking a bite of earlobe dermis, cheek flap dermis, and conchal perichondrium to minimize any tension. A small dog-ear might be present behind the earlobe; this is easily trimmed and tailored into a short incision in the retroauricular sulcus. A closed suction drain is usually brought out through a separate stab in the retroauricular sulcus. Figs. 9.6.6 & 9.6.7 are representative pre- and postoperative photos of patients who have undergone lateral SMASectomy.

Postoperative care For the first 48 hours of the postoperative period, blood pressure monitoring is continuous to avoid systolic spikes and potential bleeding. Treatment of rising blood pressure is essential to minimize hematoma formation. We usually utilize suction drains and a soft head dressing to cover the flaps and incisions. Although drains never prevent expanding hematomas, I prefer to remove serosanguineous fluid in this manner. Sutures are removed on the seventh and tenth postoperative days. When large hematomas are recognized early, they are usually successfully managed at the bedside with sedation, blood pressure control, and irrigation. The overall incidence of hematoma for women is about 1.5%; for men it is 4%.

218

SECTION II

CHAPTER 9.6  • Facelift: Lateral SMASectomy facelift

Complications Table 9.6.1 summarizes the complications of this technique, which are consistent with other standard facelift operations. Despite special attention to blood pressure control in the postoperative period, the hematoma rate is still 1.5%. The most common problems are minor revisions of earlobe and temporal hairline scars. Secondary lifts are occasionally performed, but we require all patients to allow healing for 1 year before considering any revisions. Our goal is to keep the occurrence of all revisions to less than 5%. When revisions exceed this limit, it is time to re-evaluate the technique.

Table 9.6.1  Complications associated with 3500 lateral SMASectomy facelifts

Complication

Incidence (%)

Hematoma (female/male)

1.5/4.0

Facial nerve weakness

0.1*

Earlobe scar revision

2.0

Skin slough

2.0

Retroauricular and temporal scar revisions

2.0

Infection

1.0

“Minilift” after 1 year

2.0

*

Access the reference list online at   Elsevier eBooks+

All resolved in 6 months.

Further reading

Further reading Baker DC. Anatomy and injuries of the facial nerve in cervicofacial rhytidectomy. In: Kaye BL, Gradinger GP, eds. Symposium on Problems and Complications in Aesthetic Plastic Surgery of the Face. St. Louis, MO: CV Mosby; 1984. Baker DC. Deep dissection rhytidectomy: a plea for caution. Plast Reconstr Surg. 1994;93:1498–1499. Baker DC. Lateral SMASectomy. Plast Reconstr Surg. 1997;100:509–513. Baker DC. Rhytidectomy with lateral SMASectomy. Facial Plast Surg. 2000;16:209–213. Baker DC. Minimal incision rhytidectomy (short scar facelift) with lateral SMASectomy: evolution and application. Aesthet Surg J. 2001;21:68–79.

218.e1

Baker DC, Aston SJ, Guy CL, et al. The male rhytidectomy. Plast Reconstr Surg. 1977;60:514–522. Baker DC, Chiu ES. Bedside treatment of early acute rhytidectomy hematomas. Plast Reconstr Surg. 2005;115:2119–2222. Baker DC, Conley J. Avoiding facial nerve injuries in rhytidectomy. Anatomical variations and pitfalls. Plast Reconstr Surg. 1979;64:781–795. Baker DC, Rees TD. Complications of cosmetic facial surgery. In: Lewis JR, ed. Aesthetic Plastic Surgery. Boston, MA: Little, Brown & Co.; 1989. Baker DC, Stefani WA, Chiu ES. Reducing the incidence of hematomas requiring surgical evacuation following male rhytidectomy: a thirty year review of 985 cases. Plast Reconstr Surg. 2005;116:1973–1985.

 

SECTION II •  Aesthetic Surgery of the Face

9.7 Facelift: The extended SMAS technique in facial rejuvenation James M. Stuzin

Access video lecture content for this chapter online at Elsevier eBooks+ 

SYNOPSIS

ƒ As the human face ages, many of the stigmata that are typically seen in aging relate to a change in the anatomic relationship that occurs between the superficial and deep facial fascia. ƒ Improving technical control when contouring the superficial facial fascia and platysma provides for a more consistent, aesthetically pleasing result. ƒ Performing a two-layer SMAS-type facelift requires commitment on the part of the surgeon, not only to understand facial soft-tissue anatomy but also to perform a procedure that demands technical precision. ƒ A two-layer SMAS-type facelift is a time-consuming operation, with both the skin flap elevation as well as the dissection of the SMAS requiring meticulous and accurate dissection. ƒ Obtaining consistency with this procedure is challenging because of the variability in thickness of subcutaneous fat and the SMAS that exists among individual patients ƒ Following precise dissection, secure fixation of both SMAS and platysma is mandated to maintain the shaping desired in postoperative contour. ƒ Meticulous hemostasis followed by careful skin flap inset are required to minimize postoperative scar perceptibility and ensure a rapid postoperative recovery. ƒ The biggest advantage of the extended SMAS technique remains its aesthetic versatility, allowing the surgeon to vary the contouring aspects of the procedure according to the aesthetic needs of the patient.

Introduction Surgical rejuvenation of the aging face has evolved into one of the most frequently performed surgical procedures in the US. Facelifting, initially performed as a skin tightening procedure since the early 1900s, has technically matured during the past quarter of a century. This evolution is directly related to the scientific investigation of facial soft-tissue anatomy, resulting

in a better understanding of the facial anatomic changes that occur with aging. Over the past 30 years, a plethora of procedures have evolved that utilize a variety of technical approaches, having as a common goal the reconstruction of aging-related anatomic changes. The public’s perception and the aesthetic concepts in facelifting have similarly evolved over time. Initially, both patients and surgeons focused solely on the laxity that occurs with facial aging, attempting to tighten what was loose rather than shape the face. Hence the term “facelift” (as opposed to “facialplasty”), a mechanical term implying a procedure, the goal of which is to lift what has fallen. Unfortunately, this mechanical approach to facial rejuvenation often produced a tight-appearing, operated look, the stigma of the “wind-tunnel appearance” so often associated with surgical rejuvenation of the aging face. Nonetheless, based on a better understanding of facial soft-tissue anatomy and the anatomic changes that occur in aging, facelifting has developed into both a reconstructive procedure (whose goal is to reconstruct the anatomic changes that occur with aging) as well as a more artistically defined technique that attempts to enhance facial appearance while minimizing signs that a surgical procedure has been performed (Video Lecture 9.7.1 ). There are many treatment goals in facelifting besides simply correcting the hallmarks of the aging face, including improvement of the nasolabial folds and facial jowling, and correction of obliquity of cervical contour. As important as the mechanical aspects of tightening a loose, aged face are the aesthetic concepts of improving facial shape and bringing out the beauty in the face that existed during youth. To these goals, the surgeon attempting facial rejuvenation must have a thorough understanding of facial soft-tissue anatomy, comprehend the anatomic changes that occur in aging that produce a change in facial shape, and understand the ideal facial shape that can be obtained for a particular patient. Artistic design of surgical access incisions to minimize scar perceptibility, as well as prevent hairline distortion, is also key in preventing surgical stigmata.

220

SECTION II

CHAPTER 9.7  • Facelift: The extended SMAS technique in facial rejuvenation

The evolution of aging in the human face is complex and multifactorial. Problems that the plastic surgeon confronts in midface rejuvenation include (1) the dermal component of aging related to intrinsic and extrinsic skin changes (dermal elastosis); (2) facial fat descent; (3) facial deflation, which tends to be regionally specific; (4) radial expansion as facial fat becomes situated centrifugally away from the facial skeleton; and (5) the degree of skeletal support of the soft tissue, which influences both loss of volumetric highlights, as well as the descent of facial fat.1–4 All of these factors influence facial shape changes with aging. Individual patients will exhibit various degrees of these problems at the time they request surgery, and each component of the aging face should be addressed according to individual patient needs. Evaluation of patient photographs taken during youth and middle age are helpful in determining how a specific patient has aged. Young photographs will usually demonstrate the location of the volumetric highlights present in youth or serve to document areas that have deflated over time, delineating both the position and vector of facial fat descent. These factors illustrate patient-specific changes in facial shape from youth to middle age, as well as clarifying the possibilities of methods that facial fat repositioning can improve and restore shape. From my perspective, the restoration of facial shape is a more worthy aesthetic goal than attempting to tighten a loose face.

Anatomic considerations The anatomic basis that allows rhytidectomy to be performed safely is that the facial soft tissue is arranged as a series of concentric layers. This concentric arrangement allows dissection within one anatomic plane to proceed completely separate from structures lying within another anatomic plane. The layers of the face are the: (1) skin; (2) subcutaneous fat; (3) superficial musculo-aponeurotic system (SMAS; superficial facial fascia); (4) mimetic muscles; (5) parotidomasseteric fascia (deep facial fascia); and (6) plane of the facial nerve, parotid duct, buccal fat pad, and facial artery and vein. (This information is thoroughly reviewed in Chapter 9.2.) In an overview of the architectural arrangement of the facial soft tissue, the essential point is that there is a superficial component of the facial soft tissue that is defined by the superficial facial fascia and includes the SMAS and those anatomic components that move facial skin (including superficially situated mimetic muscle invested by SMAS, the subcutaneous fat, and skin). This is in contrast to the deeper component of the facial soft tissue, which is defined by the deep facial fascia and those structures related to the deep fascia (including the relatively fixed structures of the face, such as the parotid gland, masseter muscle, periosteum of the facial bones, and facial nerve branches). As the human face ages, many of the stigmata that are typically seen in aging relate to a change in the anatomic relationship that occurs between the superficial and deep facial fascia. With aging, facial fat descends in the plane between superficial and deep facial fascia, and the radial expansion of the superficial soft tissue away from the facial skeleton occurs within this plane. In my opinion, these anatomic changes justify repositioning facial fat through subSMAS dissection to restore facial shape.5,6

Retaining ligaments The communication between the superficial and deep facial fascia occurs at the level of the retaining ligaments, which are discussed in Chapter 9.2. These structures fixate facial soft tissue in normal anatomic position, resisting gravitational forces.1,7 In the evolution of midface aging, the zygomatic and masseteric cutaneous ligaments bear particular attention. The zygomatic ligaments originate from the periosteum of the malar region. Their function is to fixate the malar pad to the underlying zygomatic eminence in the youthful face. Support of the soft tissues of the medial cheek is provided by a series of fibrous bands that extend along the entire anterior border of the masseter muscle. These are the “masseteric cutaneous ligaments” and are identified superiorly in the malar area where they mingle with the zygomatic ligaments and extend along the anterior border of the masseter as far inferiorly as the mandibular border. These fibers represent a coalescence between the superficial and deep fascia, extending from the masseter muscle vertically to insert into the overlying dermis. These masseteric ligaments support the soft tissues of the medial cheek superiorly above the mandibular border in youth. The surgical significance of the retaining ligaments is that they represent the anatomic communication between superficial and deep facial fascia. As this support system becomes attenuated, facial shape changes. The position of the retaining ligaments also dictates the degree of dissection required in a facelift. To adequately mobilize the skin flap, the dissection needs to be carried at least to the peripheral extent of the retaining ligament system, specifically dissecting the skin flap into the malar region, as well as past the anterior border of the masseter. Similarly, the location and restrictiveness of the retaining ligaments dictates the degree of SMAS elevation required to adequately release the superficial fascia. In general, this requires the surgeon to extend the SMAS dissection into the malar region, releasing the superficial fascia from the restraint of the zygomatic ligaments, the upper masseteric ligaments, and medial to the anterior border of the parotid.

Aesthetic analysis and treatment planning As the human face ages, facial shape changes; morphologic facial changes are multifactorial. Some of these changes are straightforward to address, while others remain difficult technical challenges. A paradox has always been that facial anatomy (in terms of basic soft-tissue architecture) is essentially unchanged from youth to middle age, but facial appearance changes greatly over time and is patient-specific. Although each face ages differently, there are common themes noted in all aging faces.

Descent of facial fat As the human face ages, facial fat descends and, consequently, facial shape changes. Typically, the youthful face is full of well-supported fat. Volumetric highlights are located within facial aesthetic subunits, which have a high density of

Aesthetic analysis and treatment planning

retaining ligaments (zygomatic eminence and zygomatic arch, preparotid, orbital rim) and serve to fixate this volume of fat to underlying structures. Juxtaposed to the volumetric fullness (or convexity) of the malar and preparotid region is commonly a concavity within the submalar region, overlying the buccinator muscle and buccal recess. The combination of fullness in the malar region and lateral cheek, associated with submalar concavity and a well-defined mandibular border, accounts for the angular, tapered appearance of the youthful face. With aging, facial fat can descend and produce significant changes in facial shape. In middle age, as ligamentous support becomes attenuated, facial fat volumetrically becomes situated anteriorly and inferiorly in the cheek, producing a contour that is square and bottom heavy, with little differential between malar highlights and submalar fat. As facial fat is situated more inferiorly in the face, middle-aged faces appear vertically longer than young faces (see Fig. 9.3.7).3,4

Volume loss and facial deflation Youthful faces are full of well-supported facial fat. Over time, deflation occurs and this tends to be most apparent in regions of the face with a high density of retaining ligaments. For this reason, the areas that are noted to be volumetrically full in youth (malar, preparotid, lateral and infraorbital rim, lateral chin) become volumetrically deflated over time. With deflation, soft tissue becomes less supported and therefore appears lax. Youthful faces have a smooth blending of contour between the aesthetic subunits of the face. Middle-aged faces, secondary to both deflation and facial fat descent, develop lines of demarcation between one region of the face and another, which is intuitively identified as old. An accurate aesthetic treatment plan to improve facial shape requires the repositioning of descended soft tissue into areas of facial deflation to improve shape, not only by restoring volume to the position noted in youth, but also serving to blunt the lines of

A

B

221

demarcation between aesthetic subunits. Volumetric augmentation through autologous fat injection or other injectable soft-tissue fillers are ancillary agents that can be useful in augmenting areas of deflation. Deflation in the aging face is a complex process that tends to be regional and age-specific. Key elements in understanding how deflation occurs have been enlightened following an elucidation of the compartmentalization of subcutaneous fat within the cheek as defined by Rohrich and Pessa.8 What these investigators realized was that the cheek subcutaneous fat, rather than being homogeneous, is compartmentalized, with each facial fat compartment surrounded by specific septal membranes and with each compartment having an independent perforator blood supply. Aesthetically, the significance of compartmentalization of facial fat is that deflation tends to occur within a specific region of the cheek, explaining why the entire cheek does not deflate homogeneously (Fig. 9.7.1). At the risk of over-simplification, one key to understanding facial deflation is the recognition of the location of zygomaticus major muscle, which traverses from the malar eminence to the oral commissure. Deflation of the cheek lateral to the zygomaticus major muscle tends to occur independently from deflation in the malar region, medial to the zygomaticus major. For many patients, lateral cheek deflation develops at an earlier age than malar pad deflation and is often noted in patients in their forties. Medial cheek and malar pad deflation tend to occur later in life and is responsible not only for the loss of volumetric support within the anterior cheek, but also leads to the development of what has been termed the infraorbital V-deformity. Deflation in this region results in an apparent increase in the vertical length of the lower lid, as the lid–cheek junction visually descends inferiorly into the poorly supported anterior cheek (Fig. 9.7.2). An interesting region of deflation develops in some patients in the submalar region lateral to the oral commissure. In these patients, deflation can result in accentuation of the submalar concavity, which can become more obvious following the

Figure 9.7.1  (A) Preoperative appearance of a 42-year-old patient with early facial aging resulting primarily from deflation. Note the hollowing effect within the lateral cheek and preparotid region. Deflation in this young patient has occurred in the fat compartments lateral to the zygomaticus major muscle. (B) Postoperative result following face- and necklift. Note, as anteriorly situated fat is brought into the upper lateral midface, it fills the areas of deflation, thereby blunting the lines of demarcation between aesthetic subunits that develop with age. Also notice the change in facial shape, which now appears more structured and supported following facial fat repositioning.

222

A

C

SECTION II

CHAPTER 9.7  • Facelift: The extended SMAS technique in facial rejuvenation

B

D

Figure 9.7.2  (A,C) Preoperative appearance of a 59-year-old male following a 90-lb weight loss from a gastric bypass procedure. Notice the significant areas of facial deflation along the infraorbital rim, lateral orbital rim and malar region. Also note the apparent length of the lower lid as the infraorbital V-deformity develops in association with malar pad deflation. Also note the radial expansion of skin and fat lateral to the nasolabial fold, most marked on the right side. Not only does malar fat deflate and descend, but also attenuation of the retinacular connections between skin, fat, and deep facial fascia lateral to the nasolabial line allows centrifugal prolapse of soft tissue, which accentuates nasolabial prominence. (B,D) Postoperative result. The areas of deflation along the infraorbital rim, lateral orbital rim and malar region are improved as facial fat has been repositioned into these regions. The nasolabial folds are somewhat improved following malar pad repositioning, but correction is incomplete, especially on the right. Malar pad elevation helps to flatten the prominent nasolabial fold, and improve the infraorbital V-deformity, but does little to correct radial expansion, with the skin lateral to the nasolabial line remaining prolapsed from its attachments to the facial skeleton. (From Stuzin JM. Restoring facial shape in facelifting: the role of skeletal support in facial analysis and midface soft-tissue repositioning. Plast Reconstr Surg .

vertical soft-tissue shifts associated with facelifting procedures. An accentuation of submalar depression lateral to the oral commissure can result in the development of what has been termed “joker lines” or cross-cheek depressions, which are a typical stigmata that a patient has undergone a facelift. Avoidance of vertical soft-tissue repositioning in conjunction with volume addition in the submalar recess lateral to the oral commissure is useful in preventing the accentuation of postoperative cross-cheek depressions (Fig. 9.7.3).9

Figure 9.7.3   A cadaver dissection illustrates the muscular insertions into the oral commissure and modiolus. The small arrow overlies the facial portion of the platysma and points to the risorius muscle. The large arrow points to the depressor anguli oris in the region where it merges with the platysma. Superiorly, note the insertion of the zygomaticus major into the lateral commissure with a slip of muscle inserting inferiorly into the modiolus. Following deflation in this area, the medial component of the cross-cheek depression develops in the watershed between the elevator and the depressors of the lip. (From Lambros V, Stuzin JM. The cross-cheek depression: surgical cause and effect in the development of the “joker line” and its treatment. Plast Reconstr Surg. 2008;122:1543–1552.)

Radial expansion Not all facial aging is vertical and a major challenge in facial rejuvenation is the radial expansion of facial soft tissue that occurs along specific areas of the midface. In youth, the skin and underlying subcutaneous fat are densely attached to the deep facial fascia by retinacular fibers that transverse between skin, subcutaneous fat and superficial fascia, and insert into the deep fascia and facial musculature. Over time, with prolonged animation such as smiling, the skin along the nasolabial line is forced deep to the subcutaneous fat, positioned lateral to the nasolabial fold, attenuating these retinacular attachments. Prolonged animation therefore forces the skin and fat lateral to the nasolabial fold to expand radially and prolapse outward from the facial skeleton, accounting for much of the nasolabial fold prominence in the aging face. Radial expansion lateral to the oral commissure and marionette line similarly accounts for the prominence of the jowl in many middle-aged patients, making the older face appear square in shape and bottom heavy.4,10 Radial expansion is technically difficult to correct, as there are few surgical solutions to re-establish the retinacular attachments between skin, subcutaneous fat and deep fascia.

Radial expansion

223

Nonetheless, repositioning of facial fat through some form of support to the superficial fascia will not only reposition fat vertically, but will also provide some degree of internal repositioning such that the superficial facial soft tissues lie closer to the facial skeleton. As the soft tissues become situated closer to the underlying deeper structures of the face, facial morphology tends to be restored to a more youthful configuration. Because of the technical difficulty in completely treating radial expansion in many faces, incomplete correction of both the jowl and nasolabial fold resulting in undercorrection can be noted postoperatively despite heroic efforts at repositioning descended facial fat.

Role of skeletal support in formulating a surgical treatment plan Facial shape and contour is intuitively evaluated when analyzing a patient for facial rejuvenation. Often the twodimensional considerations seen in photographs are the easiest aspects of aging to identify, and such factors as nasolabial fold depth, jowl prominence, and cervical contour become the primary objectives to improve appearance in the middle-aged face. While these factors are certainly important considerations in treatment planning, the more subtle three-dimensional qualities of facial shape are equally important to evaluate and are greatly influenced by underlying skeletal support. In evaluating facial shape during preoperative analysis, some of the major factors that are helpful to consider are as follow.4

Facial width, bizygomatic diameter and malar volume The emphasis in facelifting over the last 30 years has focused on malar pad elevation.2,11–19 While malar pad elevation and restoration of malar highlights an important factor in improving facial shape, it needs to be patient-specific. Many patients present preoperatively with wide faces, strong malar eminences and large malar volume, with little evidence of malar fat descent. In these individuals, it is necessary to evaluate preoperatively the degree of malar pad elevation required to improve facial shape. While limited degrees of malar pad elevation can be helpful in patients who present with wide bizygomatic diameters, in general, if the malar volume is significantly enhanced in these types of individuals, the aesthetic effect is to make a wide face appear even wider on the front view postoperatively. In patients with adequate facial width, I tend to limit both SMAS release and malar pad elevation to the lateral aspect of the zygomatic eminence such that bizygomatic diameter is not increased postoperatively (Fig. 9.7.4).

Facial length and the relative vertical heights of the lower and middle third of the face Compared with wide faces, patients who present with vertical maxillary excess often have long, thin faces on front view. As facial fat descends in middle age, it becomes situated anteriorly and inferiorly in the face, and the face appears even longer with age. Malar pad elevation and enhancing malar volume in these types of patients is usually beneficial. As malar volume is enhanced and bizygomatic diameter is

Figure 9.7.4  Facial width and bizygomatic diameter reflect the underlying degree of skeletal support. Patients who exhibit strong malar eminences and wide bizygomatic diameter often benefit from having malar highlights restored but usually do not require significantly enhancing malar volume (which will cause a wide face to appear wider postoperatively). Shaping considerations in these types of faces usually focus on improving the appearance of the lower two-thirds of the cheek, specifically addressing jowl fat repositioning, as well as creating submalar hollowing, which improves the aesthetic relationship between malar and submalar regions. (From Stuzin JM. Restoring facial shape in facelifting: the role of skeletal support in facial analysis and midface soft-tissue repositioning. Plast Reconstr Surg . 2007;119:362–376.)

increased, the face appears wider on the front view, detracting from relatively excessive facial length (Fig. 9.7.5).

Convexity of the malar region juxtaposed to the concavity of the submalar region In youth, facial fat is situated overlying the malar and preparotid region. This malar fullness is juxtaposed to a concavity within the submalar region overlying the buccinator. As patients age, the relationship between the malar and submalar regions changes and with it, facial shape changes. As facial fat descends and facial deflation occurs, there is less volume overlying the malar eminence and an associated increase in fullness resulting from radial expansion within the submalar region. As the aesthetic relationship between the malar and submalar region becomes modified with time, there is a loss of the angular, tapered configuration in shape noted in youth, and middle-aged faces often appear oval. With greater facial fat descent and an increase in submalar fullness, older faces appear square. Preoperatively, an evaluation of the relationship between the malar and submalar region on front view is an essential component of aesthetic treatment planning. For many patients, a restoration in this relationship by increasing malar highlights and malar volume, in association with a restoration of

224

SECTION II

CHAPTER 9.7  • Facelift: The extended SMAS technique in facial rejuvenation

volumetric augmentation, either alloplastic or autogenous, to enhance skeletal support.

Aesthetic advantages of formal SMAS elevation in a two-layer dual plane SMAS facelift

A

B

C

D

Figure 9.7.5  Long, thin faces often benefit from an enhancement of malar volume. SMAS dissection and facial fat repositioning carried anteriorly over the zygomatic eminence allows the surgeon to restore malar volume, thereby increasing bizygomatic diameter. When malar volume is enhanced, the face appears wider, detracting from the relatively excessive facial length. (From Stuzin JM. Restoring facial shape in facelifting: the role of skeletal support in facial analysis and midface soft-tissue repositioning. Plast Reconstr Surg . 2007;119:362–376.)

concavity in the submalar region through repositioning fat internally overlying the buccinator muscle, becomes a central component in improving facial shape (Figs. 9.7.6 & 9.7.7).

Vertical height of the mandibular ramus and horizontal length of the mandibular body The vertical height of the mandibular ramus and the horizontal length of the mandibular body provide skeletal support for the lower two-thirds of the face. Patients who present with a normal mandibular ramus height, as well as adequate horizontal length of the mandibular body, usually have excellent skeletal support for soft-tissue repositioning and are, therefore, less of a surgical challenge. In contradistinction, patients with a short mandibular ramus, an open mandibular plane angle, and a short length of the mandibular body typically have poor skeletal support for midface and perioral soft-tissue repositioning. These patients are a greater surgical challenge in restoring facial shape, and often benefit from

All modern techniques share a commonality in that postoperative contour is largely dependent on facial fat repositioning through some form of SMAS manipulation. The advantage of formal SMAS flap elevation lies in its aesthetic versatility. Once the superficial fascia has been freed from the restraint of the retaining ligaments, it offers the surgeon several advantages, including (1) vector versatility; (2) greater control in terms of long-term vertical facial fat repositioning; and (3) greater control in terms of long-term internal facial fat repositioning. Regarding vector versatility, dermal elastosis and skin laxity in the aging face often do not occur in the same direction, nor at the same rate as aging related to the descent of fat. The main advantage of performing skin dissection separate from SMAS dissection is that it allows these two layers to be draped along vectors that are independent of one another (Fig. 9.7.8).2,19–21 Another advantage of a two-layer SMAS facelift is that the tension of contouring is placed on the superficial fascia, thereby allowing the surgeon to use less tension for skin closure. This improves control regarding scar perceptibility.20,21 In terms of vectors, in my experience, facial fat is commonly repositioned in a more vertical vector than skin flap redraping. Strong vertical shifting of the cervicofacial flap is a maneuver that has traditionally been utilized in many facelift techniques. While skin tightening can produce a dramatic effect in terms of improvement of facial laxity, the aesthetic effects of vertical skin vectoring unfortunately have been poorly delineated. Specifically, when skin is shifted in a cephalad direction, the effect of skin tension commonly produces an accentuation of flatness in the preparotid region, an area that typically deflates with aging. In my opinion, vertical skin shifting can produce an unnatural tightness to facial shape, producing some of the typical stigmata associated with rhytidectomy. If the surgeon has been successful in repositioning descended facial fat, the use of strong vertical skin tension is neither desirable nor required to enhance the postoperative result (Fig. 9.7.9).

Surgical technique: extended SMAS dissection Restoration of support to the underlying deeper facial soft tissues has become the key ingredient to the approach to improve facial aging. If the SMAS is thin, plication is an alternative method. Nonetheless, better contouring and longer lasting results are obtained following a formal dissection of the superficial fascia. In my experience, after the superficial fascia is freed from the restraint of the retaining ligament, it slides freely, allowing greater control in vertically repositioning of facial fat. Full release of the SMAS also allows the superficial fascia to better conform internally to the underlying deeper facial soft tissue and facial skeleton. Greater control of internal

Surgical technique: extended SMAS dissection

A

A

B

B

fat repositioning provides for more complete correction of radial expansion. The key to performing successful dissection of an extended SMAS flap is precise dissection of the skin flaps during subcutaneous undermining, with care to leave a moderate amount of fat intact on the superficial surface of the SMAS, especially in the regions where the SMAS is to be dissected. If the skin flaps are dissected so that little fat is left along the superficial

225

Figure 9.7.6  (A) Preoperative appearance. Note that facial shape is oval, secondary to malar deflation associated with an increase in submalar fullness. (B) Postoperatively, following malar pad elevation, malar volume is enhanced in association with a restoration of submalar concavity, producing a more angular appearance to facial shape. (From Stuzin JM. Restoring facial shape in facelifting: the role of skeletal support in facial analysis and midface soft-tissue repositioning. Plast Reconstr Surg. 2007;119:362–376.)

Figure 9.7.7  (A) Preoperatively, the patient shows a similar blunting of the relationship between the malar and submalar regions. (B) Postoperative appearance. Enhancing malar volume (and bizygomatic diameter) and restoring the concavity within the submalar region make the face appear more angular, as well as vertically shorter. (From Stuzin JM. Restoring facial shape in facelifting: the role of skeletal support in facial analysis and midface soft-tissue repositioning. Plast Reconstr Surg. 2007;119:362–376.)

surface of the SMAS, the SMAS becomes more difficult to raise, appearing thin, tenuous, and prone to tearing. In a SMAS-type facelift, much of the contouring that is obtained is due to elevation and fixation of the SMAS layer. The more substantial the SMAS flap, often the better are the long-term results that can be obtained in terms of facial contouring. The use of contralateral transillumination is helpful in providing a clearer definition of the interface between subcutaneous fat

226

SECTION II

CHAPTER 9.7  • Facelift: The extended SMAS technique in facial rejuvenation

and superficial fascia, allowing for greater precision in skin flap elevation. Preoperatively, I decide the extent of subcutaneous skin flap undermining based on the most medial aspect of where I want to end the SMAS dissection, which typically is situated just medial to the retaining ligaments. I prefer to limit the skin undermining several centimeters lateral to the nasolabial fold rather than undermining the skin to this facial landmark. The reason is that if one limits the dissection of the skin flap in the medial aspect of the cheek, this will preserve some of the attachments that go from the deep fascia through the SMAS to facial skin. The preservation of these attachments, followed by adequate undermining of the superficial facial fascia (SMAS), will allow the surgeon to re-elevate anteriorly displaced fat and skin through SMAS rotation rather than to redrape the superficial fascia completely independent of skin flap redraping. The ability to re-elevate and resuspend facial soft tissue through SMAS rotation produces a more pleasing aesthetic result and a greater degree of correction of radial expansion within the cheek, as the facial fat is brought internally to conform to the underlying buccinator muscle (Fig. 9.7.10).

SMAS elevation

Figure 9.7.8  The direction of SMAS redraping in the face tends to be cephalad in its orientation as opposed to skin flap redraping, which is oriented along a more horizontal vector. The aesthetic versatility of vectoring the SMAS in a direction independent of skin flap redraping is a major advantage of a two-layer SMAS-type facelift.

Figure 9.7.9  These two patients show the effect of vertical rotation of the cervicofacial flap associated with hairline distortion. A skin flap that is overly rotated in a cephalad direction not only can compromise the temporal hairline, but also tends to produce flatness in the lateral midface overlying the masseter and parotid. This imparts a tight, unnatural appearance to the face. Also notice the effect of scar perceptibility when strong skin tension is used in an attempt to contour the aging face.

A

The dissection of the superficial fascia allows the surgeon to re-elevate jowl and descended malar fat back upwards into the face toward their previous, normal anatomic location.2,5 In patients with prominent nasolabial folds and significant infraorbital hollowing, it is my feeling that the SMAS dissection should extend into the malar region in an effort to re-elevate the malar fat pad back upward overlying the zygomatic eminence. An added benefit of performing a more extensive anterior dissection of the SMAS is that it frees this layer from the

B

Surgical technique: extended SMAS dissection

A

227

B

Figure 9.7.10  (A) If an extended SMAS dissection is to be performed, it is important not to widely undermine the skin all the way to the nasolabial fold, but rather to preserve some of the attachments that exist between the skin and the SMAS (the limit of subcutaneous undermining is the shaded area). If these attachments are left intact, this allows the surgeon to simultaneously resuspend undissected anterior facial skin at the time of SMAS rotation and fixation. (B) It is important to understand which portion of the SMAS flap will affect facial contouring. In this diagram, the most superomedial aspect of the SMAS dissection affects contour along the nasolabial fold, whereas the more lateral portion of the SMAS dissection is used to re-elevate jowl fat upward into the cheek. A portion of the SMAS flap is rotated into the postauricular region, with the vector of rotation of this portion of the SMAS dissection affecting submental and cervical contouring.

restraint of both the zygomatic and masseteric ligaments, and this anterior release provides for a more complete elevation of the facial fat below the oral commissure and along the anterior portion of the jowl. The incisions (Fig. 9.7.11) for extended SMAS dissection begin approximately 1 cm inferior to the zygomatic arch to ensure frontal branch preservation. This horizontal incision is continued several centimeters forward to the region where the zygomatic arch joins the body of the zygoma. At this point, the malar extension of the SMAS dissection begins with the incision angling superiorly over the malar eminence toward the lateral canthus for a distance of 3–4 cm. On reaching the edge of the subcutaneous skin flap in the region of the lateral orbit, the incision is carried inferiorly at a 90° angle toward the superior aspect of the nasolabial fold. A vertical incision is designed along the preauricular region, extending along the posterior border of the platysma to a point 5–6 cm below the mandibular border. In essence, the malar extension of the SMAS dissection simply represents an extension of a standard SMAS dissection into the malar region in an attempt to obtain a more complete form of deep-layer support. The SMAS in the malar region is then elevated in continuity with the SMAS of the cheek. When elevating this flap, the fibers of the orbicularis oculi, as well as the zygomaticus major

and minor, are usually evident and the flap is elevated directly along the superficial surface of these muscles. It is important to carry the dissection directly external to these muscle fibers, where a natural plane exists, remembering that the facial nerve branches lie deep to these muscular bellies. The malar SMAS is then elevated until the flap is freed from the underlying zygomatic prominence. Freeing of the SMAS completely from the zygomatic attachments is an important technical point in obtaining the mobility necessary to reposition the malar soft tissue superiorly. To obtain this mobility usually also requires a division of the upper fibers of the masseteric cutaneous ligaments, which will expose the underlying body of the buccal fat pad. The cheek portion of the SMAS dissection is performed, beginning directly overlying the parotid gland and then extending this dissection anterior to the parotid, utilizing a combination of sharp and blunt dissection toward the anterior border of the masseter. In most patients, following extended SMAS dissection of the cheek and malar regions, mobility of the soft tissues lying lateral to the nasolabial fold remains restricted unless the dissection is carried more medially. This restriction in movement results from the undivided retaining ligaments that originate medial to the zygomaticus minor. To improve mobility, I commonly continue malar pad elevation medially in an area

228

SECTION II

CHAPTER 9.7  • Facelift: The extended SMAS technique in facial rejuvenation

A

B

Figure 9.7.11  (A) In patients with malar deflation or malar pad descent, I typically perform what is termed an extended SMAS dissection. By this, I mean the SMAS dissection is extended into the malar region in an attempt to re-elevate ptotic malar fat back upward over the zygomatic prominence. The incisions begin at the junction where the zygomatic arch joins the body of the zygoma. From this point, the incision in the SMAS is angled superiorly toward the lateral canthus and along the lateral orbital rim. The incision in the SMAS is then carried medially and inferiorly toward the peripheral extent of skin flap undermining, angling toward the uppermost portion of the nasolabial fold (the amount of subcutaneous undermining is shaded in pink, whereas the amount of SMAS undermining is shaded in yellow). (B) The malar-SMAS dissection is then performed in continuity with the cheek-SMAS dissection. Dissecting in the malar region carries the dissection directly along the superficial surface of the zygomaticus major and usually exposes the lateral aspects of the zygomaticus minor as well. To obtain adequate mobility in terms of SMAS dissection, it is necessary to elevate the malar portion of the dissection completely from the zygomatic eminence and free it from the zygomatic ligaments. To obtain mobility in terms of SMAS movement affecting the jowl contour, the uppermost portions of the masseteric cutaneous ligament commonly are divided, especially where they merge with the zygomatic ligaments of the malar area. If these fibers are not divided, they will restrict the upward redraping of jowl fat. On division of the upper portion of the masseteric cutaneous ligaments, the buccal fat pad becomes evident and commonly the zygomatic nerve branches traversing toward the undersurface of the zygomaticus major muscle are visualized. This diagram illustrates the typical degree of mobilization performed in our extended SMAS dissection.

where I have not subcutaneously undermined the skin. This dissection is carried directly in the plane between the malar fat and the superficial surface of the elevators of the upper lip. It is usually quite easy to delineate this level of dissection after the malar SMAS elevation is complete and the superficial surface of the elevators of the upper lip visualized. The scissors are then inserted directly superficial to the elevators of the upper lip, and blunt dissection is quickly performed by pushing the scissors in a series of passes bluntly toward the nasolabial fold. I find that when we insert the scissors in the proper plane, the dissection quickly glides through the malar soft tissues and I usually will feel a “snap” as we dissect through the remaining retaining ligaments. Once these structures are divided, one notes greater mobility when traction is applied to the malar portion of the SMAS flap, translating into greater movement along the uppermost portion of the nasolabial fold (Fig. 9.7.12).

SMAS fixation Repositioning and closure of the SMAS is then performed. The malar SMAS flap is advanced superolaterally over the zygomatic prominence in a direction perpendicular to the nasolabial fold and usually paralleling the zygomaticus major muscle. After superior and lateral advancement, if a malar augmentation is not planned, the excess tissue can be excised and the flap securely fixated to the zygomatic periosteum with interrupted sutures (Fig. 9.7.13). Once the malar flap is secure, the cheek-SMAS flap is rotated superiorly perpendicular to the mandibular border. This portion of the SMAS flap is used to contour jawline and jowl. The SMAS overlying the preauricular region and ear is then treated as a transposition flap and carried posteriorly behind the ear, helping to restore tone to the submental region and neck. Following trimming, the SMAS flap is carefully

Surgical technique: extended SMAS dissection

229

Figure 9.7.13  The vectors of redraping of the extended SMAS flap are determined according to the preoperative evaluation of the patient and are generally more cephalad than skin flap redraping. Figure 9.7.12  It is commonly necessary to extend the malar SMAS dissection more peripherally than the subcutaneous dissection to obtain adequate flap mobility of the soft tissues lateral to the nasolabial fold. This portion of the dissection is easily performed by simply inserting the scissors in the plane between the superficial surface of the elevators of the upper lip and the overlying subcutaneous fat. Once the scissors are inserted in the proper plane, the surgeon bluntly dissects in a series of passes past the nasolabial fold (area marked in green). As long as the scissors remain superficial to the elevators of the upper lip, motor nerve injury will be prevented. Usually three or four passes are required to obtain adequate flap mobility.

secured with multiple interrupted sutures. Occasionally, skin dimpling is noted after securing the SMAS flap; this results from the forces of SMAS rotation on resuspended facial skin. Skin dimpling is treated by simply performing a bit more subcutaneous undermining prior to skin flap redraping. Following proper contouring of the SMAS dissection, the facial skin flaps are rotated and closed in the direction decided upon, based on preoperative evaluation. In general, these skin flaps are inset with a minimum degree of tension placed along the key sutures and then the skin flaps are trimmed with a degree of redundancy between the key sutures to minimize tension along the incision sites. To summarize, the key points in mobilizing the superficial fascia from the restraint of the retaining ligaments of the cheek are as follows:

1.

2.

3.

The SMAS overlying the parotid gland and malar eminence tends to be substantial and easy to dissect, with both the parotid and zygomaticus major and minor muscles protecting the underlying facial nerve branches. These areas are very safe regions to begin SMAS elevation and delineate the subSMAS plane. The thinnest fascial component of an extended SMAS dissection is in the region just lateral to the zygomaticus major muscle, where the SMAS splits to invest the elevators of the upper lip. Dissecting the skin flap thinly in this region leaves a substantial amount of subcutaneous fat intact along the surface of the superficial fascia, providing greater ease in SMAS dissection and minimizing the possibility of tearing this layer. The most difficult portion of an extended SMAS dissection is freeing the superficial fascia from the restraint of the superior masseteric ligaments, which are lateral to the zygomaticus major muscle. If these ligaments are not mobilized, restricted movement is noted in the portion of superficial fascia that affects contouring along the lower nasolabial fold, oral commissure, and anterior jowl. The zygomatic branches of the facial nerve are in close proximity to the upper masseteric ligament. At times it can prove difficult to differentiate between ligaments and facial nerve branches. Caution is stressed in this region of dissection.

230

SECTION II

CHAPTER 9.7  • Facelift: The extended SMAS technique in facial rejuvenation

Variations in extended SMAS technique to affect a restoration in facial shape The biomechanics of SMAS repositioning have been previously described and are influenced by the degree of release, vector of fat repositioning, and how the superficial fascia is fixated.22 As postoperative contour is dependent on each of these factors, preoperative planning needs to be patientspecific in terms of the degree of SMAS release required, the vectors in which facial fat is repositioned, and the location and method for SMAS fixation.

Release The incision design of an extended SMAS dissection allows for complete release of the SMAS from its underlying retaining ligamentous attachment in the lateral midface. As surgeons, there is a tendency to believe that a greater degree of SMAS dissection equates with a better result, but this has not been this author’s experience. Rather, precision in the degree of SMAS dissection and its release from the retaining ligaments as dictated by the aesthetic needs of a patient increases surgical control and consistency while minimizing morbidity.3 How much to release the SMAS, and how high and anterior to carry the SMAS dissection, needs to be decided preoperatively. As discussed previously, in patients who present with adequate malar volume, wide bizygomatic diameter, and little evidence of malar pad descent, it is usually unnecessary to carry the SMAS dissection medial to the lateral orbital rim (although I usually carry the dissection high within the malar eminence to allow fat repositioning along the infraorbital and

A

B

lateral orbital rims). Most commonly, these types of patients require only a restoration of malar highlight and not significant anterior malar volume enhancement. Limiting the SMAS dissection to the lateral aspect of the malar eminence will not increase facial width on the front view.4 Typically, the shaping considerations for these patients is focused on reducing fullness in the submalar region (Fig. 9.7.14). Vertically long faces often benefit from carrying the malar portion of the extended SMAS dissection anteriorly, medial to the lateral orbital rim, so that malar volume restoration is performed along the anterior aspect of the zygomatic eminence. Carrying the SMAS dissection more medially allows the surgeon to enhance malar volume and restore malar highlights anteriorly over the zygomatic eminence, thereby increasing facial width on the front view (Fig. 9.7.15).

Vectors of fat elevation: facial asymmetry All patients exhibit some degree of facial asymmetry. Commonly, one side of the face is vertically longer, and the short side of the face is usually wider than the long side. Malar highlights are typically more superiorly located on the long side of the face and, with age, facial fat tends to descend in a more vertical direction on the long side. As facial asymmetry and facial skeletal configuration are asymmetric in most individuals, it follows that the vectors of fat elevation (SMAS repositioning) should be specific for the right and the left side of the face. The vector in which the SMAS is repositioned has a significant impact on the location and volume of elevated facial fat,

C

Figure 9.7.14 Patients with wide bizygomatic diameters and good underlying skeletal support typically do not require a significant anterior malar dissection to improve facial shape. Most commonly, the SMAS dissection in these patients (while kept high) is extended only as medial as the lateral orbital rim, so that malar volume restoration is limited to the lateral aspect of the zygomatic eminence. The shaping considerations for these types of faces usually emphasize reducing fullness within the submalar area, as well as jowl fat elevation. Notice that postoperatively the patient’s face appears more tapered and thinner in morphology through facial fat repositioning without removal of facial fat. (From Stuzin JM. Restoring facial shape in facelifting: the role of skeletal support in facial analysis and midface soft-tissue repositioning. Plast Reconstr Surg. 2007;119: 362–376.)  

Correction of platysma bands and cervical obliquity

A

B

thereby influencing facial shape. Decisions regarding the direction of SMAS vectoring for the right and left side of the face are best determined preoperatively, as it is very difficult to make aesthetic vector judgments intraoperatively with the patient recumbent. SMAS vectors influence postoperative facial shape. Vertical SMAS repositioning typically provides a larger amount of fat for malar eminence enhancement, as well as allowing for a reduction in fullness within the submalar region as fat is forced internally along the concavity of the buccinator. For this reason, vertical SMAS vectors are often indicated to reshape round, full faces, allowing them to appear more tapered and thinner postoperatively (Fig. 9.7.16). If the SMAS is vectored more obliquely, there is less volume of fat brought into the malar region and a greater volume of fat repositioned into the submalar region. Oblique SMAS repositioning is therefore helpful in elderly patients who appear gaunt over the buccal recess, as it allows the surgeon to volumetrically enhance the submalar region (Fig. 9.7.17).

SMAS fixation In a two-layer SMAS-type facelift, the tension of contouring is placed on the superficial fascia rather than the skin envelope. For this reason, the fascial quality and tensile strength of the superficial fascia has an influence on both the longevity of result, as well as the volume of fat that can be repositioned intraoperatively and maintained postoperatively. In other words, soft-tissue quality influences long-term contour and is the primary reason why facelifts in young patients are more predictable. In an effort to improve fascial quality in a SMAS facelift, for over a decade I incorporated Vicryl mesh into the SMAS fixation.3 It was my initial observation that incorporating Vicryl

231

Figure 9.7.15  Faces that are more dominated by their facial length (especially the lower third of the face) usually benefit from malar volume restoration. To enhance malar volume, the SMAS dissection is carried toward the anterior aspect of the zygomatic eminence, such that malar volume is increased in this region. (From Stuzin JM. Restoring facial shape in facelifting: the role of skeletal support in facial analysis and midface soft-tissue repositioning. Plast Reconstr Surg. 2007;119:362–376.)

mesh into fixation improved not only longevity of result but also greater aesthetic control. Nonetheless, I have stopped using Vicryl mesh, as I have come to realize that the predominant factor in improving fixation is the method in which the superficial fascia was secured. Obtaining a secure fixation utilizing multiple sutures placed deeply within the superficial fascia allows the surgeon greater control in postoperative shape. Suturing the SMAS securely under moderate tension affects facial shape in two ways: (1) adding more sutures allows the surgeon to stack volume in specific areas of the midface, which is useful in augmenting areas of deflation, as well as augmenting volume along the malar eminence; and (2) as the superficial fascia is sutured under tension, facial fat is not only repositioned vertically but also repositioned internally, forcing the soft tissue to conform to the underlying deep facial structures. This gives the surgeon greater control in improving radial expansion (Fig. 9.7.18).

Correction of platysma bands and cervical obliquity Correction of the neck is thoroughly reviewed in Chapter 9.10. In my hands, the best approach to the anterior platysma is via a submental incision, placed just caudal to the submental skin crease.5,23–26 If this crease is very deep, the skin cephalad is elevated toward the base of the chin pad and along the caudal mandibular border to free any retaining mandibular ligaments, which tend to accentuate the crease. Following this, the cervical skin is carefully elevated. The cervical skin is usually undermined at least to the level of the cricoid. Upon exposing the platysma muscle anteriorly, most patients exhibit a decussation of platysmal fibers across the midline, at least for a few centimeters below the mentum.

232

SECTION II

CHAPTER 9.7  • Facelift: The extended SMAS technique in facial rejuvenation

Figure 9.7.16  Vectors of SMAS elevation have a significant impact on facial shape. Vertical repositioning of the SMAS allows the surgeon to enhance malar volume and reduce fullness within the submalar region, as fat is forced up along the concavity of the buccinator. Restoration of submalar hollowing through SMAS vectoring is useful in contouring full faces, making them appear thinner postoperatively. In this patient, a small amount of jowl defatting through needle aspiration was also performed. (From Stuzin JM. Restoring facial shape in facelifting: the role of skeletal support in facial analysis and midface soft-tissue repositioning. Plast Reconstr Surg. 2007;119:362–376.)

Figure 9.7.17  This patient exhibits asymmetry in the submalar region preoperatively. Notice that she appears hollow and concave on the right, while she is fuller on the left side. For this reason, the SMAS was vectored obliquely on the right to volumetrically enhance the submalar region, while it was vertically vectored on the left side to restore submalar hollowing and balance the two sides of her face. (From Stuzin JM. Restoring facial shape in facelifting: the role of skeletal support in facial analysis and midface soft-tissue repositioning. Plast Reconstr Surg. 2007;119:362–376.)

A

B

A

B

When platysma band surgery is contemplated, these decussating fibers must be sharply divided with scissor dissection directly in the midline. Following this, the medial edge of the platysma is mobilized from the mentum inferiorly at least to the hyoid and commonly as caudal as the cricoid cartilage. Mobilization, usually performed using a combination of sharp and blunt dissection, separates the platysma from the underlying subplatysmal fat, the anterior belly of the digastric muscle, and the strap muscles overlying the thyroid cartilage. At

times, numerous small venules are encountered within the subplatysmal fat and careful hemostasis must be obtained. Following mobilization of the medial edges of the platysma, the subplatysmal fat is conservatively contoured according to preoperative planning. Following mobilization, the medial edge of the platysma muscle is grasped on either side and overlapped in the midline in order to estimate the amount of excess muscle present. Muscle excess will vary from patient to patient. A portion of

Correction of platysma bands and cervical obliquity

Figure 9.7.18  This diagram illustrates how the excess SMAS, rather than being excised, is rolled onto itself to form a double layer of SMAS thickness. Once the SMAS has been rolled, it is fixated to the periosteum of the zygomatic eminence. An added benefit of preserving the excess SMAS rather than excising it is that, as the thickened SMAS layer is secured to the zygomatic eminence, it highlights the malar region, serving as an autogenous malar augmentation. Highlighting the malar area tends to enhance angularity in facial contour. (From Stuzin JM. Restoring facial shape in facelifting: the role of skeletal support in facial analysis and midface soft-tissue repositioning. Plast Reconstr Surg. 2007;119:362–376.)

the medial edge can be excised to remove redundancy within the platysma. A conservative resection is performed so that undue tension is not present at the time of suture plication. Muscular plication consists of edge-to-edge approximation using multiple interrupted sutures at the mentum and extending at least to the level of the hyoid. Suture placement back from the leading edge of the muscle, in areas of intact muscular fascia, is an important technical point in preventing suture pull-through postoperatively. In most patients, the edge-to-edge suturing below the hyoid is continued inferiorly toward the cricoid cartilage. The goal of muscular plication is to produce an even, smooth contouring of the platysma that is tightly adherent to the underlying floor of the mouth and thyroid cartilage, providing a flat framework for redraping of cervical skin. A low plication joining a widely separated platysma over a prominent thyroid cartilage also tends to blunt a prominent larynx and produce a rounder, more feminine appearance to the neck. Following edge-to-edge approximation of the platysma, some form of muscular release is performed. This muscular release commonly involves a partial transection of the

233

platysma muscle with the myotomy performed inferiorly within the neck. Platysma transection is an effective technique in the treatment of platysma bands and in obtaining the desired cervical contour. This procedure must be performed meticulously because the early experience with transection was fraught with complications. Specifically, if the transection is performed at a high level, it can be associated with unveiling of the submaxillary glands and denervation of the platysma associated with lower lip dysfunction. Also, obvious contour depressions associated with divided muscular edges can be noted in the overly thin neck (Fig. 9.7.19). The key to platysma transection is that the transection of the muscle is performed lower in the neck, often as inferior as the level of the cricoid cartilage. The disadvantage of horizontal transection at this level is that a depression in the neck can develop if preplatysmal fat has been removed at the level where the transection is performed. Preservation of preplatysmal fat lower in the neck where the transection is to be performed is obviously an important factor in preventing this problem. In most patients, only partial division is required. The myotomy is performed from the midline laterally until the tension is completely released from the platysmaplasty closure (approximately the anterior border of the sternocleidomastoid muscle in most patients). The muscular release seen following platysma transection serves many purposes: 1. It alleviates tension along the medial portion of the platysma transection following plication. 2. It allows the platysma to shift superiorly, producing a deeper cervicomental angle. 3. It prevents the conversion of two platysmal bands to a single band following edge-to-edge approximation, which can be visible when the neck is extended. In most patients in whom I perform a platysmaplasty, small drains are placed and left in place until drainage is minimal and the skin flaps are adherent. In my experience, the use of drains has lessened postoperative edema, ecchymosis and seroma formation (Fig. 9.7.20).

Sequence of SMAS fixation versus platysmaplasty Because the SMAS and the platysma represent the same anatomic layer, if platysmaplasty is performed before the SMAS dissection, it can adversely affect facial contour.3,20,21 Contouring the neck before the midface can also be problematic. When the platysmaplasty is performed first, the descended jowl fat is locked down into the neck, and movement of the superficial fascia diminishes following elevation of the SMAS. This diminished movement tends to lessen surgical ability to modify facial shape; it also produces a loss of aesthetic contour. If the SMAS dissection is performed before platysmaplasty, descended jowl fat is brought cephalad to the mandibular border and easily repositioned. After the SMAS has been securely sutured bilaterally, the mandibular border appears more distinct, making cervical contouring less demanding. When performing platysmaplasty subsequent to SMAS fixation, the surgeon will notice less redundancy along

234

SECTION II

CHAPTER 9.7  • Facelift: The extended SMAS technique in facial rejuvenation

the medial borders of the platysma; there is also less need to resect muscle at the time of platysmaplasty. The enhanced contour effects of extended SMAS dissection, associated with precise platysmaplasty, tend to diminish the need to remove cervical fat. In general, the neck and jawlines appear softer if preplatysmal fat is preserved when contouring the neck (Fig. 9.7.21).

Incisions

Figure 9.7.19  After edge-to-edge approximation of the platysma from the mentum to the cricoid cartilage, some form of muscular release is performed. This usually consists of a horizontal cut extending from the midline to the anterior border of the sternocleidomastoid muscle.

Figure 9.7.20  (A) Preoperative appearance. Note the hollowed contour in the lateral cheek, which represents the region from which the facial fat has descended and deflated, as well as the marked cervical obliquity. (B) Postoperative result following extended SMAS dissection. If the surgeon can re-elevate descended facial fat back to its previous anatomic location and secure it there postoperatively, this will help to enhance the mandibular border, providing for predictable cervical contouring through platysmaplasty. This lessens the need for preplatysmal fat removal. In general, necks look softer if cervical fat is preserved. (From Stuzin JM, Baker TJ, Baker TM. Refinements in facelifting: enhanced facial contour using Vicryl mesh incorporated into SMAS fixation. Plast Reconstr Surg. 2000;105:290–301.)

A

Incisions have been reviewed in Chapter 9.3. The importance of incision quality cannot be overemphasized in diminishing signs that the patient has undergone a surgical procedure. One of the major advantages of a two-layer facelift is that the tension of contouring is along the superficial fascia and thus there is less need to redrape the skin flap with great force. Decreased tension on the key sutures in both the preauricular and postauricular region provides greater control for scar perceptibility. If the incisions are artistically designed, patients can typically wear their hair up off their ears without obvious stigma that a facelift has been performed.21 Whereas many authors have described the salient factors regarding incision design, I would delineate the main points: 1. I prefer tragal incisions, performed at the margin of the tragus, rather than preauricular incisions, because the color difference between the pale skin of the ear and the blush skin of the cheek is usually better camouflaged when the incision is brought internally into the ear. 2. Tragal incisions are more demanding than preauricular incisions, requiring precise design and insert so that the tragus is not distorted. The aesthetic unit of the tragus is rectangular as opposed to semilunar. If the surgeon designs the tragal incision properly, respecting the incisura of the tragus, the tragus will appear normal in its shape postoperatively, exhibiting both a visual

B

Summary

B

A

3.

beginning at its junction with the helix and a visual ending along the preserved incisura. Detached earlobes tend to appear more natural than attached earlobes. If a small cuff of cheek skin is left attached to the earlobe, it will allow surgical rotation of the skin up under the earlobe during skin flap redraping, suturing the earlobe distinctly from the cheek flap. The earlobe should be inset in an axis posterior to the axis of the pinna, thereby avoiding a pixie deformity.

There is increasing public demand for natural-appearing results in facial rejuvenation. This places the onus on the surgeon to create incisions that are imperceptible if these procedures are to be justified. No matter how well deep-layer support is obtained and facial contour improved by SMAS elevation and platysmaplasty, if the incision is obvious, scar quality poor, the hairline disturbed, or the earlobe deformed, the overall result remains disappointing.

Summary From a personal perspective, after two decades of striving to improve techniques in facial rejuvenation, it is my firm conviction that improving technical control when contouring the

Access the reference list online at 

 

Elsevier eBooks+

235

Figure 9.7.21  (A) Preoperative appearance. (B) Postoperative appearance. Another example of how facial fat re-elevation influences cervical appearance. Sequencing errors can lead to loss in contour; it is my preference to perform SMAS elevation and fixation before performing platysmaplasty. As the facial fat and skin is re-elevated back into the midface through SMAS rotation, the mandibular border becomes more distinct, making cervical contouring more predictable.

superficial facial fascia and platysma provides for a more consistent, aesthetically pleasing result, which is non-surgical in appearance. The difficulty in performing a two-layer SMAS-type facelift is that it requires a commitment on the part of the surgeon, not only to understand facial soft-tissue anatomy, but also to perform a procedure that demands technical precision. A two-layer SMAS-type facelift is a time-consuming operation, with both the skin flap elevation, as well as the dissection of the SMAS, requiring meticulous and accurate dissection. Obtaining consistency with this procedure is challenging because of the variability in thickness of subcutaneous fat and the SMAS that exists among individual patients. Following precise dissection, secure fixation of both SMAS and platysma is mandated to maintain the shaping desired in postoperative contour. Meticulous hemostasis followed by careful skin flap inset are required to minimize postoperative scar perceptibility and ensure a rapid postoperative recovery. Despite these demands, I have found the extended SMAS technique to be personally rewarding, with a high degree of patient satisfaction. All techniques have advantages and disadvantages. For me, the biggest advantage of the extended SMAS technique remains its aesthetic versatility, allowing the surgeon to vary the contouring aspects of the procedure according to the aesthetic needs of the patient.

References

References 1. Stuzin JM, Baker TJ, Gordon HL, et al. Extended SMAS dissection as an approach to midface rejuvenation. Clin Plast Surg. 1995;22:295–311. 2. Stuzin JM, Baker TJ, Gordon HL. The relationship of the superficial and deep facial fascias: relevance to rhytidectomy and aging. Plast Reconstr Surg. 1992;89:441–449. Facial anatomy is characterized as a series of concentric layers based on cadaveric and intraoperative dissection. These findingts inform a discussion of the anatomic basis of facial aging. 3. Stuzin JM, Baker TJ, Baker TM. Refinements in facelifting: enhanced facial contour using Vicryl mesh incorporated into SMAS fixation. Plast Reconstr Surg. 2000;105:290–301. 4. Stuzin JM. Restoring facial shape in facelifting: the role of skeletal support in facial analysis and midface soft-tissue repositioning. Plast Reconstr Surg. 2007;119:362–376. The author emphasizes the importance of establishing patient-specific aesthetic goals in planning a facelift. Skeletal anatomy is a key component of this analysis. 5. Baker TJ, Gordon HL, Stuzin JM. Surgical Rejuvenation of the Aging Face. 2nd edn. St Louis: CV Mosby; 1995. 6. Freilinger G, Gruber H, Happak W, et al. Surgical anatomy of the mimic muscle system and the facial nerve: importance for reconstructive and aesthetic surgery. Plast Reconstr Surg. 1987;80:686–690. 7. Furnas DW. The retaining ligaments of the cheek. Plast Reconstr Surg. 1989;83:11–16. The anatomy of the facial retaining ligaments is reviewed. The importance of addressing these structures in facelift procedures is addressed. 8. Rohrich RJ, Pessa JE. The fat compartments of the face: anatomy and clinical implications for cosmetic surgery. Plast Reconstr Surg. 2007;119:2219–2227. Cadaveric dissection demonstrated multiple discrete compartments of subcutaneous fat in the human face. The clinical significance of this finding is addressed. 9. Lambros V, Stuzin JM. The cross-cheek depression: surgical cause and effect in the development of the “joker line” and its treatment. Plast Reconstr Surg. 2008;122:1543–1552. 10. Lambros V. Fat contouring in the face and neck. Clin Plast Surg. 1992;19:401–414. 11. Lemmon ML, Hamra ST. Skoog rhytidectomy: a five-year experience with 577 patients. Plast Reconstr Surg. 1980;65:283–297.

235.e1

12. Mendelson BC. Correction of the nasolabial fold: extended SMAS dissection with periosteal fixation. Plast Reconstr Surg. 1992;89:822–833. 13. Hamra S. The deep plane rhytidectomy. Plast Reconstr Surg. 1990;86:53–61. 14. Barton Jr. FE. Rhytidectomy and the nasolabial fold. Plast Reconstr Surg. 1992;90:601–607. The Skoog facelift was modified to free the SMAS from the underlying mimetic muscles of the face. A sizeable clinical series demonstrated improvement in nasolabial fold aesthetics. 15. Owsley Jr. JQ. Lifting the malar fat pad for correction of prominent nasolabial folds. Plast Reconstr Surg. 1993;91:463–474. 16. Connell BF, Marten TJ. The trifurcated SMAS flap: three-part segmentation of the conventional flap for improved results in the midface, cheek and neck. Aesthet Plast Surg. 1995;19:415–420. 17. Aston S.J. Facelift with FAME technique. Paper presented at the 32nd Annual Baker Gordon Symposium on Cosmetic Surgery, Mercy Hospital, Miami, FL; February, 1998. 18. Little JW. Three-dimensional rejuvenation of the midface: volumetric resculpture by malar imbrication. Plast Reconstr Surg. 2000;105:267–285. 19. Owsley Jr. JQ. SMAS-platysma facelift: a bidirectional cervicofacial rhytidectomy. Clin Plast Surg. 1983;10:429–440. 20. Connell BF. Neck contour deformities: the art, engineering, anatomic diagnosis, architectural planning, and aesthetics of surgical correction. Clin Plast Surg. 1987;14:683–692. 21. Marten TJ. Facelift planning and technique. Clin Plast Surg. 1997;24:269–308. 22. Mendelson BC. Surgery of the superficial musculoaponeurotic system: principles of release, vectors, and fixation. Plast Reconstr Surg. 2001;107:1545–1552. 23. Connell BF. Cervical lifts: the value of platysma muscle flaps. Ann Plast Surg. 1978;1:32–43. 24. Aston SJ. Platysma muscle in rhytidoplasty. Ann Plast Surg. 1979;3:529–539. 25. Feldman JJ. Corset platysmaplasty. Plast Reconstr Surg. 1990;85:333–343. 26. Feldman JJ. Neck Lift. St Louis: Quality Medical Publishing; 2006.

SECTION II  •  Aesthetic Surgery of the Face

9.8

High SMAS facelift: combined single flap lifting of the jawline, cheek, and midface Timothy Marten and Dino Elyassnia

Access video lecture content for this chapter online at Elsevier eBooks+

Introduction Traditional facelift techniques have relied upon the tightening of thin flaps of aging skin to elevate and support sagging, deeper facial tissues. Although initial results from these procedures often appeared good, early recurrence of the original problems were common, and poor scars and healing problems were frequently seen due to obligatory wide flap undermining and unavoidable skin flap tension. These procedures also typically produced an easily recognized and objectionable tight-appearing, “facelifted” look that was usually exacerbated by subsequent similar procedures. As surgeons have pursued more natural-appearing and long-lasting outcomes, our understanding of the aging process has improved and facelift techniques have evolved. Experience has shown that an attractive and naturalappearing result is not possible without diverting tension away from the skin to the superficial musculo-aponeurotic system (SMAS) and platysma, and unless the aging midface is addressed. The traditional “low” cheek and “deep plane” SMAS flaps elevated below the zygomatic arch suffer the drawback that they cannot, by design, exert and effect on tissues of the midface and infra-orbital region. “Low” and “deep plane” designs target the lower cheek and jowl only, and produce little if any improvement in the upper anterior cheek area. Planning the flap “higher”, at the level of and along the zygomatic arch, and extending the dissection medially in an “extended SMAS” fashion to mobilize midface tissue, overcomes this problem and allows a combined, simultaneous lift of the jawline, cheek, and midface. When performed as described an improved outcome is obtained and no separate midface lift procedure is needed.1–11

Fundamental concepts in rejuvenation of the face Why use the SMAS? The fundamental flaw in “skin-only” facelifts, “mini-lifts”, and similar non-SMAS procedures is the fact that skin was intended to perform a covering function and not a structural or supporting one. Skin is inherently elastic and was intended to stretch and move as we emote and express ourselves. It was not intended to support sagging muscle, fat, and other structures lying underneath it that descend with age. Attempts to lift sagging deep layer tissue by tightening and removing skin corrupts its covering function and results in abnormal skin tension and related secondary problems, including poor scars, tragal retraction, earlobe malposition, and a tight and unnatural appearance. Skin tension also flattens contour, rather than restoring it, and because skin stretches as tension is applied, objectionable temple, sideburn and occipital hairline displacement is common when “skin-only” techniques are used. In addition, because skin is inherently elastic and not capable of providing a sustained support of deep facial tissues, the results of most “skin-only” facelifts, “mini-lifts” and other non-SMAS procedures are usually short-lived. Using the SMAS to restore facial contour overcomes many of the problems associated with skin-only lifts as it is an inelastic structural layer that is attached to and envelopes facial tissues sagging with age, and it is capable of providing meaningful and sustained support. Although skin must be excised in SMAS procedures, and proper excision will produce an improved result, only truly redundant tissue is removed and closure is properly made under normal skin tension. Facial skin so treated will distribute itself naturally

Fundamental concepts in rejuvenation of the face

over new contours created by SMAS modification and is capable of some self-repair and contraction. This averts a tight or “lifted” appearance, provides for optimal wound healing and well healed scars, and further enhances the overall end result.

SMAS and the midface The midface is generally defined as an inverted triangular area situated over the anterior upper cheek that is bounded by the zygomaticus major muscle laterally, the nasolabial fold medially and the orbitomalar ligament superiorly. In healthy, youthful-appearing individuals this area is full and makes a smooth transition into the adjacent cheek and lower eyelid. As a person enters their early mid-life and beyond, there is generally atrophy and a loss of volume from this area. Over time this results in a loss of confluence with the fat of the lower eyelid and cheek and, eventually, an elderly, or even ill and haggard appearance. Midface atrophy is felt by some surgeons to also be accompanied by descent of midface tissues, and the aging change seen in the upper cheek area is, as a result, often (although perhaps imprecisely) thought of and referred to as midface “ptosis”. The recognition of midface “ptosis” as a component of the changes occurring in the aging face, combined with the realization that the traditional SMAS facelift produced little or no improvement in the midface region, has led to a variety of procedures designed to specifically target the midface area. Many of these “midface lifts” have been designed to be performed as isolated procedures or have been performed in conjunction with lower eyelid surgery. Although there is merit in the idea of rejuvenating the midface, routine isolated midface lift procedures have been largely abandoned, and a consensus of opinion as to how and when they should best be performed has never been reached. Most midface lift procedures have a steep learning curve and have been fraught with complications, especially those performed through a blepharoplasty incision. These complications include lid retraction, ectropion, canthal displacement, and related corneal exposure and dry eye problems. As a result, many midface lift techniques have necessarily come to incorporate potentially problematic aggressive adjunctive surgical maneuvers including canthotomies, canthoplasties and orbicularis oculi muscle suspensions to reduce the likelihood of these problems occurring. These maneuvers often result in a “changed look” that is disturbing to many patients, however, and carry a high risk of significant and troublesome complications of their own. Careful evaluation of patients who need or request a midface lift will show that most also need a facelift. It is rare to encounter a patient with midface aging who does not also have sagging in the cheek and jowl, and midface lifts are, as a result, arguably more logically performed in conjunction with a formal facelift procedure. When performed together improvement is more balanced and comprehensive, and a more harmonious and natural-appearing result is usually obtained. Experience has also shown that healing is faster and complications are less likely if midface improvement can be obtained through the facelift incision, rather than through a blepharoplasty or intra-oral approach. Analysis of the aging face will also show that midface lifts are generally conceptually flawed in that they erroneously

237

assume the problem seen in the anterior upper cheek to be solely one of tissue ptosis. Failure to acknowledge the fact that atrophy is present to a significant degree in most cases has led to general long-term disappointment for both patients and surgeons following many procedures, and has resulted in the addition of dermis fat grafts, orbital fat transposition, “septal resets” and similar maneuvers to midface “lift” techniques. It has proven questionable whether midface procedures can provide a restoration of lost volume as simply, naturally, and effectively as can be obtained with autologous “micro” fat grafting.9,10

The “high SMAS” concept The traditional “low” cheek SMAS flap elevated below the zygomatic arch suffers the drawback that it cannot, by design, have an effect on tissues of the midface and infra-orbital region. Low designs target the lower cheek and jowl only and produce little if any improvement in the upper anterior cheek area. Planning the flap “higher”, along the border of the zygomatic arch, and extending the dissection medially in an extended SMAS fashion (see Fig. 9.8.2B) to mobilize midface tissue, overcomes this problem and produces an improved result (Fig. 9.8.1).2–5 Benefits of the high SMAS technique include a combined, balanced, and harmonious elevation of sagging tissues of the midface, cheek and jawline, without the need to perform a separate or distinct midface lift procedure. High SMAS procedures are also readily combined with midface fat grafting since midface and infra-orbital tissue planes are not opened or dissected. This averts the need to perform complex and potentially problematic procedures in which orbital fat is transposed, the orbital septum “reset”, or free grafts are placed. At least part of the popularity of “low” SMAS designs can be attributed to concerns regarding anatomical constraints about the zygomatic arch and laudable efforts to design flaps that could be dissected safely without jeopardizing the frontal branch of the facial nerve. Published studies and a careful appraisal of frontal branch anatomy, however, show that a “high” dissection is anatomically sound and, clinically safe.12 For most patients, the repositioning of midface tissue obtained with a “high” SMAS flap will be satisfactory, and no additional or separate midface lift procedure will be required.5

The extended SMAS concept The extended SMAS concept is integral to the high SMAS technique and the means by which midface tissues are liberated and subsequently elevated in an integrated fashion when a high SMAS flap is raised (Fig. 9.8.2). The extended SMAS concept as set forth by Stuzin13 is not synonymous and should not be confused with the “extended SMAS technique”, the latter being the name Stuzin gave to his personal facelift technique in which a high SMAS flap is dissected but the posterior part of the superior flap margin is set below the zygomatic arch and a more medially situated tab of SMAS tissue is created over the lateral zygoma as part of the SMAS flap that can be used to lift midface tissues. Stuzin’s extended SMAS concept was a groundbreaking one that clarified certain anatomical realities that had gone unrecognized by other surgeons employing SMAS techniques, and it comprised a new and important approach in treatment

SECTION II

238

CHAPTER 9.8  • High SMAS facelift: combined single flap lifting of the jawline, cheek, and midface

Midface improvement

No midface improvement

High SMAS

Low SMAS B

A

Figure 9.8.1  “High” and “low” SMAS techniques compared. (A) Plan for low SMAS procedure. Note that upper border of the flap lies below the zygomatic arch. Area of flap effect (blue solid circle) is limited to the lower cheek and jowl and no improvement is obtained in the midface, infra-orbital or perioral regions (red dashed circle). (B) Plan for high SMAS procedure. Note that upper border of the flap lies over the zygomatic arch. Area of flap effect (blue solid circle) includes not only both the cheek and jowl, but the midface, infra-orbital and perioral regions (red dashed circle) as well. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

A

B

Figure 9.8.2  The “extended SMAS” concept. (A) Traditional (but incorrect) area of SMAS undermining (brown shaded area). A lack of understanding of the presence and location of the ligaments restraining the SMAS layer led to an unnecessary over-dissection of the SMAS-platysma inferiorly well into the neck where no ligaments are present and an under-dissection in the upper cheek where the zygomatic ligaments restrain the upper cheek and midface (red arrow). (B) Extended SMAS dissection. Dissection is limited in the inferior SMAS-platysma to the release of the masseteric-cutaneous ligaments (small black squares along the anterior border of the parotid) and “extended” into the upper cheek and midface to release the zygomatic ligaments (small black circles located near the origin of the zygomaticus major muscle at tip of red arrow). Although more tedious, the release of the upper cheek and midface obtained when an extended dissection is performed gives the SMAS flap a more comprehensive effect and provides a more balanced and complete lift of the face. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

Lamellar dissection and bidirectional tissue shifts

of the midface during facelift procedures that remains important and germane to this day. Traditional SMAS dissections targeted largely the lower cheek SMAS and platysma and focused on releasing more inferiorly situated masseteric-cutaneous ligaments restraining the lower cheek and posterior jawline areas (see Fig. 9.8.2A). These types of dissections were likely undertaken in large part because they were relatively easier to perform in comparison to dissecting more superiorly, and perhaps due to the hyperfocus on the jawline and lack of awareness of the need to also reposition the midface that was prevalent at that time. In the extended SMAS approach, dissection is limited in the lower cheek to the release of the masseteric-cutaneous ligaments that are situated along the anterior border of the parotid, in recognition of the fact that a more extensive dissection serves no purpose and does not provide an improved release. Instead, focus is directed more superiorly to release the zygomatic ligaments situated near the origin of the zygomaticus major muscle origin and their confluence with upper masseteric-cutaneous ligaments situated just inferior to that, which was not done in traditional “non-extended” SMAS dissections (see Fig. 9.8.2B). Extending the SMAS flap dissection up over the zygoma and into this area and releasing these more superiorly situated ligaments restraining the upper SMAS, while perhaps more tedious, resulted in a release of the upper cheek and midface that provided a more comprehensive effect of the SMAS flap and a more balanced and complete lift of the face. Without an extended SMAS dissection the full potential of a high SMAS flap will not be realized.

Lamellar dissection and bidirectional tissue shifts A number of specific strategies have been devised for utilization of the SMAS that merit consideration. These include “deep plane” and “composite” one-layer dissections in which the SMAS and skin are elevated as a single monolayer and

B

A

239

advanced in the same direction along the same vector and “lamellar” dissections in which skin and SMAS are elevated as two separate “lamella” or layers and advanced “bidirectionally” along two different vectors. Deep plane and composite type “monolayer” dissections have the potential advantage that they can be performed more quickly and result in a comparatively thicker, arguably more durable and well-vascularized flap composed of both skin and SMAS. These dissections have the distinct disadvantage, however, that they provide only for “unidirectional” lifts, and skin and SMAS must be advanced the same amount, in the same direction, and suspended under more or less the same amount of tension. The deep plane technique was also abandoned by its creator due to failure to produce the midface improvement hoped for. However, because skin and SMAS age at different rates and along somewhat different vectors, optimal treatment of each layer is generally not possible when these techniques are employed, and skin over-shifting, skin over-tightening, temporal hairline displacement, “wrinkle shift” from the neck to the cheek, and other objectionable occurrences and unnatural appearances can result. In addition, if the orbicularis oculi is included in a “composite” flap as the technique as described stipulates, the muscle’s motor nerve supply can be compromised and lid dysfunction, nerve cross-regeneration, and other disturbing and objectionable abnormalities can result. Two-layer “lamellar” dissections offer the distinct advantage that skin and SMAS can be advanced by different amounts, along separate vectors, and suspended under differential tension in pursuit of optimal artistic and aesthetic goals. This “bidirectional” lift allows each of these layers to be addressed individually, and overly vertical skin shifts, counterproductive skin tension, and unwanted and objectionable “wrinkle shifts” can be better avoided. This in turn results in a more natural appearance, a more comprehensive rejuvenation, and fewer secondary irregularities (Fig. 9.8.3). Two-layer “lamellar” techniques suffer the potential drawbacks that the skin and SMAS flaps are thinner, arguably more fragile and less well vascularized, and that the dissection is

C

Figure 9.8.3 Lamellar dissection and bidirectional tissue shift. (A) Two-layer “lamellar” dissections in which the skin and SMAS are dissected as two separate layers offer the distinct advantage over one-layer “deep plane” and “composite” dissections in that each layer they be advanced independently along separate vectors, and suspended under differential tension. (B) When a lamellar dissection is performed the SMAS can be advanced more vertically along a vector parallel to the long axis of the zygomaticus major muscle (white arrow) (see also Fig. 9.8.39A), and the skin can be allowed to flow more naturally posteriorly more perpendicular to the nasolabial fold (solid black arrow). (C) When a “deep plane” or “composite” dissection is made the skin and SMAS can only be moved along the same vector and the same distance. (Courtesy of Timothy Marten, MD, FACS, used with permission.)  

240

SECTION II

CHAPTER 9.8  • High SMAS facelift: combined single flap lifting of the jawline, cheek, and midface

technically more demanding and time consuming to perform. Our combined experience strongly suggests that while a lamellar dissection is arguably technically more demanding, the bidirectional tissue shifts it affords to the skin a SMAS far outweigh the potential disadvantages, and the technique has provide improved outcomes unobtainable by other means.

“Lateral sweep” and the SMAS Traditional “skin-only” facelifts and “low SMAS” procedures typically result in over-tightening of the lateral cheek skin and provide little support of the midface, lateral perioral, and jowl areas. In time, these unsupported tissues continued to descend in a disproportionate fashion while the lateral face remained tight, resulting in a characteristic and objectionable “swept up” appearance over the jawline and lateral face, often referred to as “lateral sweep” (Fig. 9.8.4). This is particularly true of techniques that use a “vertical vector” for skin flap advancement. Lateral sweep is generally most apparent in the lateral view when the patient looks down. In this position lateral facial tightness is increased due to better tissue fixation and exaggerated SMAS support in the pre-auricular area, and the

“sweep” appearance accentuated due to the comparatively poor or non-existent support of the more anterior-medial midface and lateral perioral areas. Lateral sweep is an unavoidable eventual consequence of all traditional skin-lift, “mini-lift”, “low” SMAS, and deep plane and composite procedures that are not designed and carried out in a way that supports the midface and lateral perioral area. These skin-only and low deep layer procedures, are incapable of providing uniform support to both the anterior and lateral cheek, and are biogeometrically inclined to produce an unbalanced and unnatural appearance. A “high SMAS” flap in contrast, provides simultaneous and uniform one-flap support of the lateral facial, midface, and lateral perioral areas, and this results in a more balanced, comprehensive and natural rejuvenation, and minimizes the chance the lateral sweep will occur. Lateral sweep can result when a high SMAS technique is used if the lateral perioral region is over-dissected subcutaneously and ligamentous attachments between the SMAS and the skin are inappropriately divided (see Fig. 9.8.25B,C). These ligaments are the means by which the high SMAS flap supports the lateral perioral area, and over-dissection of this sort is a common error made by surgeons who erroneously assume that extended skin undermining will help improve the nasolabial fold. This is not a flaw in the technique, it is merely a failure to perform it correctly.

Recognizing the components of the aging change of the face and employing logical solutions to improve them

Figure 9.8.4  Lateral sweep. Traditional “skin-only” facelifts and “low SMAS” procedures typically result in over-tightening of the pre-auricular cheek skin and provide little support of the lateral perioral and jowl areas. In time, these unsupported tissues continued to descend in a disproportionate fashion while the lateral face remained tight, resulting in a characteristic and objectionable “swept up” appearance of the skin over the jawline often referred to as “lateral sweep”. (Procedure performed by an unknown surgeon.) (Courtesy of Timothy Marten, MD, FACS and the Marten Clinic of Plastic Surgery, used with permission.)

Recognizing the components of the aging change of the face and appreciating the underlying anatomical abnormalities is essential to properly advising patients and fundamental to the planning of any surgical repair. Careful analysis will reveal that most patient problems will fall into three broad categories: (1) aging and breakdown of the skin and skin surface; (2) facial sagging, skin redundancy, and loss of youthful facial contour; and (3) facial hollowing, atrophy and/or age-related lipodystrophy. Proper treatment will depend upon the types of problems present, the patient’s priorities, and the time, trouble and expense they is willing to endure to obtain the desired improvement. Patients primarily concerned with surface aging of their face may not require formal surgical procedures and may achieve the type of improvement they desire through salon care and dermatologic surface treatments of the skin. These treatments include skin peels, skin resurfacing, dermabrasion, chemodenervation (neuromodulator injections), filler injections and various forms of cutaneous laser, radiofrequency, and other treatments designed to remove or reduce “age spots”, “spider veins”, wrinkles and other age-related skin surface imperfections. Patients primarily concerned with facial sagging, skin excess and loss of facial contour will achieve minimal ultimate improvement, however, if surface treatments only are employed, and will require formal surgical lifts in which sagging tissue is repositioned and redundant tissue is excised if these problems are to be properly corrected and an attractive

Recognizing the components of the aging change of the face and employing logical solutions to improve them

and natural-appearing improvement is to be obtained. The misapplication of surface treatments of the skin to the sagging face with excess tissue will produce little more than a smooth, saggy face with no improvement in contour. This sort of “smooth-saggy appearance”, typically seen in older patients who have undergone laser resurfacing or deep skin peels, is inconsistent with a natural look as patients with loss of facial contour generally also have concomitant skin surface aging. It is arguably more attractive and natural-appearing to have a well-contoured face with a few wrinkles and surface imperfections, than a smooth but saggy one. Similarly, the misapplication of filler or fat injections to the sagging face with excess skin and an overly large skin envelope may produce a smoother face but at the same time an objectionably large, heavy, and unfeminine appearing one. One must also keep in mind that despite industry efforts to make us believe otherwise, fillers “lift” radially – that is in an outward direction – not vertically. Suggesting that fillers “lift” the face vertically may be one of the most deceptive and most thoughtlessly repeated mischaracterizations we make to ourselves and our patients. Many, if not most, of the changes associated with loss of facial contour represent primarily “deep layer” problems that will be inadequately corrected with traditional “skin-only” or “low SMAS” techniques, however. Regrettably, many surgeons unfamiliar with deep layer techniques, and other physicians insufficiently trained to perform them, often perform “skin-only” facelifts or “mini-lifts”, and resort to misguided and misapplied ancillary procedures to overcome the shortcomings of these methods. These procedures include facial

A

241

liposuction, malarplasty, submalarplasty, geniomandibular grove augmentation (“pre-jowl implant”), polytetrafluoroethylene (PTFE; “Gore-tex”) implantation, and various types of “thread lifting” and suspension suture placement. Although some of these procedures are at times useful and indicated, they will be unnecessary in the majority of cases if a high SMAS facelift and deep layer rejuvenation is performed (Fig. 9.8.5). Patients with significant facial atrophy and age-related facial hollowing and loss of facial volume will generally achieve suboptimal improvement from both surface treatments of facial skin and surgical lifts. Smoothing skin will not hide a drawn and hollow appearance due to loss of facial volume, and it is difficult to create natural and attractive contours by lifting and repositioning tissues that have abnormally thinned with age. Restoring lost facial volume with autologous fat grafting is a powerful technique that has gained widespread acceptance.9,10 Properly performed, the addition of fat to areas of the face that have atrophied due to age or disease can produce a significant and sustained improvement in appearance unobtainable by other means. In addition, autologous fat grafting may represent the first true anti-aging therapy plastic surgeons have to offer in that there is a growing body of evidence that adult stem cells transferred with fat exert a regenerative effect on tissues in areas adjacent to areas where fat is injected, including overlying skin. However, age-related facial atrophy rarely exists as an isolated event in the healthy patient, and thus patients troubled by it are not always logically or appropriately treated by fat grafting alone. Isolated fat grafting is also arguably

B

before

after

Figure 9.8.5 High SMAS facelift. (A) A 47-year-old woman before surgery. Note loss of youthful contour and marked centrofacial aging. (B) Same patient after high SMAS facelift, neck lift, forehead lift, upper and lower eye lifts, and fat grafting. Sagging tissues have been comprehensively repositioned and redundant skin excised without a tight or pulled appearance. (Courtesy of Timothy Marten, MD, FACS, used with permission.)  

SECTION II

242

CHAPTER 9.8  • High SMAS facelift: combined single flap lifting of the jawline, cheek, and midface

of questionable benefit to the patient troubled by significant facial sagging and skin redundancy. Although aggressive filling of the sagging face with fat can produce improved contour and a smoother appearance, it generally results in an unusually large, overfilled face that appears both unnatural and unfeminine. Such an overfilled face is hard to correct in an attractive manner at a later date, and it is both more logical and practical to perform fat grafting in conjunction with formal surgical lifts if needed, or after ptotic tissue has been repositioned and redundant tissue has been removed. When a high SMAS technique is used in conjunction with fat grafting, both loss of facial contour and facial atrophy can be corrected and optimal improvement in the patient’s appearance can be obtained.

Preoperative planning It is not possible to design or use a “universal” facelift technique as each patient will present with a unique set of problems that require precise anatomic diagnosis and an appropriately planned and individualized surgical repair. Committed study, careful planning, and avoiding the use of a “formula technique” will maximize improvement, limit complications, and minimize secondary irregularities.

Planning the temple incision The temporal portion of the facelift incision has traditionally been placed within the temporal scalp in a well-intended, but all too frequently counterproductive, attempt to hide the resulting scar. When cheek skin redundancy is small and abundant temple and sideburn hair is present, such a plan can sometimes be used without producing objectionable sideburn elevation and temporal hairline displacement. Patients best suited for this incision plan are usually younger and troubled

A

B

by mild to moderate cheek laxity only. In many other situations, however, larger skin shifts and the presence of sparse temple hair can result in unnatural and tell-tale sideburn elevation and displacement of the temporal hairline if such a plan is used (Fig. 9.8.6A,B). Proper analysis, careful planning, and the use of an incision along the hairline, when indicated, can avert this problem without compromising the overall outcome of the procedure (Fig. 9.8.7A,B,C). In appropriately choosing the location of the temporal portion of the facelift incision it is important to consider each patient’s particular circumstances including the amount of excess skin present over the upper lateral face and the skin shift that will occur when the facelift flap is lifted. This can be assessed by pinching up redundant skin and measuring it. The surgeon’s estimate of skin redundancy over the cheek, when considered in conjunction with an assessment of the amount of temple/sideburn hair present, allows rational selection of the best site for temporal incision placement (Fig. 9.8.8). In patients in whom minimal or modest skin shift is predicted to occur and for whom abundant temporal scalp hair is present the temporal portion of the facelift incision can be placed in the traditional location 4–5 cm within the temporal scalp, extending superiorly up from the anterior-superior aspect of the ear (Fig. 9.8.9). While individual circumstances will vary and the decision as to where the incision be placed should be based on the circumstances present and not arbitrarily based on age, typically patients in whom this incision plan is indicated are under 45 years old. In patients in whom significant skin shift is predicted to occur and in whom the inferior margin of the temporal tuft of hair (“sideburn”) is predicted to be shifted above the junction of the ear with the scalp, and for whom more sparse temporal scalp hair is present, the temporal portion of the facelift incision should be placed along the hairline (Fig. 9.8.10; see also Fig. 9.8.7) rather than within the temporal scalp. This

C

Figure 9.8.6 Displacement of the sideburn and temple hair due to poor incision planning. (A,B) The temporal portion of the facelift incision was made in the temporal scalp (red dotted line in C) in a well-intended but conceptually flawed effort to hide the resulting scar. Because cheek flap redundancy was large and skin elasticity poor, advancement of the cheek skin flap has resulted in objectionable and tell-tale hairline displacement. An incision along the hairline would have prevented this occurrence (black dotted line in C). (Procedures performed by unknown surgeons.) (C) Deconstruction of cause of temporal hairline displacement seen in A and B. The operating surgeon made an error in planning. He or she made a well-intended effort to hide the temporal portion of the facelift incision in the temporal scalp (red dotted line), but underestimated or did not appreciate the amount of skin redundancy over the upper lateral cheek. When the facelift skin flap was advanced (black arrow) skin was moved into an area were scalp and hair should be present. The black dotted line shows the incision plan that would have prevented this occurrence. (Procedure performed by an unknown surgeon.) (Courtesy of Timothy Marten, MD, FACS, used with permission.)  

Preoperative planning

A

B

243

C

Figure 9.8.7  Healed incisions along the temporal hairline. The use of an incision along the hairline, when indicated, can prevent posterior and superior hairline and sideburn displacement without compromising the end result. Although a fine scar is present along the hairline in each of these patients, it is not evident upon casual inspection. Note the preservation of lush temple hair and a full, youthful, natural-appearing sideburn (compare with Fig. 9.8.6A–C). (Courtesy of Timothy Marten, MD, FACS, used with permission.)

A

B

Figure 9.8.8  Estimating skin redundancy over the upper cheek. Gauging the skin redundancy over the cheek assists in predicting the degree of temporal hairline displacement that will occur when the facelift flap is shifted.

incision plan will accommodate large posterior-superior skin flap shifts and allows maximum improvement in the upper lateral face to be made. If the incision is made with care and closed under no tension, the resulting scar is usually inconspicuous and will be far less troublesome for the patient than a displaced hairline (see Fig. 9.8.6). While individual circumstances will vary and the decision as to where the incision be placed should be based on the circumstances present and not arbitrarily based on age, patients in whom this incision plan is indicated are typically 45 years old, or older. Options for the placement of the temporal portion of the facelift incision should be discussed with any patient in whom significant displacement of the temporal hairline or elevation of the sideburn might occur. Incision placement is best presented as a choice between two imperfect alternatives and it

is wise that the final decision as to where the incision will be located be left to patient after appropriate discussion has been made. In all, it has been our experience that most patients are disturbed by the prospect of temporal hairline/sideburn displacement and recognize it as a tell-tale sign that a facelift has been performed. When properly counseled and given the choice, most will readily consent to an incision along the hairline.

Planning the pre-auricular incision Open to inspection, the pre-auricular region exists as a frequent point of reference for those seeking to identify a facelift patient and in essence arguably comprises the surgeon’s “signature” (or lack thereof) of their work. Traditionally, incisions

244

SECTION II

CHAPTER 9.8  • High SMAS facelift: combined single flap lifting of the jawline, cheek, and midface

Figure 9.8.9  Plan for incision on temporal scalp. This plan should be used for patients with modest cheek skin excess and who have lush temporal-sideburn hair and as such are predicted to have minimal or modest superior and posterior shift of sideburn and temple hair after elevation of the facelift skin flap. It will not be appropriate for most patients, especially older patients and patients undergoing secondary or tertiary procedures. Dotted red line represents incision location. A small anterior protrusion should be made part of the design where the ear joins the temporal scalp as shown to prevent the advancement of skin into this area that should be hair-bearing scalp. The incision should then extend superiorly along a vertical line dropped through the auditory canal (white line). In certain cases the incision may extend higher or lower than shown depending on the amount of excess skin present in the upper lateral face. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

in this area are made well anterior to the anterior border of the helix and continued inferiorly, anterior to the tragus (Fig. 9.8.11A). This plan, however, works well only for the unusual patient with cheek and tragal skin of similar characteristics who, in addition, exhibits favorable healing. Unfortunately, most patients have a marked gradient of color, texture, and surface irregularities over these areas and a tell-tale mismatch will be evident, even in the presence of an inconspicuous scar. For these reasons, and in all but the unusual case (secondary and tertiary procedures in patients with minimal or no skin excess), the pre-auricular portion of the facelift incision should be precisely placed along the posterior margin of the tragus, rather than in the pretragal sulcus (Fig. 9.8.11B). In this location a mismatch of color, texture, or surface irregularities will not be noticed and the scar, if visible, will appear to be a tragal highlight (Fig. 9.8.12; see also Fig. 9.8.17). In addition, a properly planned and executed incision along the margin of the tragus will not produce tragal retraction or other anatomical irregularity (Figs. 9.8.13 & 9.8.14).

In the male patient a similar incision plan is used. In many cases skin flap shifts will be such that beard hair will not be retro-posteriorly displaced enough to be advanced onto the tragus itself. In cases where larger skin flap shifts occur, the tragus can be kept free of beard hair when a retrotragal incision is used by intra-operative destruction of beard follicles from the underside of the tragal flap when indicated (Fig. 9.8.14; see Chapter 9.11, Fig. 9.11.35 Male facelift). The pre-auricular incision consists of three component incisions: (1) a prehelical incision; (2) the tragal incision; and (3) a prelobular incision. Careful attention to the planning of each must be undertaken if a well-concealed scar and natural appearance is to be obtained. The superior, prehelical portion of the pre-auricular incision should be planned as a soft curve paralleling the curve of the anterior border of the helix. This will result in a natural-­ appearing “width” to the helix in keeping with the rest of the ear and the resultant scar, if visible, will appear to be a helical highlight and/or the natural anatomic transition from smooth pinker skin of the helix to the paler, coarser skin of the cheek (Fig. 9.8.15). If the prehelical portion of the pre-auricular incision is placed too far anteriorly or is situated so that it encroaches on the helix itself, the illusion of the scar as an anatomic interface and/or reflected highlight is lost (Fig. 9.8.16). As the tragus is approached, the mark for incision is carried into the depression superior to it and then continued along its posterior margin. In this location the scar, if visible, will appear to be a natural highlight (Fig. 9.8.17). At the inferior portion of the tragus the incision must turn anteriorly and then again inferiorly and a right angle, into the crease between anterior lobule and cheek. If a more relaxed plan is made, or if a straight line or “lazy S” incision plan is used, skin settling and scar contraction will result in crowding of the incisura, obliteration of the inferior tragal border, and a tell-tale elongated and “chopped-off” tragal appearance (Fig. 9.8.18A,B). To obtain a natural perilobular appearance, it is essential in cases where a naturally shaped earlobe is present to preserve the natural sulcus between the earlobe and the cheek and to avoid destruction of or excision of this and aesthetically important anatomic subunit. This is accomplished by marking the incision 1–2 mm inferior to this junction in women and 2–3 mm inferior to it in men. Placing the incision slightly more inferiorly in men facilitates shaving postoperatively should bearded skin be shifted superiorly against the incision as it commonly will be. In both cases, when a naturally shaped lobule is present, all other factors being equal, a superior result will be obtained when such a plan is used, in comparison to any plan in which the incision is placed directly in the sulcus and an attempt is subsequently made to directly join thin, soft earlobe with coarse, thick cheek.

Planning the postauricular incision The “postauricular” portion of the facelift incision is actually composed of three component incisions: (1) a postauricular incision extending in and along the concho-mastoid sulcus (see Fig. 9.8.20D, gray dotted line); (2) a transmastoid component incision traversing horizontally across the mastoid to the occipital scalp (see Fig. 9.8.20D red line); and (3) an occipital incision extending into the occipital scalp or along the occipital

Preoperative planning

A

245

B

Figure 9.8.10  Plan for incision along the temporal hairline – female vs. male patients. An incision along the temporal hairline should be considered whenever the surgeon’s assessment predicts objectionable superior and posterior displacement of the sideburn and temple hair will occur. This incision plan is usually indicated in older patients and almost always in patients undergoing secondary or tertiary procedures. In certain cases the incision may extend higher or lower than shown depending on the amount of excess skin present in the upper lateral face. (A) Temple hairline incision plan for the female patient (dotted red line). Note that incision is planned as a soft curve to evoke a feminine appearance extending inferiorly to a point approximately half the height of the anterior helix (solid white lines). (B) Temple hairline incision plan for the male patient (dotted red line). Note that incision is planned with a more rectangular masculine shape extending inferiorly to a point approximately half the height of the anterior helix (solid white lines). Dotted black lines show typical position of pre-auricular incisions. (An incision plan that sets the male sideburn more inferiorly than shown may compromise the blood supply to the prehelical part of the facelift skin flap. Such a plan also requires the patient to wear a long sideburn from their surgery date forward if the scar is to not show.) (Courtesy of Timothy Marten, MD, FACS, used with permission.)

hairline (see Fig. 9.8.20D, white dotted line). A careful consideration of the design of each is important if an overall wellconcealed and inconspicuous scar is to be obtained.

Planning the conchomastoid portion of the postauricular incision

A

B

Figure 9.8.11  Traditional vs. “concealed” pre-auricular incision plans. (A) Traditional (but generally incorrect) location of the pre-auricular incision. This plan places the scar in an area open to inspection by others and “brands” the patients as having had facelift surgery. Make-up will not conceal a scar in this location as the scar is smooth and the skin on either side of it is not. Making the incision in this location will also typically result in a difference of skin color on each side of the resulting scar that is an additional tell-tale tip-off that surgery has been performed (see also Fig. 9.8.12A). (B) “Concealed” (“retrotragal”) incision plan. Placing the incision along natural anatomic contours in the helical–facial sulcus, along the margin of the tragus, and in the lobular–facial sulcus conceals the preauricular scar and disguises differences in color and skin texture on each side of it as natural anatomic interfaces. While cheek skin is advanced onto the tragus, a better overall concealment of the scar is obtained (see also Fig. 9.8.12B). (Courtesy of Timothy Marten, MD, FACS, used with permission.)

Traditionally, the conchomastoid portion of the facelift incision has been made up onto and over the posterior surface of the concha. This was done as part of a well-intended effort to offset inevitable descent of the postauricular skin flap and inferior migration of the resulting scar that occurred when skin was forcefully advanced superiorly in a misguided attempt to improve neck contour by skin flap tightening. Experienced surgeons have since come to realize that such a plan embodies a number of erroneous assumptions and can result in many undesirable effects including hypertrophic scarring, postauricular webbing, and obliteration of the auriculomastoid/ conchomastoid sulcus. The postauricular portion of the facelift incision should instead be marked directly in the existing auriculomastoid (conchomastoid) sulcus in women, and 2–3 mm posterior to it in men. Placing the incision 2–3 mm posterior to the sulcus in men prevents advancement of bearded skin against the concha and facilitates shaving in this area. Such a plan places the scar along or near a natural anatomical interface where it will be difficult to detect, even on close inspection (see Fig. 9.8.25). Marking must be made with the ear resting near its natural anatomic position. If the ear is pulled forward while marks are made, mastoid skin will be pulled anteriorly over the posterior surface of the concha and the incision will end up posterior to its intended location and outside the auriculomastiod sulcus. Incorrect

246

SECTION II

CHAPTER 9.8  • High SMAS facelift: combined single flap lifting of the jawline, cheek, and midface

A

B

Figure 9.8.12  Pretragal and concealed (“retrotragal”) scars compared. (A) Pretragal incision has healed satisfactorily with an acceptable scar but is visible due to differences of color and texture on each side of it and exists as a tell-tale sign that a facelift has been performed. (Surgery performed by an unknown surgeon.) (B) Same patient after secondary facelift in which the incision was moved to the posterior margin of the tragus (“retrotragal” position). Color and texture differences, and the scar itself, are now hidden along natural anatomic interfaces and a tell-tale sign that a facelift has been performed is not present. (Surgery performed by Timothy Marten, MD, FACS.) (Courtesy of Timothy Marten, MD, FACS, used with permission.)

A

B

C

Figure 9.8.13  Healed “retrotragal” incisions. Close-up views of facelift patients with pre-auricular incisions along the margin of the tragus in a “retrotragal” position. Scars are well concealed, no tragal distortion is present, and a normal pretragal sulcus can be seen. While cheek skin has been advanced onto the tragus, a more natural appearance and better concealed scar is present than if a pretragal incision had been used. (Procedures performed by Timothy Marten, MD, FACS.) (Courtesy of Timothy Marten, MD, FACS, used with permission.)

marking in this manner is one of the most common causes of a poorly situated postauricular (conchomastoid) scar.

Planning the transmastoid portion of the postauricular incision Considerable confusion exists among surgeons performing facelift procedures as to what level the transmastoid part of

the postauricular facelift incision should cross over to the occipital scalp and, as a result, this part of the incision is often not placed strategically and in a manner that best conceals it, or in a way that allows optimal excision of skin from the anterior neck to be performed. If it is placed too low it will be visible when the patient’s hair is worn up or if they wear a short hairstyle. If it is placed too high the defect created will force and overly vertical shift of the postauricular skin

Preoperative planning

A

B

247

C

Figure 9.8.14  Healed “retrotragal” facelift scars in male patients. A retrotragal placement of the pre-auricular portion of the facelift incision has resulted in an inconspicuous and well-concealed scar. In the upper third, the scar sits in the interface between the helix and the cheek and the scar appears to be a reflected highlight of the anterior helical border (see also Fig. 9.8.15). In the middle third, the scar sits along the poster margin of the tragus and cannot be seen. Some coarse and bearded skin has been shifted up against and onto the tragus in (B) and (C), but this is less obvious than the presence of a pretragal scar with a gradient of color and texture on each side of it. In the lower third, the scar sits in a well-concealed location 2–3 mm outside the lobular–facial sulcus but far enough away from it that shaving in that area is not difficult. (Procedures performed by Timothy Marten, MD, FACS.) (Courtesy of Timothy Marten, MD, FACS, used with permission.)

flap and compromise improvement in the anterior neck and submental region (Fig. 9.8.19). Fortunately, if one assesses the goals sought and employs simple logic in meeting them, rational and effective transmastoid incision placement becomes possible. A useful guide in siting the transmastoid part of the postauricular incision is to envision a horizontal line through the point at which the anterior and superior crus of the antihelix diverge. Typically at that level the outer rim of the helix extends posteriorly back to the occipital hairline to the so-called “helix-hairline touch point” and a transmastoid incision placed at that level will be hidden behind the ear in the lateral view (Fig. 9.8.20).

Planning the occipital portion of the postauricular incision

Figure 9.8.15  Optimal position of prehelical part of the pre-auricular incision. The prehelical portion of the pre-auricular incision (red dotted line) should be planned as a soft curve paralleling the curve of the anterior border of the helix. This will result in a natural-appearing “width” to the helix in keeping with the rest of the ear (black dotted lines) and the resultant scar, if visible, will appear to be a helical highlight and be disguised as the natural transition between the smooth pinker skin of the helix and the coarser paler skin of the cheek. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

Planning the location for the occipital portion of the postauricular incision is conceptually similar to that of the temple region and the incision plan must take into account and address similar concerns of hairline displacement and scar visibility. Traditionally this incision is arbitrarily placed low transversely, into the occipital scalp, in a well-intended but almost always counterproductive attempt to hide the resultant scar (Fig. 9.8.21A). Regrettably, many other conceptually flawed, similar incision plans, which do not recognize the tissue biogeometry of the postauricular area or provide for skin excision along a useful vector, have been advocated. A thoughtful consideration of what one is trying to accomplish, however, allows one to employ incision plans that are logical and effective. For patients in whom neck skin redundancy is small and shifting and excision of postauricular skin is unnecessary, a traditional postauricular incision plan (as shown in Fig. 9.8.21A)

248

CHAPTER 9.8  • High SMAS facelift: combined single flap lifting of the jawline, cheek, and midface

SECTION II

A

B

C

Figure 9.8.16  Improper and proper placement of prehelical scar. Often the prehelical portion of the pre-auricular scar is poorly situated, and the illusion of it as an anatomic feature is lost. (A) The prehelical incision has been made too far anteriorly, and the illusion of the scar as an anatomic feature is lost. (Surgery performed by unknown surgeon.) (B) The prehelical incision has been made too far posteriorly and has obliterated the helical–facial sulcus and cheek skin has encroached on part of the helix itself. (Surgery performed by unknown surgeon.) (C) A patient with a properly planned and executed prehelical incision. The scar has been placed directly in the helical–facial sulcus. In this location a transition of color and texture is expected, and the scar appears to be a natural anatomic feature (see also Figs. 9.8.12–9.8.14). (Surgery performed by Timothy Marten, MD, FACS.) (Courtesy of Timothy Marten, MD, FACS.)

A

B

Figure 9.8.17  Optimal position of the pre-auricular incision. (A) Placing the pre-auricular scar along natural anatomic interfaces (red dotted line) places transitions of color and texture in locations where the eye is expecting to see them concealing them, and the scar itself if seen will appear as a reflected highlight (see Fig. 9.8.17B) (B) Note that the scar although hypopigmented and situated on darker skin and visible, appears to the eye to be a reflected highlight along the anterior border of the helix and the posterior margin of the tragus, and elsewhere where the incision was made. Note also how gradients of color and texture on each side of the scar appear expected and natural. A similar illusion and concealment would not be present had the incision been placed in a pretragal location. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

is appropriate if its transmastoid portion is situated superiorly enough to be concealed behind the ear (see preceding discussion) and will result in a well-concealed scar. Patients in this category are usually young and troubled by mild neck deformity only, and in these situations the incision is used for access to the lateral neck only, and not as a means to remove postauricular skin. Mistakenly using this incision to excise skin along a posteriorly directed vector will predictably result in the advancement of neck skin into the occipital scalp and “notching” of the occipital hairline (Figs. 9.8.21 and 9.8.22A,B). Similarly,

using this incision to excise skin along a superiorly directed vector will predictably result a wide transmastoid scar (Fig. 9.8.23). Skin excision along either vector using this incision is conceptually flawed and the source of all-to-common secondary facelift irregularities. Although not all patients and their surgeons will recognize these irregularities for what they are, most are nonetheless aware an unnatural appearance is present, especially those patients who wear short hairstyles, wear their hair up or back, or who lead active lives and engage in activities that

Preoperative planning

A

B

249

C

Figure 9.8.18  “Chopped-off” tragus. (A,B) The unnatural and objectionable appearing, elongated tragus with an indistinct inferior border that results from poor incision planning, improper excision of skin at the time of incision closure, and failure to provide SMAS support of deep player facial tissues. (Note also unaesthetic and objectionable displacement of sideburn hair due to improper planning of the temporal portion of the facelift incision as well.) (Procedures performed by unknown surgeons.) (C) Naturalappearing tragus following proper incision planning, excision of skin, and diversion of tension to the SMAS layer. (Procedure performed by Timothy Marten, MD, FACS.) (Courtesy of Timothy Marten, MD, FACS, used with permission.)

A

B

C

Figure 9.8.19  Making the postauricular incision higher does prevent hairline displacement. (A) A surgeon has made a well-intended but conceptually flawed attempt to hide the postauricular scar by making it high over the mastoid and extending transversely high into the occipital scalp (red dotted line). (B) Cervical skin has been advanced into an area where scalp should be (black arrow). (C) Black dotted line shows the original position of the hairline and the place where the incision should have been made. A large and objectionable displacement of the occipital hairline is evident. It can be seen that placing the incision higher compounds rather than reduces the problem of hairline displacement. (Surgery performed by an unknown surgeon.) (Courtesy of Timothy Marten, MD, FACS, used with permission.)

A

B

C

D

Figure 9.8.20 Planning the position of the transmastoid part of the postauricular incision. Strategically placing the transmastoid part of the postauricular incision conceals it and allows optimal excision of skin from the anterior neck. If it is placed too low it is visible when the patient’s hair is worn up or if they wear a short hairstyle. If it is placed too high the defect created will force and overly vertical shift of the postauricular skin flap and compromise improvement in the neck (see also Fig. 9.8.19). (A) The point of divergence of the anterior and superior crus of the helix provides a useful guide as to how high the transmastoid part of the postauricular incision should be placed (red dot). (B) At this horizontal level (red line) the rim of the helix will typically “touch” the occipital hairline in the lateral view. (C) A transmastoid scar placed at this level will cross over to the occipital scalp in a hidden location. Note that if the incision were placed lower the resulting scar would show. (D) Typical plan for the postauricular incision showing the transmastoid component (red line) to be concealed (gray dotted line shows location of the conchomastoid component incision hidden behind the ear and white dotted line the occipital incision hidden along the occipital hairline). (Note: the patient shown in Fig. 9.8.20A–D has undergone a previous facelift and it can be seen that his scars are well concealed despite his very short “military style” haircut.) (Courtesy of Timothy Marten, MD, FACS, used with permission.)  

CHAPTER 9.8  • High SMAS facelift: combined single flap lifting of the jawline, cheek, and midface

SECTION II

250

A

B

C

Figure 9.8.21  Traditional plan for the occipital portion of the postauricular Incision. (A) The incision is placed low transversely across the mastoid extending into the occipital scalp in a well-intended but usually counterproductive attempt to hide the resultant scar. This incision should only be used in younger patients for access to the lateral neck only, and cannot be used to remove excess neck skin without producing hairline notching if the postauricular skin flap is shifted along a proper posterior-superior vector. (B,C) Examples of hairline displacement caused by inappropriate use of the incision plan shown in (A). (Procedures performed by unknown surgeons). (Courtesy of Timothy Marten, MD, FACS, used with permission.)

A

B

Figure 9.8.22  Understanding the cause of occipital hairline displacement. (A) An example of avoidable notching and displacement of the occipital hairline seen in a patient whose surgeon inappropriately used a traditional occipital incision plan (note: procedure performed by unknown surgeon; see also Fig. 9.8.21). (B) Deconstruction of the occipital hairline displacement seen in (A). The surgeon made a well-intended, but conceptually flawed attempt to hide the scar in the occipital scalp (dotted red line) after underestimating the skin redundancy in the upper lateral neck. Skin has been advanced (black arrow) into a position where scalp hair should be and the hairline is “notched”. The dotted black line shows the incision plan that would have prevented the problem. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

may displace camouflaging wisps of remaining hair. Proper analysis, careful planning, and the use of an incision along the hairline (Figs. 9.8.24 & 9.8.25), when indicated and carried out in a technically correct manner, will prevent this problem, and allow skin to be excised along a correct posterior-superior vector, while simultaneously producing a well-concealed scar (Fig. 9.8.25; and see also Fig. 9.8.20A). In logically designing and deciding upon the position of the occipital portion of the postauricular incision one must gauge the skin redundancy along the predicted posterior-superior direction of flap shift. This can be accomplished by pinching up tissue over the upper lateral neck and estimating the amount present. If 2 cm or less of excess neck skin is present, a “traditional” incision over the mastoid extending posteriorly into the scalp at the level of the mid-ear (see

Fig. 9.8.21A) will, in most cases, not result in objectionable disruption of the occipital hairline. Typically this incision plan will be used in patients under 40 years old. If more than 2 cm of neck skin redundancy is present, however, the incision should be placed along the occipital hairline but designed in such a manner that a tell-tale scar will not be visible in front of the fine hair on the nape of the neck (see Figs. 9.8.24 & 9.8.25). This incision plan is typically needed in patients over 40 years old if hairline displacement is to be avoided and neck skin is to be excised along a proper and useful vector. The length of the occipital portion of the postauricular incision will necessary vary depending on the quality of the patient’s tissues and the amount of redundant skin present in the anterior neck and submental area (size of “wattle”), and

Preoperative planning

A

251

B

Figure 9.8.23  Understanding the cause of a wide and hypertrophic postauricular scar. (A) An example of avoidable postauricular scar widening and hypertrophy seen in a patient whose surgeon inappropriately excised skin along a superiorly directed vector (see red arrow in (B)). (Procedure performed by unknown surgeon.) (B) Deconstruction of the scar widening and hypertrophy seen in (A). The surgeon made a well-intended, but conceptually flawed attempt to advance the postauricular skin flap along a superiorly directed vector (red arrow), typically in an effort to avoid occipital hairline displacement and reconstitute the occipital hairline. This erroneously assumes excess skin is present in the lower lateral neck (black circle) and produces a false apparent redundancy of skin over the mastoid (skin shown in red circle) due to the elevated position of the patient’s shoulder while lying supine on the operating table. When the patient assumes an upright position postoperatively and the shoulder drops, a skin deficit is created and traction of the wound produces a wide and hypertrophic scar (see (A)). Gray circle shows actual area of neck skin excess and green arrow the proper vector of skin flap advancement if optimal improvement in the anterior neck and submental region is to be obtained. The green circle denotes the area where skin actually should be excised (along an occipital hairline incision). No skin should be excised in the area of the red circle. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

A

B

Figure 9.8.24  Plan for incision along the occipital hairline. This incision plan allows skin to be excised along a proper posterior-superior vector, prevents hairline displacement, and results in a well-concealed scar if carried out in a technically correct fashion. Note that the incision is planned so that its inferior portion turns posteriorly into the occipital scalp at the junction of thick and thin hair. (A) Schematic of occipital hairline incision plan. (B) Occipital hairline incision plan marked on patient. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

“small,” “medium,” and “long” (length of incision along the occipital hairline) incision plans are used as indicated (see Fig. 9.8.26). In patients with good tissue quality and minimal anterior neck and submental skin excess (“small wattle”), a “short” incision along the hairline will be indicated (Fig. 9.8.26A). In patients with modest loss of skin quality and

modest anterior neck and submental skin excess (“medium wattle”), a “medium”-length incision is made along the occipital hairline (Fig. 9.8.26B). In elderly patients with poor skin elasticity and a large anterior neck and submental skin excess (“large wattle”), a “long” incision along the occipital hairline will be needed (Fig. 9.8.26C).

SECTION II

252

A

CHAPTER 9.8  • High SMAS facelift: combined single flap lifting of the jawline, cheek, and midface

B

C

D

Figure 9.8.25  Healed scars along the occipital hairline. Proper analysis, careful planning, and the use of an incision along the hairline, when indicated will allow skin to be excised along a correct posterior-superior vector, while simultaneously preventing hairline notching and producing a well-concealed scar. (A,B) Healed scars along the occipital hairline in two women. (C,D) Healed scars along the occipital hairline in two men. (Surgery performed by Timothy Marten, MD, FACS). (Courtesy of Timothy Marten, MD, FACS, used with permission.)

A

B

C

Figure 9.8.26  Plan for length of incision along the occipital hairline. The length of the occipital portion of the postauricular incision (red dotted line) will vary depending on the quality of the patient’s tissues and the amount of redundant skin present in the submental area (size of the “wattle”). (A) In patients with good tissue quality and minimal submental skin redundancy (“small wattle”), a “short” incision along the hairline will be indicated. (B) In patients with modest loss of skin quality and modest submental redundancy (“medium wattle”), a ” medium” incision is made along the occipital hairline. (C) In elderly patients with poor skin elasticity and a large submental skin excess (“large wattle”), a “long” incision along the occipital hairline will be needed. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

As is the case with temporal incision placement, options for the placement of the occipital portion of the postauricular incision should be discussed with the patient preoperatively and presented as a choice between two imperfect alternatives: a scar “hidden” in the occipital scalp but with hairline notching and displacement; or a scar along the hairline but with hairline preservation. It is wise that the final decision as to where the incision will be located is ultimately left to the patient, after the advantages and disadvantages of each have been thoroughly discussed. In all, it has been our experience that most patients are disturbed by the prospect of occipital hairline displacement and recognize it as a tell-tale sign that a facelift has been performed. When properly counseled and given the choice, most will readily consent to an incision along the hairline.

Preoperative preparations General All patients undergo a preoperative physical evaluation and any patients with significant medical problems must be cleared by their internist or personal physician before their procedure is performed. Each patient is required to avoid agents known to cause platelet dysfunction for 2 weeks prior to surgery.

Smoking All patients who smoke are asked to quit 4 weeks before their procedure and are required to avoid smoking and all

Anesthesia

second-hand smoke for 2 weeks after surgery. Patients who smoke, or have a significant past history of smoking but have quit, are advised in writing that their risk of serious complications, including poor healing, flap necrosis, skin slough and thromboembolic phenomena is significantly higher than in non-smokers. Smokers should be approached with caution, however, and it should be recognized that these patients are suboptimal candidates for surgery and at higher risk for serious local and systemic complications.

Radiofrequency and ultrasonic “skin-shrinking” treatments Patients should be questioned carefully about previous non-invasive radiofrequency (RF) and ultrasonic “skin-shrinking” procedures, as these treatments appear to damage skin subdermal microcirculation and compromise superficial micro-lymphatic vessels, and patients who have undergone these treatments seem to be compromised candidates for facelift procedures. Similarly, patients who are long-standing filler users, especially if they have used more inflammatory fillers such as poly-L-lactic acid (PLLA), are likely to have internal facial fibrosis and inflammatory changes, rendering them more challenging candidates as well. The patient who has undergone facial RF and/or ultrasonic “skin-shrinking” treatments is part of a growing body of patients who seem to sustain clinically significant compromise of their skin microcirculation as a result of these and similar treatments that puts them at greater risk of slough and healing-related problems following facelift procedures and suboptimal take when fat grafting is performed. Unlike when laser resurfacing is performed, in “skin-shrinking” procedures energy is directed and dispersed under the skin rather than on its surface, and energy meant to “tighten” the face appears to damage the subdermal microcirculation, superficial micro-lymphatic vessels, and adjacent subcutaneous fat. The incidence of problems seems to parallel the number and intensity of treatments the patient has undergone, which one would expect to parallel the degree of compromise to their tissues. These patients also seem to experience prolonged edema and a longer period of recovery following facelift surgery. Consideration should be given to advising patients who have undergone previous RF and ultrasonic “skin-shrinking” treatments in writing that their risk of serious complications, including poor healing, flap necrosis, and skin slough, is significantly higher than in patients who have not undergone these procedures, especially if they have undergone multiple previous treatments. From the surgeon’s standpoint, these patients should be regarded, approached, and treated as similar to smokers.

Hair color and chemical treatment of hair All patients are instructed not to color, “perm”, or otherwise chemically treat their hair during the 2-week period before and after surgery. Failure to do so may result in hair breakage and hair loss, especially if the procedure includes incisions on hair-bearing scalp. Patients are required to shower and shampoo with antiseptic soaps the night prior to surgery, paying careful attention to the periauricular areas.

253

Infection prophylaxis Patients are required to shampoo and cleanse their hair and shower with antibacterial soaps the night prior to surgery, paying careful attention to the periauricular areas. Consideration should also be given to preop chlorhexidine home prep of the body if fat grafting is to be performed. Patients who have a history of methicillin-resistant Staphylococcus aureus (MRSA) infection, patients who are healthcare workers, and other patients at risk of being MRSA carriers should be considered for MRSA testing and decolonization.

Allocating operating room time It is important that adequate OR time be allotted for contemporary facelift procedures as they are deceptively time consuming when compared to traditional techniques. A high SMAS facelift, when performed in conjunction with foreheadplasty, eyelid surgery, fat grafting, laser resurfacing and other procedures, will often encompass up to 6–8 h or more, even when performed by a “fast” surgeon working with a wellorganized and experienced operating room team. For difficult procedures, or when multiple procedures are requested, consideration should be given to staging the patient’s surgery over two consecutive days.

Anesthesia While it is possible to perform a limited procedure that one can technically call a “facelift” under local anesthesia, any such procedure necessarily encompasses significant compromises in the treatment of the SMAS and platysma that form the foundation of the modern facelift. The use of local anesthetic will not allow the performance of important related and ancillary procedures including comprehensive fat grafting, deep neck lifting, and often-needed forehead surgery, upper lip lift, laser skin resurfacing, and earlobe reduction, etc. due to limits on the amount of local anesthetic that can be administered and on the patient’s and surgeon’s tolerance for the procedures’ complexity and length. Adding oral and/or intravenous (IV) sedation (“conscious sedation”) to procedures performed under local anesthesia can improve the patient’s experience and facilitate the performance of more comprehensive operations, but it negates many of the purported advantages of a “local” technique. It also places the surgeon in the role of anesthesiologist and in charge of monitoring the patient and managing and treating intra-operative problems (hypertension, arrhythmias, etc.). Most modern facelift techniques, including the high SMAS procedure, are time consuming and technically demanding and arguably will test the patience and composure of almost any surgeon. It is highly recommended that any surgeon new to these techniques enlists the services of an anesthesiologist or competent Certified Registered Nurse Anesthetist (CRNA) as part of a team approach to patient care. This is particularly important when the procedure is to be performed upon a patient who is apprehensive or has a history of anesthetic difficulties, hypertension, or other significant medical problems. This will avert the frustration and aggravation of trying to perform a technically demanding

254

SECTION II

CHAPTER 9.8  • High SMAS facelift: combined single flap lifting of the jawline, cheek, and midface

procedure while simultaneously being shouldered with the responsibility of supervising the administration of an anesthetic, monitoring the patient, and managing intra-operative problems. The majority of our facelifts are performed under deep sedation administered by an anesthesiologist using a laryngeal mask (“LMA”) airway (Fig. 9.8.27) and this technique has allowed us to perform more comprehensive surgeries with increased patient comfort. A laryngeal mask allows the patient to be heavily sedated without compromise of their airway, but the patient need not receive muscle relaxants and can be allowed to breath spontaneously. A laryngeal mask is also less likely to become dislodged during the procedure than an endotracheal tube, and it is less likely to trigger coughing and bucking when the patient’s head is turned or when they emerge from their anesthetic. It is useful to modify the way in which the laryngeal mask is used in facelift procedures. Traditionally, the LMA cuff is inflated to create a seal so that a ventilator and positive pressure ventilation can be used and inhalation anesthetics can be administered. This is not necessary when patients are not paralyzed and only heavily sedated using IV agents, however,

and when the patient is allowed to breath spontaneously. In such cases the cuff of the LMA can be left uninflated, or be minimally inflated, and the LMA left to function as simply a large oral airway. Not inflating the cuff limits pressure in the hypopharynx and related postoperative discomfort in the throat and positive pressure ventilation. Some surgeons have expressed concern that the LMA, especially with the cuff inflated, will cause distortion of the neck that would result in confusion in decision making when performing deep neck and other neck lift procedure maneuvers. We have found this not to be the case, and while a bulge is often evident if the LMA cuff is inflated, the surgeon can simply ignore it and carry out all neck maneuvers as usual and as indicated. The bulge created by the inflated cuff will not affect gauging the extent to which deep layer neck maneuvers are carried out (submandibular gland reduction, subplatysmal fat resection, and digastric muscle reduction) or interfere otherwise with the neck lift procedure (platysmaplasty, platysmyotomy, drain placement, etc.).

Preoperative anesthesia medications Most patients receive preoperative medication tailored and adjusted to their age, weight, height, personality, specific circumstances, and general health. Typical preop medications currently used for patients in good health without contraindications and as appropriate for their weight and general conditions include clonidine (1–3 mg orally), atenolol (12.5–25 mg orally), and midazolam 3–5 mg intramuscular (typically deltoid injection). These medications should be administered after all preoperative discussions have been made, patient questions answered, and preoperative consents and other related paper-work signed. Oral narcotics should not be given as part of the premedication, as they commonly result in nausea and vomiting. Cocaine, anticholinergics, and parasympathomimetics are also avoided in our practices. Antiemetics are given routinely in a preemptive fashion at the beginning of each procedure and typically include ondansetron (10 mg IV) and dexamethasone (3–5 mg IV). It should be noted that dexamethasone is administered for its antiemetic properties and not as a means to reduce swelling. Patients with a history of motion sickness, perioperative nausea and vomiting, or other risk factors, are given medications to block the emetic reflex at multiple levels that typically include aprepitant (Emend; 40–80 mg orally) and/or a scopolamine patch (placed on the upper inner thigh).

Patient monitoring during anesthesia

Figure 9.8.27  The flexible laryngeal mask airway, which maintains an open airway during deep sedation but allows patients to breathe spontaneously. When the flexible model shown is used and the breathing circuit is draped separately, unobstructed access to the neck and submental region can be obtained.

All patients are fully monitored with electrocardiography, automatic sphygmomanometry, pulse oximetry, and capnography. Perioperative blood pressure is closely monitored and aggressively treated should it become significantly elevated, especially in patients with existing hypertension or a “borderline” condition. The latter group of patients should be watched closely and treated preemptively, as they typically become hypertensive once the surgery and anesthesia are begun.

Surgical technique

Method of intra-operative sedation The current method of patient sedation during our facelift procedures relies on the administration of intravenous propofol. Typically a bolus (1–2 mg/kg) is administered by the anesthesiologist prior to LMA insertion, followed by a drip infusion administered via an infusion pump depending on the patient’s circumstances and titrated to their needs (75–200 μg/kg/min). If fat grafting is being performed, fat harvesting is performed at the beginning of the procedure and before the patient’s face is prepped and draped, and the anesthesiologist may temporarily inflate the cuff on the LMA so that an inhalation anesthetic (sevoflurane or similar) can be administered to provide a brief period of deep sedation during that part of the procedure. The cuff is then deflated or its pressure reduced before the face is prepped and the patient draped for the facelift procedure. In most cases the IV anesthetic infusion is titrated to a deeper level for a brief period once the patient has been prepped and draped to give the surgeon a few minutes of deep sedation in which to perform local anesthetic nerve blocks and infiltrate all proposed sites for incision with local anesthetic solution.

Surgical technique The sequence of events in the facelift procedure as we perform it is outlined in Box 9.8.1.

Patient positioning, urinary catheter insertion, and patient marking The patient is placed supine on a well-padded operating table and attached to appropriate physiological monitors. Time is taken to ensure and document that the elbows, heels, and other potential pressure points are well protected. The lower extremities are then elevated and antiembolic pedal compression devices applied. An indwelling balloon-tipped urinary catheter (“Foley catheter”) is placed after sedation is begun or anesthesia administered, and the facelift incision plan is marked with a fine-tipped surgical marker after skin to be marked is degreased with isopropyl alcohol. If fat grafting is being performed, fat is harvested at this time, before the face is prepped and draped. This typically entails turning the patient into a right and left lateral decubitus position. A temperature probe is then taped in the axilla or groin, and the patient sufficiently covered or a patient warming device used, to allow the room to be cooled for the comfort of the scrubbed team members.

Patient prepping and draping Patients receive a full prep of the entire scalp, face, neck, shoulders, and upper chest with full strength (1:750) benzalkonium chloride (Zephiran) solution after bland ophthalmic ointment is instilled into each eye. Drapes are then applied leaving the entire head and neck region unobscured from the clavicles up. This allows unimpaired examination of cervicofacial contours throughout the procedure and provides complete access to all areas of the scalp. No head drapes are

255

used as they will limit scalp access and make it difficult to determine hair shaft inclination and to make incisions properly parallel to hair follicles. The breathing circuit is draped separately from the patient by wrapping it with a section of sterile sheet or covering it with a sterile stockinette. This allows it to be moved during the procedure as the patient’s head is turned from side to side and away for the submental area when working in the neck through the submental incision. After the general prep of the scalp, face and neck is complete and drapes have been applied, the auditory canals are prepped with povidone-iodine (Betadine) using cotton-tipped swabs by a scrubbed member of the surgical team. Each nasal vestibule and the perioral area are prepped with povidoneiodine as well. “Peanut” (Kittner) sponges are subsequently placed in each auditory meatus and these are changed as necessary during the procedure to prevent the accumulation of blood in the ear canals. No hair is cut or shaved at proposed sites for incisions. Shaving or trimming hair will preclude accurate assessment of hair shaft inclination relative to the scalp and this can, in turn, result in incisions that injure hair follicles. Because tightly applied rubber bands, adhesive tape, surgical lubricants, antibiotic ointment, and hair clips produce similar problems, their use should be avoided as well.

Administering local anesthesia Local anesthetic is administered even if general anesthetic is used. This limits simulation of the patient during surgery and the overall amount of anesthetic needed. A significant hemostatic effect is also obtained when epinephrine and tranexamic acid containing solutions are used. Sensory nerve blocks are performed using 0.25% bupivacaine (Marcaine) with epinephrine 1:200,000. Sites marked for incisions are then infiltrated with the same solution (Fig. 9.8.28). Fat grafting, if planned, is then performed. After fat grafting is complete, areas where subcutaneous dissection is to be made are infiltrated with 0.1% lidocaine (Xylocaine) with epinephrine 1:1,000,000) and tranexamic acid (1000 mg per 500 cc of local anesthetic solution) using a 22 ga spinal needle and 1.6 mm × 20 mm blunt infiltration cannula, taking care to ensure that the total dose of lidocaine (Xylocaine) does not exceed 7 mg per kilogram per 4 h. No direct infiltration of the SMAS or platysma is necessary if the overlying subcutaneous tissues are infiltrated generously at the beginning of the procedure. Approximately 150–200 cc of dilute local anesthetic solution is infiltrated subcutaneously into each side of the face and neck. Maintenance of the local block is achieved by systematically re-infiltrating the key areas (pre- and postauricular regions) and readministering nerve blocks before the local anesthetic effect wears off. This prevents loss of continuity of the local anesthetic effect and stimulation of the patient that would otherwise occur should re-injection be delayed until after sensation has returned.

Making incisions Incising the skin is a key step in which the surgeon exercises direct control over the quality of the resultant scar, and incisions should not be made in a casual or careless manner.

256

SECTION II

CHAPTER 9.8  • High SMAS facelift: combined single flap lifting of the jawline, cheek, and midface

BOX 9.8.1  Sequence of events in facelift procedure: overview • • • • • • •

• • • • • • • • • • • •

• • • • •

• •

•

• •

• •

Induce anesthesia Mark incisions while Foley catheter placed Harvest fat Position patient, prep. face, drape Perform nerve blocks and inject incisions with 0.25% bupivacaine w epinephrine Inject fat Infiltrate skin to be subcutaneously undermined with 0.1% lidocaine w epinephrine solution w 1.6 mm × 20 cm blunt infiltration cannula Raise skin flap on right side face Raise skin flap on left side of face Raise SMAS flap on right side of face Raise SMAS flap on left side of face Make submental incision and subcutaneously undermine submental skin and join with subcutaneous dissection made in lateral neck Incise platysma midline Elevate platysma on right over anterior belly of digastric to submandibular gland (SMG) Incise capsule of SMG and mobilize SMG inside capsule (mobilize more than planned resection) Identify anterior belly of right digastric muscle near mentum Dissect under lateral boarder of subplatysmal fat pad on inferior surface of digastric to insertion on lateral hyoid and into SMG capsule Divide lateral boarder of subplatysmal fat over anterior belly of digastric (using cautery) Dissect right side of subplatysmal fat pad off anterior belly of digastric and deep fascia with cautery (do not include interdigastric fat) Inject approximate line of resection of mobilized SMG and anterior belly of digastric with 0.25% bupivacaine w epinephrine) Repeat elevation of platysma left side Incise capsule of SMG and mobilize left SMG inside capsule (mobilize more than planned resection) Identify anterior belly of left digastric muscle near mentum Dissect under lateral boarder of left side of subplatysmal fat pad on inferior surface of digastric to insertion on lateral hyoid on the left and carry into SMG capsule Excise subplatysmal fat pad leaving interdigastric fat between anterior digastric bellies and in suprahyoid sulcus Inject approximate line of resection of mobilized left SMG and anterior belly of left digastric muscle with 0.25% bupivacaine w epinephrine) Resect protruding portion of right SMG along plane tangent to ipsilateral border of mandible and anterior belly of ipsilateral digastric muscle using cautery Resect protruding portion of right anterior digastric belly if indicated Resect protruding portion of left SMG along plane tangent to ipsilateral border of mandible and anterior belly of ipsilateral digastric muscle using cautery Resect protruding portion of left anterior digastric belly if indicated Raise and suspend superior margin of SMAS flap on side of face that sags most parallel to long axis of zygomaticus major muscle

All incisions on hair-bearing scalp must be made precisely parallel to hair follicles to avoid injury to them. A carelessly made incision will injure follicles and can result in peri-incisional alopecia. Frequently this is mistakenly attributed to the patient’s own poor healing and incorrectly regarded as a “wide scar”.

• Trim posterior margin of ipsilateral SMAS flap to match cut edge beneath it and close over parotid gland under no tension • Raise and suspend superior margin of SMAS flap on opposite side of face parallel to long axis of zygomaticus major muscle and trim posterior margin of ipsilateral • SMAS flap to match cut edge beneath it and close over parotid gland under no tension. • Gauge platysma excess on medial platysmal borders and excise • Suture trimmed medial borders of platysma muscles edge-to-edge in one layer with interrupted sutures from menton to mid-thyroid cartilage without invaginating tissue and under normal muscle tension (perform platysmaplasty). Do not tighten in corset fashion • Suspend postauricular transposition flaps to mastoid fascia on right and left side • Perform chin augmentation if indicated • Divide medial half of right and left platysma muscles at level of mid-thyroid to cricoid cartilage through submental incision (with electrocautery or Metzenbaum scissors) • Divide lateral half of right and left platysma muscles below inferior aspect of postauricular transposition flaps through postauricular incisions (with electrocautery or Metzenbaum scissors) • Place subcutaneous and subplatysmal 10 F round JP drains • Irrigate with antibiotic solution and make final check for hemostasis • Redrape skin on right side of face, gauge excess within supraauricular area with facelift marker and suspend under normal skin tension at key point of anchoring above ear • Anchor postauricular skin flap in apex of postauricular defect at key point of anchoring behind ear without trimming superior margin of skin flap • Trim anterior edge of postauricular skin flap to match curve of posterior concha and close with simple interrupted sutures of 4-0 nylon • Use facelift marker to gauge skin excess along occipital portion of postauricular incision. Trim excess skin. Close under no tension with a combination of half-buried vertical mattress sutures of 4-0 nylon and simple interrupted sutures of 6-0 nylon • Trim and close temporal incision under no tension • Trim and close prehelical part of pre-auricular incision under no tension • Trim and close the prelobular part of pre-auricular incision under no tension • Trim and close the tragal incision under no tension and maintain skin to fill the pretragal sulcus • Inset the lobule (perform earlobe reconfiguration or reduction if indicated first) • Perform temple-foreheadplasty as indicated • Perform blepharoplasties, canthopexy, and levator reinsertion as indicated • Perform upper lip lift if indicated • Close the submental incision • Perform buccal fat reduction if indicated • Perform perioral and/or lower eyelid laser resurfacing if indicated (no lasering should be performed on cheek skin that has been undermined).

In most cases, follicles and hair shafts will be similarly inclined, but this may not be true in patients with kinky or curly hair, or when a patient’s hair is wet, saturated with surgical lubricants, or restrained with drapes, tape, or rubber bands. Because of this it is important to confirm by direct

Surgical technique

257

Figure 9.8.28  Local anesthetic solutions. (A) Nerve blocks and incision sites: 0.25% bupivacaine with epinephrine. Maximum safe doses of bupivacaine with epinephrine in mg: patient’s weight in kg × 3. For example, for a typical 60-kg female patient, maximum dose equals 70 mL of 0.25% bupivacaine with epinephrine. Rule of thumb: 1 mL of 0.25% bupivacaine with epinephrine per kilogram of body weight. (B) Subcutaneous infiltration with 0.1% lidocaine with 1:1,000,000 epinephrine. Solution mixture: 50 mL of 1% lidocaine, 10 mL 0.25% bupivacaine, 1 g tranexamic acid, 1 ampule epinephrine, in 500 mL normal saline. Maximum safe dose of lidocaine with epinephrine in mg: patient’s weight in kg × 7. For 60-kg female patient, 150–200 mL of solution per side. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

observation that the incision is precisely parallel to hair follicles as it is made on the scalp. One must also recognize that hair follicle inclination is not uniform over the scalp and that follicles will be inclined differently at different areas along the planned incision. Because of this, the angle of the scalpel blade with the scalp must change correspondingly as the incision is made, and the completed incision will be beveled to varying degrees and in different directions, if properly made. Incisions made along skin–scalp interfaces should be beveled slightly to the scalp side to leave one or two rows of hair follicles beneath the sutured incision. An exaggerated bevel, advocated by some surgeons, is not needed and is typically counterproductive, as it usually results in regrowth of hair that is kinky and unruly and thus of concern to the patient.

Skin flap elevation After incisions are made, skin flaps are elevated in a subcutaneous plane according to the preoperative plan (Fig. 9.8.29B). Partial separation of the skin flap from the SMAS (“lamellar dissection”) is necessary because skin and SMAS flaps need to be advanced in different directions if an optimal outcome is to be obtained. This “bidirectional” tissue shift is not possible if a “deep plane” or “composite” elevation of a combined, monolayer, skin-SMAS flap is made. Skin flaps should be elevated sharply under direct vision and blind dissections avoided. This is particularly important in the great auricular corridor, the pre-auricular region, and over the upper-medial cheek where a deep dissection can injure the underlying SMAS and compromise its use as a flap. It has been our observation that many surgeons using non-SMAS facelift techniques engage in a deeper dissection than they realize and inspection of their flaps after dissection often reveals that part of the SMAS has elevated as part of the “skin” flap. Adjustments to their technique must be made if damage to the SMAS is to be avoided and a robust SMAS flap to be raised.

Although subtle, some visual clues are helpful in determining when the proper plane has been established. If skin flap dissection is made too deep and SMAS fibers are elevated with it, the undersurface of the skin flap will appear relatively smooth and covered by streaks of fine white tissue. When transilluminated, flaps dissected in this manner will appear “cloudy” and relatively “thick”. If dissection is made in the proper plane, however, the undersurface of the flap will have a characteristic rough, “pebbled” or “cobblestone” appearance and be more yellow in color. Transillumination of a flap dissected in the correct plane enhances this appearance. Although subcutaneous undermining is necessary, it should not arbitrarily include the entire face. If a SMAS dissection is planned, preservation of the anterior platysma-cutaneous ligaments will allow attractive and youthful-appearing elevation of perioral tissue that cannot be obtained with a “skin-only” technique, or when wide skin undermining is performed (see Fig. 9.8.29A,B; and 9.8.30). These ligaments anchor the dermis of the perioral cheek to the SMAS and upper platysma and provide a means of lifting the lateral perioral area without over-tightening the skin of the upper lateral face. Preservation of the platysma-cutaneous ligaments also preserves important accompanying perforating vessels to the cheek flap. This reduces the likelihood of flap slough, swelling and compromise.

Temple dissection The temple incision is made according to the preoperative plan based on the redundancy present over the upper lateral cheek and the predicted degree of displacement of the sideburn and temporal hairline (see preceding section). When a traditional incision on the temporal scalp is indicated, it is made precisely parallel to hair follicles. This will generally require that the incision be beveled to varying degrees and in different directions along its length and hair follicles are not uniformly inclined over the scalp. The dissection is then deepened and carried down through the galea (“superficial temporal fascia”) to the

258

CHAPTER 9.8  • High SMAS facelift: combined single flap lifting of the jawline, cheek, and midface

SECTION II

Traditional undermining

A

Extended undermining

B

Figure 9.8.29  Extent of subcutaneous undermining. Shaded (yellow) area shows area of subcutaneous skin flap undermining in (A) traditional (incorrect) and contemporary “extended” (B) (correct) plans. Note that the platysma-cutaneous ligaments (black dots in (B)) are not undermined and are preserved in the extended plan. Preservation of platysma-cutaneous ligaments and proper elevation and fixation of the SMAS provide a lift and support of lateral perioral tissues that is lost if the cheek is over-dissected as shown in (A). Note also in the extended undermining plan the temple is released (1) to accommodate upper cheek and midface tissue shift, the zygomatic ligaments (2) are divided to release upper cheek and midface, the mandibular ligaments (3 – see also Fig. 9.8.30) are divided to optimize improvement in the jowl and along the jawline, and the submental restraining ligaments (4 – see also Fig. 9.8.30) are divided to soften the “double chin” and allow the fat of the chin and the submental region to be blended once deep layer neck maneuvers have been completed. These releases were not made in traditional skin undermining plans. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

platysma-cutaneous ligaments

mandibular ligaments

submental retaining ligaments

Figure 9.8.30  Plan for subcutaneous undermining shown on patient. Shaded (yellow) area shows area of subcutaneous skin flap undermining. Note that skin undermining is limited in the perioral cheek to preserve the platysma-cutaneous ligaments but extend up along the posterior onto the inferior border of the jawline to release the mandibular ligaments that contribute to jowl and pre-jowl groove formation, and superiorly up onto the anterior-inferior chin to release the submental retaining ligaments that contribute to a “double chin” appearance. The transverse solid purple line marked on the skin of the submental area is the site where the submental incision will be made. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

fascia of the temporalis muscle and the temporal hair-bearing fasciocutaneous flap anterior to the incision undermined. This dissection is usually easy to perform and should be carried anteriorly to the lateral brow, inferiorly to the mid-temple, and superiorly to the temporal line. The bridge of tissue lying inferiorly between the subgaleal dissection in the temple and the subcutaneous dissection in the cheek (“mesotemporalis”) can then be safely and conveniently partially divided posterior to the temporal hairline if the anatomy of the frontal branch of the facial nerve is understood and the division is made thoughtfully and in the correct location (Fig. 9.8.31). Usually this bridge of tissue contains the anterior branch of the superficial temporal artery and it must be divided and ligated when encountered, or thoroughly cauterized. The frontal branch of the facial nerve lies well anterior and inferior to this chosen point of transition between planes however, and this dissection, when executed as described, is anatomically sound and clinically safe. Partially dividing the bridge of tissue between the deep plane of the temple and the subcutaneous plane of the cheek is an important maneuver that allows the two planes of dissection to be joined laterally. This in turn facilitates exposure in the upper cheek and lateral orbital area, dissection of the SMAS, and redraping of the temporal portion of the facelift flap. This scheme of dissection also protects hair follicles on the undermined temporal scalp by moving the plane of dissection subgaleally and well deep to them. Temporal skin can then be undermined subcutaneously up to the lateral orbit, bringing the dissections in the cheek and temple into wide continuity.

Surgical technique

A

259

B

Figure 9.8.31  Dividing the mesotemporalis. When conditions dictate that the temporal portion of the facelift incision should be made within the temporal scalp the bridge of tissue situated between the subgaleal dissection in the temple and the subcutaneous dissection in the cheek (A) can safely be divided posterior to the course of the frontal branch of the facial nerve (B) (dotted yellow line (see also Fig. 9.8.36 and Pitanguy’s landmark). This bridge of tissue contains the anterior branch of the superficial temporal artery, which must be divided and cauterized or ligated (white arrows in (B)) (Courtesy of Timothy Marten, MD, FACS, used with permission.)

A

B

C

Figure 9.8.32  Length of the temple hairline incision. The superior extent of the temporal hairline incision will vary depending upon the amount of cheek skin shift predicted (and whether a forehead lift is to be concomitantly performed) if puckering and gathering are to be avoided in this area. Note that a female patient is shown; in male patients the incision should have a more rectangular masculine design (see Chapter 9.11, Male facelift and Fig. 9.8.10). (A) Superior extent of temple hairline incision when modest cheek skin displacement is predicted (white dotted line). (B) Superior extent of temple hairline incision when moderate cheek skin displacement is predicted (white dotted line). The incision must be made higher to accommodate the cheek skin shift, but it still is situated in a well-concealed location. (C) Superior extent of temple hairline incision when large cheek skin displacement is predicted (white dotted line). This incision should be made no higher than the junction of the temporal hairline with the frontotemporal hairline, however (white arrow). If it is carried more superiorly along the frontotemporal hairline (red X), the resulting scar will usually be visible, as hair tends to grow posteriorly in that area.

When an incision along the temporal portion of the anterior hairline is called for, it is made a few millimeters within it with a slight bevel, or parallel to the hair follicles. The superior extent of temporal hairline incision will necessarily vary depending upon the amount of cheek skin shift predicted and whether a forehead lift is to be concomitantly performed if puckering and gathering are to be avoided in this area. Often small superior extensions beyond what was marked preoperatively are needed if a smooth and well-tailored closure is to be obtained. This incision should be made no higher than the junction of the

temporal hairline with the frontotemporal hairline, however. If it is carried more superiorly, the resulting scar will usually be visible, as hair tends to grow posteriorly in that area (Fig. 9.8.32). A temporal skin flap is carefully undermined subcutaneously and joined with the subcutaneous dissection in the cheek. No transition between planes is necessary in these situations, no hair-bearing flaps are raised, and the superficial temporal vessels and frontal branch of the facial nerve are left undisturbed, beneath the superficial temporal fascia (Fig. 9.8.33).

260

SECTION II

CHAPTER 9.8  • High SMAS facelift: combined single flap lifting of the jawline, cheek, and midface

Figure 9.8.33  Skin flap dissection with temporal hairline incision. When an incision is made along the temporal hairline all dissection is in a subcutaneous plane and no transition between planes is necessary, no hair-bearing flaps are raised, and the superficial temporal vessels are left undisturbed. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

Figure 9.8.34  Markings for the high SMAS flap. The superior margin of the high SMAS flap (methylene blue ink line) is marked over the zygomatic arch (black lines) and not below it, starting at the level of the infra-orbital rim and extending posteriorly to a point approximately 1 cm anterior to the superior margin of the tragus. It is then turned inferiorly in front of the ear and extends inferiorly and slightly posteriorly to the anterior border of the sternocleidomastoid muscle approximately 2–3 cm below the mandibular border. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

SMAS dissection Once skin flaps have been elevated they are retracted and the zygomatic arch palpated. A line is then traced “high” over its mid-portion in water-soluble surgical ink (methylene blue) from infra-orbital rim to a point approximately 1 cm anterior to the superior aspect of the tragus. This line lies “higher” than the dissection made in most other techniques (and thus the origin of the name “high SMAS”) , and well above the malar origin of the zygomaticus major muscle. The mark is then turned inferiorly and carried over the pre-auricular portion of the parotid 1.5–2 cm anterior to the ear. Inferior to the lobule it is carried inferiorly and slightly posteriorly to the anterior border of the sternocleidomastoid muscle approximately 2–3 cm below the mandibular border (Fig. 9.8.34).

Figure 9.8.35  Plan for posterior margin of the high SMAS flap and the marginal mandibular nerve branch. The marginal mandibular branch of the facial nerve (yellow line) emerges from the anterior border of the inferior portion of the parotid gland (black line) well anterior to the SMAS incision over the posterior jawline/ upper lateral neck region. Note that mark for posterior incision curves posteriorly to the anterior border of the sternocleidomastoid muscle and extends 2–3 cm inferior to the mandibular border. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

A basic “high” flap of this type is raised on most patients and there are several important advantages in its design worth considering. First, planning the superior margin of the flap over and along the zygomatic arch, rather than inferior to it, expands the effect of the flap to include the midface and infraorbital regions, and allows a better vector to be applied to them. Carrying the incision posteriorly and inferiorly over the tail of the parotid to the anterior border of the sternocleidomastoid muscle in the upper lateral neck, also maintains a “safety zone” between the incision and the mandibular margin and moves the dissection away from the marginal mandibular nerve (Fig. 9.8.35). Flap elevation is begun by incising the SMAS over the zygomatic arch. This is accomplished by grasping the preauricular tissue overlying the lateral arch with an Allis clamp on each side of the marked line. An incision is then made with Metzenbaum scissors or needle-tipped cautery set on a low current setting and continued medially 1–2 cm along the marked line in the tensed plane. Allis clamps are then released and reapplied incrementally as the dissection proceeds further medially along the marked line in the tensed plane in 1–2 cm segments in a similar fashion. A considerable amount of tissue lies over the arch and the frontal branch will be safely concealed beneath several millimeters of fibrous fat (Fig. 9.8.36). The margin for error may be reduced, however, in the thin, aged patient with advanced facial atrophy and less soft-tissue cover over the arch – or in a secondary procedure. Extra caution must be taken in those situations. The pre-auricular limb of the SMAS incision is then made using a similar technique over the posterior parotid along the marked line in the pre-auricular region. It is continued inferiorly and posteriorly to the anterior border of the sternocleidomastoid muscle approximately 2 to 3 cm inferior to the mandibular border. These two incisions define the “high” SMAS flap to be elevated. After initial SMAS incisions have been completed preauricular tissue comprising the posterior-superior corner of the SMAS flap is grasped with Allis forceps and flap elevation

Surgical technique

Figure 9.8.36  Pitanguy’s landmark for the frontal branch of the facial nerve. Pitanguy’s landmark for the frontal branch of the facial nerve (yellow dotted line) is a line extending from the inferior margin of the tragus to a point 1.5 cm superior to the lateral eyebrow. It can be seen that the nerve lies under the flap only at its upper lateral-most corner where it is anatomically consistent at 9 mm deep, and safely deep and posterior to all but the very first part of the SMAS flap dissection. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

Figure 9.8.37  Extent of SMAS undermining. Complete release of the SMAS flap requires that both the masseteric-cutaneous ligaments along the anterior border of the parotid gland (small black squares) and the zygomatic ligaments near the origin of the zygomatic major muscle (small black circles) are released. Note that minimal undermining is needed inferiorly because there are no restraining ligaments restraining the SMAS in that area but a more “extended” SMAS release is needed in the upper cheek and midface area. (The group of parallel lines shown in the cheek represent the origin of the zygomaticus major muscle.) (Courtesy of Timothy Marten, MD, FACS, used with permission.)

is then begun using careful scissors dissection or needle-tipped cautery set on a low current setting. Undermining should be limited in the pre-parotid cheek, more extensive over the zygoma and upper midface (Fig. 9.8.37 – see also Fig. 9.8.2, traditional vs. extended SMAS).

261

SMAS flap elevation will entail dissection in the plane just superficial to the facial nerve and in close proximity to important motor branches. Although flap elevation over the parotid is safe, great care must be taken when dissecting more medially and over the zygomatic arch. Frequently, motor nerve branches accompany perforating vessels and each bleeding point must be carefully identified when hemostasis is being performed. Blind clamping should not be performed and low coagulation current should always be used. The patient’s face should also be carefully watched whenever cauterization is performed and the current discontinued immediately if facial twitching is noted. Sub-SMAS dissection must generally be carried over the anterior border of the parotid in the lower cheek to insure that masseteric-cutaneous ligaments tethering the SMAS are released (see Fig. 9.8.37, small squares/round dots). These are most easily identified by fingertip palpation along the front of dissection. If these restraining attachments are not released, an optimal SMAS effect will not be realized in the lower cheek and along the jawline, and suboptimal overall benefit will be obtained. As SMAS flap dissection is carried anteriorly and medially in the upper cheek over the superior portion of the parotid and its accessory lobe, the SMAS will be seen to thin and invest the lip elevators. At this point the dissection must be “extended” to the superior portion of the zygomaticus major muscle and its origin typically is visualized and carefully partially exposed. Just at the malar origin of the zygomaticus major muscle, the zygomatic ligaments will be encountered (see Fig. 9.8.37, small black circles). These fibrous connections between the periosteum and skin restrain the upper cheek and midface and must be divided if an optimal “high SMAS” effect is to be obtained. Directly inferiomedial to the origin of the zygomaticus major muscle, and superiomedial to the accessory lobe of the parotid and the parotid duct, lies the zone of transition between the zygomatic and masseteric-cutaneous ligaments and the most potentially difficult part of the SMAS dissection. Proper liberation and release of the SMAS flap usually requires at least partial division of restraining attachments in this area, but moves the dissection into very close proximity to the zygomatic branch of the facial nerve (see also Fig. 9.8.38). Although experienced surgeons make this dissection appear easy and they often seem to minimize the risk involved, it can be difficult for the less-experienced surgeon to distinguish between nerve branches and ligamentous attachments in this area. Anatomic variations are also common in this region, and in some cases nerves will penetrate the deep fascia early and travel directly in a sub-SMAS plane or send a branch over the zygomaticus major to the orbicularis oculi. If confusion is encountered or the anatomy seems unclear, it is better to limit dissection until additional experience and familiarity with this region is obtained. A helpful technique in making a safe sub-SMAS dissection is to raise the SMAS flap with a needle-tip cautery set on a low setting rather than using a scissors. When such a technique is used a gentle separation of the tissue layers can be made and when proximity to motor nerve branches occurs soft facial twitching will be noted. If a question arises as to whether an area of tissue contains a nerve branch or a ligament, the surgeon can briefly apply a pulse of low cautery current near the area in question. If it twitches a nerve branch is likely present and further dissection must be made with care. If no twitch is seen

262

SECTION II

CHAPTER 9.8  • High SMAS facelift: combined single flap lifting of the jawline, cheek, and midface

Neck lift Before SMAS flaps are suspended and cheek skin flaps trimmed and sutured, attention is turned to the neck and deep neck maneuvers (subplatysmal fat resection, submandibular gland reduction, and modification of the anterior bellies of the digastric muscles) are performed. If an attempt is made to perform these procedures after SMAS flaps have been suspended, exposure will be difficult. Platysmaplasty should not be performed before SMAS flap suspension, however. If platysmaplasty is performed first, the overall effect of the SMAS on the face will be compromised.2

Figure 9.8.38  Completed SMAS flap dissection. An extensively dissected SMAS flap showing important surgical anatomy. Inferior to the origin of the zygomaticus major muscle, and superior-medial to the accessory lobe of the parotid, lies the zone of transition (red circles) between the zygomatic ligaments (blue circles) and the masseteric-cutaneous ligaments (black circles), and the most potentially dangerous part of the SMAS dissection. Proper release of the SMAS flap usually requires at least partial division of restraining attachments in this area of transition, but moves the dissection into close proximity to zygomatic branches of the facial nerve. Care should be taken when dissecting in this area. Other important anatomy shown includes the origin of the zygomaticus major muscle, the origin of the zygomaticus minor muscle, the malar fat pad, and the platysma. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

a nerve branch is not present and the dissection can be continued further if indicated. Wearing low magnification (2.5 ×) loupes also helps the surgeon follow the correct plane and stay on top of the shiny parotidomasseteric fascia that overlies the facial nerve branches as they emerge from the anterior border of the parotid and over the masseter muscle by providing the surgeon better visualization of the tissue being dissected and the structures that are present. Loupes and low energy needle-tip cautery dissection allow the surgeon to advance the front of dissection incrementally by cutting only a thin veil of tissue at a time and avoiding cutting a large amount that might contain a nerve branch.

Assessing completeness of SMAS flap dissection While anatomy and anatomical structures provide important signposts to the surgeon, as clinicians we seek a clinical result (lift of facial tissues) and dissection of the SMAS flap and release of restraining ligaments is continued until gentle traction on the flap produces motion at the cheek, nasal ala, philtrum and stomal angle, and elevation and compression of infra-orbital and lower eyelid region. This “traction test” clinically confirms adequate flap release and is a more important indicator of a complete dissection than any arbitrary anatomical endpoint. If flap release is incomplete, residual tethering fibers are identified, carefully divided, and the traction test repeated. When dissection is complete, the malar pad and attached skin will move freely as part of the “high” SMAS flap superiorly and laterally and no separate suturing or subperiosteal dissection is required.

SMAS suspension and proper SMAS vector Once the SMAS flap has been elevated and adequately released the superior edge of the flap is grasped and it is shifted variously to determine which direction produces the best effect on the upper midface, cheek and jowl. In all but the unusual case this is along a posterior-superior vector parallel to the long axis of the zygomaticus major muscle. If a “vertical” or posterior vector is used, the function of the zygomaticus major muscle will be corrupted and abnormal appearances during animation may result (Fig. 9.8.39). Management of the superior margin of the SMAS flap and the technique of flap suspension will vary depending on considerations particular to the patient including sex, race and overall facial morphology, and the chosen location of the temporal part of the facelift incision. As such, how the superior margin of the SMAS flap is suspended is not arbitrary, and it will depend on the patient’s circumstances and the aesthetic outcome desired. SMAS flap suspension options provide the surgeon an opportunity to improve and optimize the patient’s appearance and should be carefully considered.

SMAS suspension in the narrow face In many cases no trimming of the superior margin of the flap is performed as the overlapping tissue segment adds volume to and restores lost projection over the zygomatic arch and “ovalizes” the Caucasian female face, restoring shape lost with age. In these situations and when the temporal part of the facelift incision has been made within the temporal scalp, the superior edge of the SMAS flap is raised along a vector parallel to the long axis of the zygomaticus major muscle (see Fig. 9.8.39) up over the zygomatic arch and is anchored with interrupted sutures of 3-0 PGA (Vicryl) (or other suture of choice) well over the zygomatic arch directly to the deep tempo­ral fascia, superior to the divided mesotemporalis. Suspension in this manner is greatly facilitated if the inferior border of the divided mesotemporalis is gently pushed inferiorly as sutures are placed. This scheme solidly suspends the midface, upper cheek and jowl with no risk of injury to the frontal branch of the facial nerve (Fig. 9.8.40). No suturing is needed or should be performed over the zygoma or along the infra-orbital rim. These parts of the face are mobile and need to move during animation and for

SMAS suspension when the temporal incision is along the temporal hairline

B

A

263

C

Figure 9.8.39  Proper and improper vector of SMAS shift. (A) The proper direction of shift of the SMAS is along a vector parallel to the long axis of the zygomaticus major muscle (green arrow). If the SMAS is shifted along a posteriorly directed vector (B) (red arrow) and not along the long axis of the zygomatic major muscle, the muscle is pulled off its axis and its function compromised. This can result in deepening of the nasolabial fold, abnormal appearances during facial movement, and a pulled “clown mouth” appearance, as pull is applied to the risorius muscle (black arrow). An analogous problem is encountered when a vertical vector (C) (red arrow) is used in a “vertical facelift” and the zygomaticus major muscle is pulled medially off its axis of function. A vertical vector also applies pull to the zygomaticus minor muscles and can result in a sneering appearance to the mouth (black arrow). (Courtesy of Timothy Marten, MD, FACS, used with permission.)

A

B

Figure 9.8.40  High SMAS flap suspension when the temporal part of the facelift incision has been made within the temporal scalp. (A) The temporal portion of the facelift incision was made within the temporal scalp (see Fig. 9.8.31 – dividing the mesotemporalis). The SMAS flap has been advanced superiorly, parallel to the long axis of the zygomaticus major muscle (see Fig. 9.8.39 –proper and improper vector of SMAS shift), the mesotemporalis pushed inferiorly, and the flap is shown being sutured directly to the deep temporal fascia. (B) Suspension of the superior and posterior SMAS flap margins is complete (after the posterior margin has been trimmed – see Figs. 9.8.45 & 9.8.46). Note that no suturing is required over the anterior zygoma or along the infra-orbital rim as the midface is included in the flap and rises with it. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

natural expression. Directly suspending the midface along the zygoma or infra-orbital rim can result in tissue tethering and dimpling upon animation.

SMAS suspension when the temporal incision is along the temporal hairline When an incision along the temporal hairline is used and temporal dissection is made in a subcutaneous plane, temporalis muscle fascia will not be exposed and a mesotemporalis will

not be present. In these cases an incision through the galea can be made at the inferior edge of the sideburn to expose the temporalis muscle fascia. If thoughtfully planned the superficial temporal artery can typically be preserved when this galeotomy incision is made and if dissection is carefully performed. However, it should be noted that these vessels are routinely divided when the mesotemporalis is divided in cases where the temporal part of the facelift incision is made on the temporal scalp, and they can be divided and ligated in this situation without concern as well. Once the galeotomy has been performed, SMAS flap suspension can then be made to the temporalis muscle fascia, as previously described (Fig. 9.8.41).

SECTION II

264

A

CHAPTER 9.8  • High SMAS facelift: combined single flap lifting of the jawline, cheek, and midface

B

C

D

E

F

Figure 9.8.41 High SMAS flap suspension when the temporal portion of the facelift incision is made along the temporal hairline. (A) Completed high SMAS flap dissection in a patient who has a temporal hairline incision. Here the patient is male: therefore the incision has a more masculine angular plan. For women, incisions should be planned with soft curves and made in a less angular fashion (dotted white line). If the high SMAS flap were raised at this point, it would impinge on the sideburn area. (B) Temporal galeotomy to expose deep temporal fascia for high SMAS flap anchoring. To avoid impingement on the sideburn and to facilitate firm anchoring of the high SMAS flap, the sideburn is retracted with a double-pronged 10-mm skin hook, and the galea aponeurotica (superficial temporal fascia) is incised with electrocautery anterior the superficial temporal vessels to expose the deep temporal fascia. (C) Comparison of fascial exposure with temporal incision within the temporal scalp vs. along the temporal hairline. Left side: the superficial temporal fascia (galea) has been incised beneath the sideburn and the sideburn reflected superiorly. This process exposes the deep temporal fascia, to which the SMAS will be anchored. Note that the superficial temporal artery can often (but need not) be preserved as shown when this dissection is made. Right side, above: division of the mesotemporalis when the temporal portion of the facelift incision (white dotted line) has been made in the temporal scalp (younger patients). Right side, below: completion of division of the mesotemporalis (galeotomy). Note that the subgaleal plane in the temple and the subcutaneous plane in the cheek have been united and the deep temporal fascia has been exposed, similarly to that shown at left, where the temporal portion of the facelift incision is made along the temporal hairline. (D) Protection of the frontal branch of the facial nerve while performing temporal galeotomy and exposing deep temporal fascia. The sideburn is retracted and the galeotomy completed with electrocautery on each side of the superficial temporal vessels, preserving them to expose the deep temporal fascia. Note that to avoid injury to the frontal branch of the facial nerve (dotted orange line), the galeotomy must roughly follow the external contour of the sideburn and must not extend anteriorly to the lateral canthus. (E) Anchoring the high SMAS flap to the deep temporal fascia exposed in steps A–D. The high SMAS flap has been raised parallel to the long axis of the zygomaticus major muscle (see Fig. 9.8.39A) and its superior margin anchored to the deep temporal fascia exposed in steps A–D with 3–0 Vicryl sutures (or other suture of choice). Black triangles represent approximate sites of suture placement. Gently pushing the divided mesotemporalis inferiorly facilitates suture placement. “trifurcating” the SMAS flap (see Figs. 9.8.42 and 9.8.43) also facilitates high SMAS flap anchoring if the flap does not easily reach the galeotomy site. Note that no sutures are needed over the zygoma or onto the anterior cheek, as the anterior portion of the flap and the midface ride up with the lateral part of the flap. (F) Completed anchoring to the high SMAS flap. The SMAS flap has been advanced and its superior margin securely suspended to the deep temporal fascia. After SMAS flap suspension, the reflected sideburn is returned to its original position (dotted black line) and reanchored there before skin trimming and suturing in the temporal area is performed. Note that overlapping of SMAS widens the interzygomatic distance and “ovalizes” the face. Dotted black line along the zygomatic arch shows where the high SMAS flap was harvested from and the degree of overlapping. (Courtesy of Timothy Marten, MD, FACS, used with permission.)  

Trimming and management of the posterior margin of the SMAS flap

A

265

1 2

C

3

B

D

A

B

C

Figure 9.8.42  Trifurcated high SMAS flap. (A) A high SMAS flap can be trifurcated into three component parts, the superior portion of which can optimize support of the anterior face and facilitate suspension to the temporalis muscle fascia. The flap is raised superiorly after it has been dissected and an incision is made 2–3 cm into it as shown over the zygomatic arch (dotted red line). The black dotted lines (A) show the superior margin of the high SMAS flap, the black dotted line (B) show the posterior margin of the flap, and black dotted line (C) shows where the high SMAS flap will be trimmed to create the postauricular transposition flap, and the black dotted line (D) shows the approximately location of a partial platysma myotomy. (B) The three component parts of the trifurcated SMAS flap are shown: (1) the superior portion to be anchored to deep temporal fascia to suspend the midface (see Fig. 9.8.43), the (2) main portion to be anchored to the cut edges where the flap was harvested from that suspends the lower cheek and jowl, and (3) the postauricular transposition flap created from excess tissue on the posterior margin of the flap that is left attached to the cervical platysma that will be anchored to mastoid fascia to suspend the lateral platysma border. (C) The trifurcated SMAS flap advanced and sutured. The red arrow shows the enhanced vector of anchoring of the anterior face and midface that is provided by the superior segment of the flap. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

SMAS suspension with a trifurcated SMAS flap A useful and convenient variation of overlapping the superior margin of the SMAS flap over the zygomatic arch and suspending it to the deep temporal fascia described in the two scenarios above that can optimize support transmitted to the upper cheek and midface is the “trifurcated SMAS flap”14 (Fig.  9.8.42). The name comes from the idea that the main body of the SMAS flap can be divided into three component parts to optimize its effectiveness – a superior segment to optimize support the upper cheek and midface (discussed here), the main body of the flap to support the mid-lower cheek and jowl, and a postauricular transposition flap to support the lateral border of the platysma in the upper lateral neck. This flap is best used in circumstances when a robust SMAS flap has been raised and it is particularly useful when the superior SMAS flap margin does not easily reach the exposed temporalis muscle fascia. Conversely, it is less useful when the flap is thin and fragile, or when it easily is raised to the point of suspension on the temporalis muscle fascia. To create a trifurcated SMAS flap, the SMAS flap once dissected and released is elevated parallel to the long axis of the zygomaticus major muscle and an incision is made 2–3 cm into the posterior margin of the flap at the level it was originally harvested from creating a tab of tissue that is then rotated superiorly and anchored to the temporalis muscle fascia (Fig. 9.8.43). The cut edge from which the flap was separated is then sutured to the cut edge overlying the zygomatic

arch where the original flap was harvested from. Substantial anchoring of the SMAS flap can be obtained in this manner, and in many cases increased support of the anterior face and midface can be obtained.

SMAS suspension when interzygomatic widening is not desired While overlapping the SMAS in the upper lateral face is beneficial and will improve the shape and contour of the faces of many patients undergoing facelift procedures, in patients with wide faces and a small mandible, in many men, and in many patients of Asian or Slavic ancestry, enhancement of the upper cheek and arch and the broadening the face obtained by overlapping the SMAS as described above may not be aesthetically appropriate, necessary, or desired. In such cases the redundant tissue along the superior flap margin can be excised and discarded, and the superior flap margin sutured edge-to-edge to the superior margin of the initial incision made in the SMAS over the zygomatic arch where the SMAS flap was harvested (Fig. 9.8.44).

Trimming and management of the posterior margin of the SMAS flap Regardless of how the superior margin of the flap is secured, some trimming of the posterior margin of the cheek SMAS

266

SECTION II

CHAPTER 9.8  • High SMAS facelift: combined single flap lifting of the jawline, cheek, and midface

A

B

Figure 9.8.43  Trifurcated high SMAS flap in a patient. (A) A trifurcated high SMAS flap has been formed by incising the superior margin of the flap to create a superior segment of SMAS tissue. (B) The three component parts of the trifurcated SMAS flap are shown: (1) the superior segment seen anchored to temporalis muscle fascia to suspend the midface, (2) the main portion to be anchored to the cut edges and where the flap was harvested from that suspends the lower cheek and jowl, and (3) the postauricular transposition flap created from excess tissue on the posterior margin of the flap that is left attached to the cervical platysma that will be anchored to mastoid fascia to suspend the lateral platysma border. The white arrows show the separate component applied vectors. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

A

B

Figure 9.8.44  High SMAS flap suspension when facial widening is not desired. (A) The SMAS flap has been advanced superiorly, the excess marked, and the excess tissue along the superior margin of the SMAS flap excised. (B) Excision of the superior and posterior SMAS flap margins is complete. Note that the trimmed edge of superior margin of the SMAS flap can now be sutured to the cut edge beneath it where the flap was harvested from avoiding any widening of the interzygomatic distance and facial widening. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

flap is invariably subsequently required if the flap is advanced along a proper vector parallel to the long axis of the zygomaticus manor muscle to allow an edge-to-edge approximation to the SMAS remnant in the pre-auricular region. Overlapping of the SMAS in the pre-auricular area is functionally unproductive and artistically inappropriate as such an action lends no additional support to the anterior face and obliterates natural pre-auricular contours and the pretragal hollow. Trimming of the posterior margin of the cheek SMAS flap should be performed after the superior margin has been suspended over or along the zygomatic arch as indicated. Excision is accomplished by carefully gauging the redundancy present and tracing a line in marking ink over the cut edge laying beneath it (Fig. 9.8.45A). The amount of tissue excised will vary depending upon the size of a given face, the degree of release of the flap, and the chosen vector of advancement. It is unproductive and an error, however, to place traction on the SMAS in the pre-auricular region and the posterior margin of the flap should be trimmed carefully to avoid over-excision and a tight closure. Posterior traction on the SMAS will result in traction on the risorius muscle, perioral distortion, a “pulled look” and objectionable “clown mouth” appearances (see Fig. 9.8.39B).

Suspension of the lateral SMAS border Trimming the posterior margin of the SMAS flap can be performed in a way that will provide added support to the upper lateral neck and along the cervicomental angle by leaving the tongue of tissue separated from the posterior SMAS border attached to the cervical platysma and transposing it to the mastoid process (see Fig. 9.8.45) and using it as a postauricular transposition flap.2 Combined with an anterior platysma­ plasty this creates a mastoid-to-mastoid sling of autologous tissue along the cervicomental angle to deepen and accentuate it. Note that when a postauricular transposition flap is used, platysmaplasty should be performed before it is suspended. If the postauricular transposition flaps are suspended first, midline approximation of the platysma may not be possible. When such a plan is used it is important to design the flap so that it exerts its pull below the mandibular border, and not up along it (Fig. 9.8.47). After trimming of the posterior margin of the SMAS flap, the cut edge is approximated to the pre-auricular remnant with multiple interrupted inverted sutures of 3-0 PGA (Vicryl) suture or other suture of choice (see Fig. 9.8.45C). These sutures consolidate the cheek, restore SMAS cover of the parotid gland,

Trimming and management of the posterior margin of the SMAS flap

B

A

267

C

Figure 9.8.45  Management of the posterior margin of the SMAS flap. (A) The SMAS flap has been advanced along a vector parallel to the long axis of the zygomaticus major muscle and suspended superiorly (in this case the excess along the superior margin of the flap has been excised and not overlapped). Dotted black line shows the excess along the posterior edge of the flap to be separated from it. (B) The excess SMAS on the posterior margin of the flap has been separated but left attached to the cervical platysma below the mandibular margin and transposed to the mastoid for use as a postauricular transposition flap (PATF) (see Fig. 9.8.46). (C) The posterior defect is closed edge-to-edge over the parotid gland with multiple interrupted sutures of 3-0 PGA (Vicryl). If anterior platysmaplasty is performed the PATF will be sutured to the mastoid after the platysmaplasty has been completed (see also Fig. 9.8.46). (Courtesy of Timothy Marten, MD, FACS, used with permission.)

A

B

C

Figure 9.8.46  A postauricular transposition flap can be created from the posterior margin of a SMAS flap and the flap can be used to effect improvement in the neck. (A) Schematic plan for postauricular transposition flap (PATF). (B) After separation of excess tissue on the posterior margin of the SMAS flap and transposition to the postauricular area. Note that flap is left attached to the cervical platysma. Note also that to be effective the flap must be created so that it pulls under the mandibular border and not higher up along it. (C) After elevation and suturing of a SMAS flap and suturing of a PATF to the mastoid fascia (typically some shortening of the flap is performed). In combination with anterior platysmaplasty (dashed line) a mastoid-to-mastoid sling of autologous tissue that accentuates the cervicomental angle is created. (Note: platysmaplasty should be performed first and then suspension of PATF is made.) (Courtesy of Timothy Marten, MD, FACS, used with permission.)

and help support the superior suture line, but should not be used to put posterior traction on the SMAS flap. Upon completion of suturing of the cheek SMAS improved facial contour should be seen and a faint smile in the anesthetized patient’s face should be evident. Usually elevation of the lid–cheek junction and compression of lower eyelid tissue will also be seen if a complete high SMAS effect has been achieved (Fig. 9.8.48).

Drain placement Drains are routinely used and experience has shown that they reduce postoperative ecchymosis and seromas, and allow patients to return to their work and social lives sooner. A 10 F round “end-perforated” “Jackson-Pratt” style closed-circuit

suction drain is placed subcutaneously across the anterior-­ inferior neck through a small stab incision on the occipital scalp 1–2 cm posterior to the apex of the occipitomastoid incision. No drains are placed in the cheeks. When extensive modifications have been made to the anterior cervical and submental regions, when the patient’s face is large and the drain will not reach across to the other side, or when complete dissection across the neck is not made, one drain is placed on each side. If concomitant neck lift2 has been performed that included subplastysmal fat excision, submandibular gland reduction, and/or digastric muscle reduction, a subplatysmal drain is required and a 10 F Jackson-Pratt-style drain is placed in the subplastysmal space and exteriorized and anchored on the occipital scalp or in the postauricular area. Failure to place a

268

CHAPTER 9.8  • High SMAS facelift: combined single flap lifting of the jawline, cheek, and midface

SECTION II

Incorrect

A

Correct

B

Figure 9.8.47  Improper and proper construction of the postauricular transposition flap (PATF). (A) Improper design and construction of the PATF. The flap has been designed and constructed too superiorly and pulls along the lower face and lateral mandibular border. Such an arrangement does little to improve the neck and accentuate the jawline. (B) Correct design and construction of the PATF. The flap has been designed and constructed more inferiorly so that its resultant pull is below the mandible and along the cervicomental angle. Such a design optimizes cervicosubmental contour. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

Skin flap repositioning and suspension suture placement

Figure 9.8.48  High SMAS effect seen on the operating table. The SMAS has been suspended on the right side only and the skin has been laid back on the face but not trimmed or sutured. The effect of high SMAS flap elevation can be seen: the corner of the mouth on the right has been raised and the posture of the mouth and perioral tissues on the right side improved, the patient has upper dental show and appears to be smiling on the right side (note that the patient is under anesthesia and that this is purely the effect of SMAS flap elevation), the cheek on the right side has been raised and is fuller and more projected than on the left, and it can be seen that the lid–cheek junction has been raised on the right side and that skin has been advanced into the right lower eyelid. Compare these changes with the opposite left side where the SMAS flap has not yet been suspended. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

subplatysmal drain when doing deep layer maneuvers (subplatysmal fat excision, submandibular gland reduction, and partial digastric myotomy) will result in fluid collections (seromas, lymph fluid collections, and sialomas), and prolonged induration of the neck and submental regions and these in turn can result in permanent lumps and other irregularities.

When trimming and suturing the skin flap it must be remembered that in the contemporary facelift procedure contour is created by modifying the SMAS and deep layers of the face and that the purpose and goal of skin excision is to remove redundancy, and not to tighten the skin flap. Skin was meant to serve a covering function, not a structural or supporting one. Trying to lift the face by tightening the skin is a conceptually flawed concept that will corrupt the skin’s intended covering function and is destined to produce poor scars and unnatural “facelifted” appearances. Skin must also be shifted along a vector that is compatible with its covering function and does not result in secondary irregularities. Shifting skin along an overly “vertical” vector, or suspending skin flaps under tension, will result in poor scars, a tight, unnatural appearance, and other objectionable problems. Shifting skin too posteriorly can result in an insufficient vertical repositioning of tissue and distortion of the mouth and typically results in a “pulled”, “windblown”, and objectionable “pulled mouth look”. Cheek skin flaps should be shifted along a vector approximately perpendicular to the nasolabial fold and along a distinctly different and somewhat more posteriorly directed vector than the SMAS (see Fig. 9.8.3 and Discussion). When this is done skin will lie more naturally over the cheek and tragal region once healing is complete and an improved effect will also be obtained on the nasolabial area. The key concept to be kept in mind is that lift and contour is created by SMAS repositioning and that only skin that is truly redundant should be removed. There are two points of skin flap anchoring that set the stage for the remainder of the closure. The first point is located in the supra-auricular area where the anterior-superior-most

Skin flap trimming and closure

part of the ear joins the scalp. To set this point the cheek skin flap should be shifted along a vector roughly perpendicular to the nasolabial fold and skin redundancy then gauged with a facelift marker (Fig. 9.8.49; www.cmfmedicon.com). A “T”-shaped incision is then made into the flap at the marked point in such a manner that excess skin only is removed and the flap is anchored under normal skin tension. Making the incision in a “T”-shape facilitates suture placement and simplifies subsequent trimming of adjacent skin without cutting the anchoring suture. The flap is then anchored at this point with a half-buried vertical mattress suture of 4-0 nylon with the knot tied on the scalp side. No deep sutures are necessary or used. The second point of suspension is located in the postauricular area at the anterior-superior aspect of the transmastoid portion of the postauricular incision. To set this point the postauricular skin flap is placed over the ear and shifted posteriorly and somewhat superiorly, roughly parallel to transverse neck creases and the mandibular border, and in such a manner that skin is suspended under minimal or no tension and that little or no skin need be trimmed from the anterior border of the auricular skin flap. This provides optimal improvement in the anterior neck and submental region where it is needed most, and allows maximum excision of skin flap redundancy without shifting cervical skin and wrinkle lines onto the lower face and “lateral sweep” (see Fig. 9.8.4) that occurs when a more “vertical” vector is used. The flap is then secured at this second point with a simple interrupted suture of 4-0 nylon. No incision into the flap is necessary at this point of anchoring and no deep suture is needed or used. It is an error to excise any skin over (superior to) the apex of the transmastoid portion of the incision and to shorten the postauricular flap along the long axis of the sternocleidomastoid muscle (see red arrow in Fig. 9.8.23B) as is commonly practiced, and closure of the transmastoid portion of the postauricular incision should be made without trimming any skin. Despite an apparent redundancy in this area when the patient is supine on the

269

operating table, there is not a true skin excess at this location. This pseudo-excess of skin is present only because of the patient’s elevated shoulder position in the supine position. It will vanish when they sit up and the shoulders drop to a normal position. Skin along the axis of the sternocleidomastoid muscle is also needed for side-to-side head tilt. Inappropriate excision of skin over the apex of the occipitomastoid defect is the ultimate underlying cause of hypertrophic healing along the transmastoid part of the postauricular incision, and of a wide postauricular scar in the area (see Fig. 9.8.23A). Closure of the transmastoid incision is made with several half-buried vertical mattress sutures with the knots tied on the scalp side. If the postauricular skin flap is shifted along a more superiorly directed vector, less skin will be removed from the submental area (where it is needed most), improvement in the anterior neck will be compromised, skin will be inappropriately excised over the apex of the occipitomastoid incision, and a wide scar will likely end up being present where the scar crosses the mastoid area once healing is complete (see Fig. 9.8.23).

Exteriorizing the lobule Once the two key anchoring sutures have been placed, the flap overlying the inferior portion of the ear should be cautiously divided and the lobule exteriorized. This is a key step in the procedure that must be performed with great care if a visible perilobular scar, lobular malposition and objectionable secondary earlobe deformities are to be avoided. If the incision to exteriorize the lobule is made correctly, the apex of the incision should rest snugly against the inferior-most portion of the conchal cartilage.

Skin flap trimming and closure Trimming and closure along the conchomastoid/auriculomastoid sulcus Skin flap trimming and incision closure is typically begun in the postauricular area along the conchomastoid/auriculomastoid sulcus after anchoring sutures have been placed and the lobule exteriorized, and this is usually undertaken before trimming and closure of the pre-auricular and occipital portions of the incision and resetting of the lobule. It is begun by conservatively trimming the anterior border of the postauricular skin flap into a soft curve to match the curve of the incision made in the conchomastiod/auriculomastoid sulcus. No attempt should be made to excise large amounts for tissue from this area as this would require an overly superiorly directed vector of advancement of the postauricular skin flap. The incision is then closed with several interrupted sutures of 4-0 nylon. The closure need not be “watertight” and no deep suture is needed or used.

Figure 9.8.49  Facelift skin flap marker. The use of a facelift flap marker provides a reliable means for appropriate excisions of facial skin to be made. The pin on the lower jaw of the instrument is designed to be placed near the edge of the incision. The skin flap is then pulled over the lower jaw of the instrument, and when normal resting skin tension has been set the instrument is closed. On closing, the upper jaw of the instrument marks the precise position of the edge of the scalp flap beneath it. Top: close-up view of the instrument tip design. Bottom: schematic of the instrument in use (www.medicon.de). (Courtesy of Timothy Marten, MD, FACS, used with permission.)

Trimming and closure of the occipital incision Trimming and closure of the occipital portion of the postauricular incision should be performed after primary two-point flap anchoring, exteriorization of the lobule, and conservative trimming and closure of the incision along the conchomastoid/ auriculomastoid sulcus. If the occipital incision was made into the occipital scalp (typically patients under 40 years old – see

270

SECTION II

CHAPTER 9.8  • High SMAS facelift: combined single flap lifting of the jawline, cheek, and midface

Fig. 9.8.21), it should be closed without the excision of skin or scalp in one layer with multiple simple interrupted sutures of 4-0 nylon. This incision plan does not allow for skin to be excised without notching of the occipital hairline or counterproductive advancement of the postauricular skin flap along an overly superior vector. In addition, because this incision is usually beveled when properly made, staples will not usually provide precise wound edge approximation, and sutures are generally required if malalignment and step-offs are to be avoided. If the occipital incision has been made along the occipital hairline (typically patients over 40 years old – see Fig. 9.8.24), skin only will be excised along the posterior border of the postauricular skin flap. A facelift marker should be used to gauge skin flap redundancy (see Fig. 9.8.49), and all points along the flap should be intentionally trimmed with 2–3 mm of redundancy. If trimming is performed correctly, wound edges should abut one another, and no gaps should be present, before sutures are placed (Fig. 9.8.50). The incision is then closed in one layer with multiple half-buried vertical mattress sutures of 4-0 nylon with the knots tied on the scalp side and simple interrupted sutures of 6-0 nylon (Fig. 9.8.51). No deep sutures are required and staples are not used. This scheme will provide precise wound edge alignment and prevent cross-hatched scars (suture marks). In addition, if the incision is closed under no tension as described, an inconspicuous scar will be obtained. If the surgeon does not exercise proper restraint, however, and skin flap trimming is done in such a way that the defect must be closed under tension, a suboptimal scar will typically result.

should be obtained in many cases (see Figs. 9.8.50 and 9.8.51). If postauricular skin flap tissue quality is less that optimal, if neck skin redundancy is large, or if the postauricular flap has been over-shifted and suspended under tension, a woundlength discrepancy will be present with the skin flap side seen to be longer than the scalp side – and a “dog-ear” will often be present at the inferior-most portion of the occipital incision. This should not be chased down the occipital hairline as an obvious scar will result in the fine hair on the nape of the neck. A better result is obtained under these circumstances if the wound-length discrepancy is managed in two ways. First, a significant portion of the wound-length discrepancy can be reduced by suture placement in a manner that “micro-gathers” the longer skin flap side (Fig. 9.8.52). That is, the half-buried

Microgathering of occipital wound-length discrepancy and dog-ear management

Figure 9.8.51  Closure of the occipital portion of the postauricular incision. The occipital portion of the postauricular incision when made along the occipital hairline (typically patients over 40 years old) is closed after precise trimming so that wound edges abut one another before sutures are placed with a combination of half-buried vertical mattress sutures of 4-0 nylon with the knots tied on the scalp side and simple interrupted sutures of 6-0 nylon to provide precise wound edge alignment. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

If the postauricular skin flap is of good quality and it has been shifted along a proper vector and tissue distributed appropriately under no tension over the occipital area, little or no wound-length discrepancy should be seen and a precise fit

Figure 9.8.50  Trimming and closure of the occipital portion of the postauricular incision. A facelift marker should be used to gauge skin flap redundancy (see Fig. 9.8.49), and all points along the flap should be intentionally trimmed with 2–3 mm of redundancy. If trimming is performed correctly, wound edges should abut one another, and no gaps should be present before sutures are placed as shown. Note that skin should be excised along the occipital hairline only and not above the transmastoid portion of the postauricular incision. Note that illustration shows the location of the second point of skin flap suspension (white arrow). (Courtesy of Timothy Marten, MD, FACS, used with permission.)

Figure 9.8.52  “Microgathering” of skin to reduce wound-length discrepancy along the occipital incision. When the postauricular skin flap is advanced along an optimal posterosuperior vector roughly parallel to the mandibular border, a wound-length discrepancy will often be present, with a longer incision on the skin flap side and a shorter incision on the scalp side. This can be reduced by “microgathering” of the skin flap side by placing half-buried vertical mattress sutures of 4–0 nylon with the knots tied on the scalp side 10 mm apart from each other on the scalp side and 12–14 mm apart on the skin flap side. Each suture placement reduces wound-length discrepancy and the amount of dog-ear present at the inferior-most part of the incision.

Skin flap trimming and closure

vertical mattress sutures of 4-0 nylon are placed 10 mm apart on the scalp side but 12–14 mm apart on the skin flap side. With each such suture placement the wound-length discrepancy is incrementally reduced. In most cases, if this manner of suture placement is continued as one proceeds inferiorly, by the time the inferior-most part of the incision is reached the majority of the wound-length discrepancy has been addressed and is no longer present, and typically what was once a large “dog-ear” has been markedly reduced or eliminated. The second maneuver used to address wound-length discrepancy along the occipital incision and the residual dog-ear still present after microgathering of the majority of the discrepancy by the suture technique described above is to inset the remaining dog-ear posteriorly into the occipital scalp, above the junction of thick and fine hair. This typically requires a small extension of the incision inferiorly and that

271

a small ellipse of scalp then be excised from the scalp side of the incision. This maneuver simultaneously lengthens the still slightly shorter scalp side of the incision (a curve is longer than a straight line), creates a cut-out into which the dog-ear can be inset, and moves the end of the incision into dense hair where it is well-concealed (Fig. 9.8.53).

Trimming and closure of the temporal incision Once closure of the postauricular area has been completed, attention is typically turned next to the temple area. If the temporal portion of the facelift incision has been made in the temporal scalp (see Fig. 9.8.9 – typically patients under 45 years old) the incision is closed in one layer without excision of any hair-bearing temporal tissue with multiple simple interrupted sutures of 4-0 nylon. A small amount of cheek

A

B

C

D

Figure 9.8.53 Insetting the postauricular dog-ear at the inferior aspect of the occipital incision. (A) A wound-length discrepancy is typically present at the inferior-most aspect of the occipital portion of the postauricular incision, resulting in a dog-ear at its inferior aspect on the skin flap side. When a dog-ear does form, as shown, the redundant tissue is best managed by insetting it into the occipital scalp (green line). Trimming the dog-ear off in a traditional fashion (red line) will not fully accommodate the wound-length discrepancy present and will move the scar into a more visible location in the fine hair on the nape of the neck. (B) Lengthening the scalp side and creating an inset for the dog-ear by excision of an ellipse of tissue from the scalp side. The incision has been extended inferiorly a short distance parallel to the hair follicles, and an ellipse of scalp tissue (in forceps) is excised from the scalp flap side of the incision, into which the dog-ear will be inset (note that the dog-ear itself on the neck side is only minimally trimmed or not trimmed at all). This creates a curved, geometrically longer (longer distance between two points) curved surface into which the dog-ear will be fitted on the scalp side. (C) Ellipse of scalp excised and dog-ear inset. The ellipse of tissue has been excised from the scalp side of the incision and removed, and the wound-length discrepancy has as a result been eliminated. The dog-ear itself has been undermined and released, but not trimmed (or trimmed only a small amount) and has not been sutured. (D) Completed insetting of the dog-ear into the inferior aspect of the occipital hairline incision. After suturing, it can be seen that the dog-ear has been eliminated by insetting it into the cut-out made on the opposite, scalp side, and the inferior-most part of the incision has been moved into thicker hair on the scalp, where it is less visible than if it had been excised in a traditional fashion (red line in (A)).  

SECTION II

272

CHAPTER 9.8  • High SMAS facelift: combined single flap lifting of the jawline, cheek, and midface

skin and scalp only will be excised immediately above the ear at the completion of the closure. In most cases a modest wound-length discrepancy will present with the flap edge side longer than the scalp edge side and this can be managed by the “microgathering” technique discussed previously for management of would length discrepancy along the occipital hairline incision – that is, simple interrupted sutures of 4-0 nylon are placed 10 mm apart on the scalp side but 15 mm apart on the flap side. With each such suture placement the wound-length discrepancy is incrementally reduced. In most cases, if this manner of suture placement is continued as one proceeds superiorly, by the time the superior-most part of the incision is reached the majority of the wound-length discrepancy has been addressed and is no longer present. If not, the incision can be extended superiorly and anteriorly slightly to allow a well-aligned closure. Because the incision on the temporal scalp is usually beveled when properly made, sutures, and not staples, are generally required to obtain a well aligned wound, and if malalignment and step-offs are to be avoided. If the temporal portion of the facelift incision has been made along the temporal hairline (typically patients over 45 years old; see Figs. 9.8.7 and 9.8.10), skin only will be trimmed when it is closed. A facelift marker should be used to gauge temporal skin excess and the flap intentionally trimmed with 2–3 mm of redundancy. If trimming is performed correctly, wound edges

A

should abut one another, and no gaps should be present, before sutures are placed. The incision is then closed in one layer with a combination of half-buried vertical mattress sutures of 4-0 nylon with the knots on the scalp side and simple interrupted sutures of 6-0 nylon. Staples should not be used.

Trimming and closure of the pre-auricular incision Pre-auricular trimming and closure should be performed next. Skin flap redundancy should be gauged using a facelift marker while the pretragal portion of the skin flap is held down into the pretragal hollow with an instrument by the assistant (Fig. 9.8.54). This ensures that enough skin will be present to fill the pretragal sulcus and to provide a natural and attractive transition from the cheek to the ear once healing is complete. This is also a key step in avoiding “retracted tragus” and “buried tragus” irregularities (see Chapter 9.12, Secondary facelift).

Earlobe reconfiguration and reduction Before insetting the lobule into the cheek flap the surgeon should consider its shape and size and the transition it made to the cheek preoperatively to see whether it can be made

C

B

D

E

Figure 9.8.54 Preserving a pretragal sulcus and avoiding the “buried tragus” and “retracted tragus” deformities. (A) The cheek skin flap should be held down into the pretragal sulcus by the assistant while the cheek skin flap is marked and subsequently trimmed by the surgeon if a natural and aesthetic appearance is to be obtained. Note that a facelift marker (see Fig. 9.8.49) is being used to mark the location of the superior aspect of the tragus and to define and mark the amount of skin to be excised from the skin flap along the anterior border of the helix. (B) Trimming the prehelical skin flap. The prehelical part of the pre-auricular incision has been trimmed. Note that the skin edges abut one another before any sutures are placed. This is key to obtaining an inconspicuous scar. (C) Trimming the tragal skin flap. The prehelical and prelobular portions of the skin flap have been trimmed and sutured. Note that the surgical assistant holds skin in the pretragal sulcus while the skin along the (retro) tragal part of the pre-auricular incision is trimmed by the surgeon. (D) Completed trimming of the tragal skin flap. Note that following trimming of the tragal skin flap, the skin edges abut one another before any sutures are placed and that a distinct depression is present in the pretragal sulcus. (E) Completed closure of the pre-auricular incision. Note that, following trimming and closure of the component parts of the pretragal incision along the pre-auricular skin flap, a tension-free approximation of tissue has been made, natural contours are present, incisions are situated along natural anatomic interfaces, and a distinct depression is present in the pretragal sulcus. Using marks made by the facelift marker as points of reference, the pre-auricular portion of the flap is trimmed to form soft curves that match the pre-auricular incision. If trimming is performed correctly, wound edges should abut one another, and no gaps should be present, before sutures are placed. The prehelical, retrotragal, and prelobular portions of the incision are then closed in one layer with multiple simple interrupted sutures of 6-0 nylon. No deep sutures are necessary or should be used. Over-trimming the tragal skin flap is a serious artistic error that will result in tragal retraction and an unnatural “chopped-off”, “buried”, or “retracted” tragal appearance (see Chapter 9.12, Secondary facelift).  

Skin flap trimming and closure

more youthful and natural-appearing. Often the earlobe will be seen to be suboptimally shaped, too large, or unnaturally attached to the cheek. In these situations an improved and more natural appearance can be obtained by reconfiguring the earlobe before insetting it into the cheek flap (see Fig. 9.8.54). Earlobe reconfiguration is begun by marking the redundant portion on both the outer and inner sides of the lobule. Often the existing pierced earhole can be used as a radius about which the line can be planned and drawn (red dotted line in Fig. 9.8.55B). Once marked, the lobule is hyperinflated with local anesthetic solution. This makes incising the skin along the marked lines and resecting the redundant tissue easier and reduces bleeding from the cut edges. If the earlobe is floppy and lacking in turgor, skin only can be excised and the fat present spared and pushed into the lobule upon wound closure. Closure is then made meticulously with a simple running suture of 6–0 polypropylene (Prolene, Ethicon, Somerville, NJ, US) or other suture of choice. Care should be taken to ensure that the closure is not overly tight and that the wound edge is well approximated and not scalloped. Once reconfigured, the lobule can then be inset into the cheek as described in the following section. A variation of earlobe reconfiguration is earlobe reduction, in which the lobule is simply not reshaped but actually reduced in size. In such cases a longer incision is typically necessary and a larger piece of tissue is removed as appropriate for the situation and in keeping with the characteristics of the rest of the ear. When the earlobe is reduced, often existing pierced earholes are sacrificed or need to be punched out with a biopsy punch and closed to avoid having them too close to the margin of the reconstructed lobule. Reducing the earlobe when it is overly large creates a more youthful and natural

A

B

273

look, reduces a “grandfatherly” or “grandmotherly” appearance, and helps avert a tell-tale “young face–old ear” appearance (Fig. 9.8.56). Once reduced, the lobule can then be inset into the cheek as described as follows.

Insetting the lobule There is nothing as tell-tale and aesthetically objectionable as abnormal position of the earlobe following facelift surgery and for this reason the lobule should be inset into the cheek flap as the last step in the closure of the periauricular area. Cutting into and trimming the cheek flap to inset the lobule must be performed with great care and artistic sensitivity, and should always be performed incrementally in stages to prevent over-excision of cheek skin and an abnormal position of the earlobe. The cheek flap should be trimmed and the earlobe inset in such a manner that the lobule ends up situated in a posterior and somewhat superior position with a rounded overall shape of the lobule, even it if was in a more anterior or inferior position and square in shape before surgery. This is because the long axis of the earlobe of an artistically ideal, “non-surgical” appearing ear ideally sits approximately 15° posterior to the long axis of the ear itself in the lateral view (Fig. 9.8.57) and the lobular–facial junction should sit in a concealed, elevated position and not in a lower more visible location (Fig. 9.8.58). As this angle is reduced or shifted anteriorly, or if the lobule is mistakenly placed too far inferiorly, an old, unnatural and “facelift look” is produced (Fig. 9.8.59). Insetting the lobule into the cheek so that its long axis sits posterior to the long axis of the rest of the ear often requires that the lobule is released from tethering tissue. It is then secured in two layers. The first layer consists of several deep dermal sutures of 5-0 Monocryl. These sutures provide initial

C

Figure 9.8.55 Earlobe reconfiguration. The earlobe can be reconfigured when unaesthetically and unnaturally shaped to provide a more youthful and natural, rounded overall shape and to create a more natural-appearing transition between the lobule and the cheek, even if it was more inferiorly situated and square before surgery. (A) A patient who has undergone a previous facelift. The earlobe is unnaturally square in shape, is joined unaesthetically with the cheek, and appears heavy and masculine. Note that the tragus has an unnatural “chopped-off” appearance as well. (Procedure performed by an unknown surgeon.) (B) The red dotted line shows the portion of the lobule that is excised to obtain a more natural shape. The wound is then closed with a simple running suture of 6–0 Prolene, and the resulting scar will be situated on the lobule margin. (C) Same patient after secondary facelift that included earlobe reconfiguration. The earlobe is smaller; has a more natural, rounded, feminine shape; and no longer has a telltale “attached” appearance. The natural cleft between the lobule and the cheek has also been reestablished, and the perilobular scar no longer sits in a visible location and is tucked up into a location where it cannot be seen. The “chopped-off” tragus has also been corrected.  

274

SECTION II

CHAPTER 9.8  • High SMAS facelift: combined single flap lifting of the jawline, cheek, and midface

B

A

Figure 9.8.56  Earlobe reduction. Reducing the earlobe when it is overly large creates a more youthful and natural look and helps avert a tell-tale “young face–old ear” appearance. (A) A patient seen preoperatively with a large, “grandfatherly” earlobe. (B) Same patient after facelift and related procedures that included earlobe reduction. The earlobe is smaller and has a more youthful and natural appearance (procedure performed by Timothy Marten, MD, FACS). (Courtesy of Timothy Marten, MD FACS, used with permission.)

Long axis of ear

Normal ear

Axis of earlobe posterior to axis of ear

Figure 9.8.57  Correct insetting of the lobule. The long axis of the earlobe (red line) of an artistically ideal, “non-surgical” appearing ear ideally sits approximately 15° posterior to the long axis of the ear itself (black line) in the lateral view (procedure performed by Timothy Marten MD). (Courtesy of Timothy Marten, MD, FACS, used with permission.)

position and alignment, and protect the incision from disruption in the first few weeks after surgery. Final approximation is then made with simple interrupted sutures of 6-0 nylon (or other suture of choice).

Closure of the submental incision If a submental incision has been made and a neck lift has been performed as part of the procedure, it is typically left open but covered with a moist sponge until all other incisions have been closed to allow for a final inspection of the neck area before leaving the operating room. While ostensibly straight forward, closing this incision must be done meticulously and with care if an inconspicuous scar is to be obtained. Even a small irregularity in this area can become a great concern to the patient and spoil an otherwise excellent result. Typically the submental incision has been subject to considerable trauma from retractors and often there is a discrepancy in the thickness of the two sides, with the chin side thicker and the submental side thinner. This discrepancy must be addressed before closure is begun. A two-layer closure is then generally needed to insure a good closure and avoid a depressed scar. Closure is made with multiple interrupted subcutaneous sutures of 5-0 Monocryl followed by simple interrupted sutures of 6-0 nylon in the skin.

Dressings After all planned procedures have been completed and all incisions have been closed, the patient’s hair is washed with shampoo and conditioner and rinsed with warm water and the patient’s hair typically placed in a loose braid (if long).

Postoperative care

275

B

A

Figure 9.8.58  Concealing the perilobular scar. The cheek flap should be trimmed and the earlobe inset in such a manner that the lobule ends up situated in a superior position with a rounded overall shape and a modest cleft between the lobule and the cheek, even it if was in a more inferiorly situated and square in shape before surgery. (A) The perilobular scar has been made too low and the natural cleft between the lobule and the cheek has been obliterated. The scar sits in a visible location and the lobule has a tell-tale “attached” and square and unnatural shape (procedure performed by an unknown surgeon). (B) The perilobular scar is tucked up in a concealed location and is not visible and a cleft is present between the lobule and cheek (procedure performed by Timothy Marten, MD). (Courtesy of Timothy Marten, MD, FACS, used with permission.) Long axis of ear

Facelift ear

No dressing is required or applied as the use of closed suction drains has supplanted their use. Patients are typically discharged with a hat, scarf and sunglasses. If perioral laser resurfacing, dermabrasion, or lip augmentation has been performed a rigid disposable surgical (“cone”) mask that rests off of the perioral area is provided for the patient to use to conceal and protect the treated areas.

Postoperative care

Axis of earlobe anterior to axis of ear

Figure 9.8.59  Incorrect insetting of the lobule. If the earlobe is inset into the cheek so that the long axis of the earlobe (red line) sits anterior to the long axis of the ear (black line) in the lateral view the ear will have an unnatural “facelifted appearance” (procedure performed by an unknown surgeon). (Courtesy of Timothy Marten, MD, FACS and the Marten Clinic of Plastic Surgery, used with permission.)

A final inspection of sutured incisions is made after the hair wash is complete. If poor alignment in any area is found, it is locally re-prepped and sutures are removed and replaced as required.

All patients are discharged to an aftercare specialist with specific written instructions as to the care they are to receive. Patients are asked to rest quietly and apply cool compresses to their eyes and face for 15–20 min of every hour they are awake for the first 3 days after surgery. For most patients, edema peaks at about this time. It is not necessary or productive to apply cool compresses continually throughout the day, or at night. Compresses should be cool but not ice cold. Ice, “ice packs”, “blue ice”, and ice in plastic bags, etc., should never be applied directly to the face as this can cause frostbite in facial skin and damage fat grafts. Currently, and for some time, most of our patients use a facial cooling mask and cool water system (AqueCool Masque [Aqueduct Medical – www. aqueductmedical.com]) that provides dry, thermostatically controlled, consistent cooling. This system is convenient and comfortable for the patient, and can be used by some patients even when they sleep.

SECTION II

276

CHAPTER 9.8  • High SMAS facelift: combined single flap lifting of the jawline, cheek, and midface

A

B

C

D

E

Figure 9.8.60 Patient example1: a 42-year-old woman who had no prior plastic surgery. (A) Anteroposterior (AP) view. Left: before surgery.1 Note suboptimal eyebrow position7,11 and configuration, cheek and jawline laxity,9,10 and atrophy in the cheeks and infra-orbital area. Right: same patient, 13 months after facelift, neck lift, limited incision forehead lift, conservative upper and lower eyelifts, fat transfer, and upper lip lift. No skin resurfacing, facial implants, or other ancillary procedures were performed. Note soft, natural facial contours and the absence of a tight, pulled, or facelifted appearance. Note also improved eyebrow position, providing a more feminine and alert appearance. The cheeks and jawline have been repositioned and redundant skin removed. Atrophy in the upper cheek and infra-orbital areas has been corrected by lifting sagging cheek tissue to a youthful position and by fat transfer. (B) AP smiling view. Left: before surgery. Note that she has a sad and melancholic appearance even when she is smiling. Only half of her upper teeth can be seen. Right: same patient, 13 months after surgery. Note that the patent now has a full dental smile following her upper lip lift, and a more pleasant and radiant appearance (note that the patient had her teeth whitened and straightened after the surgery was performed). (C) Lateral view. Left: before surgery. Note that the patient appears tired and unfit even though she is trim and in excellent overall health. Right: same patient, 13 months after surgery. Note that her scars are well concealed, no distortion of the ear is present, and the earlobe is in normal position. She appears fit, decisive, and more attractive. (D) Lateral flexed view. Left: before surgery. Note neck laxity and poor neckline, suggesting an older and unfit appearance. Right: same patient, 13 months after surgery. (E) Oblique view. Left: before surgery. Right: same patient, 13 months after surgery. Note improved position and configuration of the eyebrow, restoration of cheek fullness, improved transition from lower lid to cheek, elevation of corners of mouth, smooth jawline, and improved neck. The lip lift has shortened the distance from the base of the nose to the upper lip border and improved the appearance of her mouth in repose. (All surgical procedures performed by Timothy Marten, MD, FACS.) (Courtesy of Timothy Marten, MD, FACS, used with permission.)  

Postoperative care

A

B

C

D

E

F

277

Figure 9.8.61 Patient example 2: a woman who had no previous surgery. (A) Anteroposterior (AP) view. Left: before surgery.7,11 Note ptotic eyebrows, cheek and jawline laxity, bottom heavy facial shape, and atrophy of the lips, cheeks, and infra-orbital areas. Right: Same patient after facelift, neck lift, forehead lift,1 upper and lower eyelifts, and pan facial fat grafting.9,10 No skin resurfacing, facial implants, or other ancillary procedures were performed. Note soft, natural, sfacial contours and the absence of a tight, pulled, or facelifted appearance. Eyebrow configuration has been improved. The cheeks and jawline have been lifted and the face has a more youthful, inverted oval shape. Atrophy in the temples, orbits, midface, infra-orbital, lips and perioral areas have been offset by fat grafting to create a smooth more youthful appearance. (C) AP smiling view. Left: before surgery. Note that despite a bright smile she has a tired and melancholic appearance. Right: same patient after surgery. Her smile is natural. An improved neckline can also be seen even in this front view. (D) Oblique view. Left: before surgery. Note brow ptosis, loss of cheek contour, poor posture of the mouth, heavy jowl, and oblique neck. Note also that the patient has a large submandibular salivary gland, evident as a fullness in the upper neck area. Right: same patient after surgery. Note improved transition from lower eyelid to cheek, smooth jawline, and attractive neckline. The enlarged submandibular gland has been reduced in size to obtain optimal neck contour. (E) Lateral view. Left: before surgery. Note lower eyelid fat protrusion, flat cheek, atrophic mouth, heavy jowl, and poor neckline. Right: same patient after surgery. Note improved brow position, improved transition from the lower eyelid to the cheek, improved cheek contour, well-defined jawline, and attractive, youthful-appearing neckline. Note that lips are fuller, that scars are well concealed, no distortion of the ear is present, and the earlobe is in normal position. (F) Lateral flexed view. Left: before surgery. Note how neck laxity and poor neckline lend an unfit and elderly appearance. Right: same patient after surgery. Note fuller lips, improved transition from lower eyelid to cheek, well-defined jawline, and attractive and fit-appearing neckline. (All surgical procedures performed by Timothy Marten, MD, FACS.) (Courtesy of Timothy Marten, MD, FACS, used with permission.)  

SECTION II

278

CHAPTER 9.8  • High SMAS facelift: combined single flap lifting of the jawline, cheek, and midface

A

B

C

D

E

Figure 9.8.62 Patient example 3: a 55-year-old woman, who has had no prior surgery. (A) Lateral view. Left: before surgery. Note eyebrow ptosis, infra-orbital atrophy, poor lip projection, labiomandibular groove, geniomandibular groove, and poor neckline. Right: same patient, 1 year and 3 months after surgery. Note elevation of the eyebrow, improved transition from the lower eyelid to the cheek, shorter upper lip, improved projection of the lips, correction of jowl, filling of labiomandibular and geniomandibular grooves, welldefined jawline, and attractive, youthful-appearing neckline. Note that all scars are well concealed, no distortion of the ear is present, and the earlobe is in normal position. Fat grafting of the radix has produced the appearance that a rhinoplasty was performed, even though it was not. (B) Anteroposterior (AP) view. Left: before surgery. Note suboptimal eyebrow configuration, sagging of cheek, poor integration of jawline with chin, atrophy of the lips, cheeks, and infra-orbital area, and long upper lip. Right: same patient, 1 year and 3 months after facelift, neck lift, forehead lift, upper lip lift, laser resurfacing of lower eyelids and upper lip, and fat injections to the forehead, temples, radix, cheeks, mouth, lips, geniomandibular groove, jawline, and under eye areas. Note soft, natural, facial contours and the absence of a tight, pulled, or “facelifted” appearance. Facial shape has been significantly improved and the patient now has a fit, healthy appearance. Although fat has been added to the patient’s face, it has a more trim and fit appearance. Note also that lips are fuller but natural-appearing. (C) AP smiling view. Left: before surgery. Note dull smile with suboptimal upper dental show and that even while smiling she has a tired and melancholic appearance. Right: same patient, 1 year and 3 months after surgery. The patient has a better smile with improved upper dental show due to the upper lip lift procedure. Fat grafting of the lips has produced a healthier and more sensual oral appearance. (D) Lateral flexed view. Left: before surgery. Note how neck laxity and poor neckline lend an unfit and older appearance. Right: same patient, 1 year and 3 months after surgery. Note improved eyebrow position, improved transition from the lower eyelid to the cheek, more attractive cheek profile, fuller lips, shorter upper lip, well-defined jawline, and attractive and fit-appearing neckline even when the patient looks down. All scars are well concealed, no distortion of the ear is present, and the earlobe is in normal position. Improvement in her nasal profile as a result of fat grafting the radix is evident. (E) Oblique view. Left: before surgery. Note eyebrow ptosis, sagging of her cheeks and jawline, and bottom-heavy, boxy facial shape. Note also long upper lip, poor posture of the mouth, deep geniomandibular groove, and hollow temple that impart an older and unfit appearance. Right: Same patient, 1 year and 3 months after surgery. Note softer, fuller face, improved transition from lower eyelid to cheek, improved cheek contour, smooth jawline, and improved posture of the mouth. The long upper lip has been shortened and the lips themselves fat grafted and resurfaced to produce a more youthful and sensual appearance. (All surgical procedures performed by Timothy Marten, MD, FACS.) (Courtesy of Timothy Marten, MD FACS, used with permission.)  

Postoperative care

A

B

C

D

279

E

Figure 9.8.63 Patient example 4: a 37-year-old woman who had had prior upper blepharoplasty, rhinoplasty, chin implant, and neck liposuction performed by unknown surgeons. (A) Anteroposterior (AP) view. Left: before surgery. Note cheek sagging, jawline laxity, poor posture of the mouth and suboptimal eyebrow configuration. Note also upper eyelid hollowness resulting from her previous blepharoplasty procedure. Right: same patient 1 year and 3 months after facelift,6 neck lift,1 temple lift,7,11 lower blepharoplasty, and fat injections.9,10 She has also had cosmetic eyebrow, eye line, and lip tattooing performed elsewhere. No skin resurfacing, facial implants, or other ancillary procedures were performed. The patient has soft, natural facial contours and no tight, pulled, or facelifted appearance. Note improved eyebrow position and configuration, improved cheek fullness, improved jawline, and overall more alert, fresher, more feminine appearance. Fat grafting has reduced hollowing in the upper and lower orbital areas, filled the tear trough areas, blended the chin and jawline, and subtly augmented the lips. (B) AP smiling view. Left: before surgery. Note somewhat sad appearance, even when smiling. Right: same patient 1 year and 3 months after surgery. Note improved facial shape, soft, natural facial contours, and the absence of distortion when emoting. The posture of the mouth is improved and the smile appears warmer. Overall, the patient appears more rested and engaged. (C) Lateral flexed view. Left: before surgery. Note fullness and “double chin” appearance despite previous submental liposuction. Right: Note improved jawline; and fit-appearing, attractive neckline. (D) Lateral view. Left: before surgery. Note tear trough, sagging cheek, labiomandibular groove, and poor jawline. Note also neck fullness and poor neckline, despite prior submental liposuction. Right: same patient 1 year and 3 months after surgery. Note restoration of cheek fullness, improved transition from lower eyelid to cheek, elevation of corners of mouth, smooth jawline, and improved neck. No scars are visible, no distortion of the ear is present, and the earlobe is in normal position. Note also subtle enhancement of nose, lips and chin from fat injections. (E) Oblique view. Left: before surgery. Note cheek sagging, jawline laxity and poor posture of mouth. Note also unaesthetic transition from lower eyelid to cheek. Right: Same patient 1 year and 3 months after surgery. Note improved facial shape, restoration of cheek fullness, improved transition from lower eyelid to cheek, and smooth jawline. Note also subtle filling of lips achieved by fat grafting. The patient’s face has a fresher, fitter, more athletic, and more feminine appearance. (All surgical procedures performed by Timothy Marten MD, FACS. (Courtesy of Timothy Marten, MD, FACS, used with permission.)  

280

SECTION II

CHAPTER 9.8  • High SMAS facelift: combined single flap lifting of the jawline, cheek, and midface

A

B

D

E

C

Figure 9.8.64  Case example 5: A 55-year-old Hispanic woman, who had had no prior plastic surgery. (A) Anteroposterior (AP) view. Left: before surgery. Note sagging cheeks, heavy jowls, protruding lower eyelid fat, nasolabial lines, and thin lips. The patient has a stern and disapproving appearance. Right: same patient 1 year and 6 months after facelift, neck lift,1 limited incision forehead lift,7,11 upper and lower blepharoplasties, chin augmentation, and fat transfer9,10 to the lips and cheeks. Note smooth facial contours, more youthful facial shape, and absence of a pulled or a facelifted appearance. The lower eyelid fullness has been reduced and a smooth transition is present between the lower eyelid and cheek. Note also that her lips and cheeks are fuller as a result of the fat injections. (B) AP frowning view. Left: before surgery, she has strong frown muscles that produce deep creases and an intense angry appearance. Right: same patient, 1 year and 6 months after surgery. She is trying to frown in this photograph, but she is no longer able to do so to the same extent because of corrugator muscle modification performed as part of the forehead lift procedure. (C) Oblique view. Left: before surgery. Note sagging cheeks, sagging jowl, hollow infra-orbital areas, and poor posture of the mouth. Right: same patient, 1 year and 6 months after surgery. Note restoration of cheek fullness, improved transition from lower eyelid to cheek, elevation of corners of mouth, smooth jawline, and improved neck. (D) Lateral view. Left: before surgery. Note protruding lower eyelid fat, tear trough, sagging cheek, sagging jowl, labiomandibular groove, poor neckline, and weak chin. Right: same patient, 1 year and 6 months after surgery. Note restoration of cheek fullness; improved transition from lower eyelid to cheek, elevation of corners of mouth, well-defined jawline; fuller lips; and attractive, fit and youthful-appearing neckline. Note that the chin implant has produced an attractive and more balanced profile. Note also that no scars are visible, no distortion of the ear is present, and the earlobe is in normal position. (E) Lateral flexed view. Left: before surgery. Neck laxity and poor neckline produces an older, unfit, indecisive appearance. Right: same patient, 1 year and 6 months after surgery. Note fuller lips, restoration of cheek fullness, improved transition from lower eyelid to cheek, elevation of corners of mouth, well-defined jawline, and attractive and fit-appearing neckline. Her chin appears subtly stronger and in better balance with the rest of her face. (All surgical procedures performed by Timothy Marten, MD, FACS.) (Courtesy of Timothy Marten, MD, FACS, used with permission.)

All patients are provided with oral analgesics, sleeping pills, antiemetics, and preservative-free ophthalmic ointment and “artificial tears” solution with instructions for their use. Patients are required to use ophthalmic ointment each night for the first 3 weeks after surgery or until all signs of eye irritation have subsided. Artificial tears are used throughout the day as needed. All patients are instructed to sleep flat on their backs without a pillow. A small cylindrical neck roll is permitted if the patient requests it. This assures an open cervicomental angle and averts dangerous neck flexion, folding of the neck skin flap, and obstruction of regional lymphatics that inevitably occurs if the patient is allowed to sleep on a standard pillow. In addition, swelling will drain to the back of the head instead of the neck when the patients lies flat, where it is not harmful, less noticeable, and more rapidly transmitted away from the head and neck area when the patient sits upright. All patients should be examined the morning after surgery. This visit is important if incipient problems are to be identified early in a treatable stage. All sutures should be checked and any appearing too tight should be cut but left in place. Releasing potentially over-tight sutures prevents necrosis, alopecia and suture marks. Leaving the cut suture in place,

rather than removing it, averts annoying bleeding from the suture site that inevitably occurs if the suture is completely removed at that time. Patients are advised to take a soft, wet, easy to chew diet, as tolerated, after surgery and are encouraged to avoid dry, salty, sour, and difficult to chew foods with a primary focus on maintaining hydration over eating. Patients are asked to abstain from the intake of alcohol for 2 weeks after surgery and until they are no longer taking pain pills (acetaminophen included) or sleeping medication. Patients begin a daily routine of showering and shampooing no later than 3 days after their procedures, but may shower the day after their surgery if they wish (“name tag” type lanyards are provided that patients can attach to their drain reservoirs). This helps remove crusting about the suture lines, keeps incisions clean and bacteria counts down, and usually improves the patient’s general overall well-being. It also facilitates suture removal. Patients are instructed that they need not be as thorough as usual when washing their hair after their procedure, and that they need not attempt to remove all dried blood and crusts. They are also assured that shower water, shampoo and conditioners are not harmful and

Summary

will not cause infection. Showering and shampooing are permitted even when drains are still in place. Drains are usually left in place until the first suture removal visit. Sutures are removed in two visits over a period of 7–9 days: 6-0 nylon sutures are removed on the first visit 5 days after surgery; half-buried vertical mattress sutures and scalp sutures of 4-0 nylon are removed on the second visit 7–9 days after the procedure. When patients return to work their social lives will depend upon their tolerance for surgery, their capacity for healing, the type of work they do, the activities they enjoy, and how they feel overall about their appearance. Patients are asked to set aside 2–3 weeks to recover from surgery. Additional time off is recommended before an important business presentation, family gathering, vacation, or like event. If patients are doing well and not experiencing problems, they are allowed to return to light office work and casual social activity 9–10 days after surgery. If a patient’s job entails strenuous activity or physical labor, a longer period of convalescence may be required. Patients are advised to avoid all strenuous activity during the first few weeks after surgery including heavy lifting, stooping, straining, and bending forward. Patients are allowed to begin light exercise within 2 weeks after surgery and gradually work up to their pre-surgical level of activity; 4–6 weeks after surgery they are allowed to engage in more vigorous activities, including most sports, as tolerated. Patients are informed that will often take 2–3 months to look good in a photograph or to be seen at an important function. They are also advised to expect some firmness in the face and submental areas for 6–9 months and that numbness will be present in some areas for 12–18 months.

Access the reference list online at   Elsevier eBooks+

281

Summary The recognition of midface ptosis as a significant component of the changes that occur in the aging face, combined with the realization that the traditional “low” SMAS and deep plane facelift produced little or no improvement in the midface region, has led to a variety of procedures designed to specifically target the midface area. Although there is merit in the idea of rejuvenating the midface, isolated midface lift procedures are aesthetically incomplete, have a steep learning curve, and have been fraught with complications. Planning a SMAS flap “higher”, along the zygomatic arch, and extending the dissection medially to mobilize midface tissue, allows a combined, simultaneous lift of the face and midface with a single unified flap and precludes the need for a separate midface lift procedure. For case examples, please see Figs. 9.8.60–9.8.64.

Declaration The concepts, methods, and techniques described and contained in this chapter are the opinions of the authors and are not intended to be construed as, or used to define, a standard of care.

Acknowledgment and retention of rights All figures, photographs, illustrations, tables, text and descriptions of concepts, methods, and techniques included in this chapter are courtesy of Timothy Marten and are used with permission.

References

References 1. Marten TJ, Elyassnia D. Neck lift defining anatomic problems and choosing appropriate treatment strategies. Clin Plast Surg. 2018;45(4):455–484. 2. Marten TJ, Elyassnia D. Management of the platysma in necklift. Clin Plast Surg. 2018;45(4):555–570. 3. Marten TJ. Lamellar high SMAS face and mid-face lift. In: Nahai Foad, ed. The Art of Aesthetic Surgery, 3rd edn. New York: Thieme Medical Publishers; 2019. 4. Marten TJ. Facelift: planning and technique. Clin Plast Surg. 1997;24(2):269–308. 5. Marten TJ. High SMAS facelift: combined single flap lifting of the jawline, cheek, and midface. Clin Plast Surg. 2008;35(4):569–603. vi–vii. 6. Marten TJ. Maintenance facelift: early facelift for younger patients in facelift: state of the art. In: Marten TJ, ed. Seminars in Plastic Surgery. New York: Thieme Medical Publishing; 2002. 7. Marten TJ. The forehead and temporal fossa: anatomy and technique. In: David Knize D, ed. Philadelphia: Lippincott Williams and Wilkins; 2001.

281.e1

8. Marten TJ. Hairline lowering during foreheadplasty. Plast Reconstr Surg. 1999;103(1):224–236. 9. Marten TJ, Elyassnia D. Facial fat grafting : why, where, how, and how much. Aesthet Plast Surg. 2018;42(5):1278–1297. 10. Marten TJ, Elyassnia D. Fat grafting in facial rejuvenation. Clin Plast Surg. 2015;42(2):219–252. 11. Marten TJ, Elyassnia D. Closed, non-endoscopic, small incision forehead lift. Clin Plast Surg. 2008;35(3):363–378. discussion 361. 12. Barton FE. Jr. The high SMAS face lift technique. Aesthet Surg J. 2002;22(5):481–486. https://doi.org/10.1067/maj.2002.128628. 13. Stuzin JM, Baker TJ, Gordon HL, Baker TM. Extended SMAS dissection as an approach to midface rejuvenation. Clin Plast Surg. 1995;22(2):295–311. 14. Connell BF, Marten TJ. The trifurcated SMAS flap: three-part segmentation of the conventional flap for improved results in the midface, cheek, and neck. Aesthetic Plast Surg. 1995;19(5):415–420. https://doi.org/10.1007/BF00453874.

 

SECTION II •  Aesthetic Surgery of the Face

9.9 The lift-and-fill facelift Stav Brown, Justin L. Bellamy, and Rod J. Rohrich

Access video and lecture video content for this chapter online at Elsevier eBooks+

SYNOPSIS

ƒ The science of facial aging as well as comprehensive knowledge of the anatomy of the facial fat compartments serve as the foundation of modern facial rejuvenation. Proper understanding of the fat compartments and danger zones in conjunction with contour-directed superficial musculo-aponeurotic system (SMAS) modifications is key to optimizing both safety and outcomes in facelifting procedures. ƒ The primary processes involved in facial aging include deep compartment fat atrophy, secondary loss of structural support and superficial fat pseudoptosis, and the resulting loss of facial shape. ƒ Historical changes in lift methodology clearly indicate the shortcomings of focusing solely on the extent of undermining, vectors and tension. Current facelift techniques have shifted from the single focus of SMAS alteration to volume restoration and facial recontouring via selective fat compartment volume augmentation. ƒ The “lift-and-fill” technique has modernized facial rejuvenation, with precise volume augmentation as a crucial component of complete facial rejuvenation. The combination of an individualized alteration of the SMAS with precise volume augmentation allows for better control in facial recontouring while addressing volume deflation. ƒ Careful analysis of facial shape preoperatively, intraoperatively and postoperatively is mandatory for successful outcomes as it allows for a tailored lift-and-fill facelift approach, optimizing facial balance and symmetry to improve facial harmony. Alternation of the direction of SMAS pull, along with individualized manipulation of SMAS volume, allow for a complete restoration of malar fullness and facial width. ƒ The deep malar (medial) compartment and nasolabial fold are always augmented first, while the high lateral (superficial) compartment and nasolabial fold are augmented last. ƒ SMAS stacking enhances width and is typically indicated for narrower faces or the narrower side. Alternatively, SMASectomy avoids enhancing fullness, which is indicated for the wider and fuller face or side. ƒ Surgical complications including hematoma and sensory and motor nerve injuries can be prevented by careful dissection under direct vision with consistent skin flap thickness evaluation. Additionally, an antihypertensive protocol for postoperative hematoma prevention is used with proactive treatment of any potential contributory factors.

Introduction Rhytidectomy remains a mainstay in facial rejuvenation today, with a 75% increase in cases observed over the past 20 years.1 With the longevity of a well-performed facelift lasting up to 10 to 12 years,2–5 rhytidectomy continues to be the most effective method of achieving long-lasting results compared to its non-surgical alternatives. It is now understood that volume deflation is one of the key components of the complex facial aging phenomenon. As a result, the focus of modern facelifting has shifted from isolated superficial musculo-aponeurotic system (SMAS) alternation to volume restoration and facial recontouring. While tissue mobilization and elevation remain a mainstay in facial rejuvenation, precise volume restoration has become a fundamental component and a powerful tool in the armamentarium of the aesthetic plastic surgeon. According to a 2015 American Society of Plastic Surgeons survey, over 85% of surgeons use fat grafting at the time of facelift,6 and significantly higher satisfaction rates have been demonstrated among patients who undergo lipofilling at the time of facelift compared with those undergoing a facelift alone.7–9 The lift-and-fill facelift, which has revolutionized the plastic surgeon’s approach to aging of the face, merges two key concepts in facial rejuvenation: (1) effective tissue manipulation by means of surgical lifting and tightening in differential vectors according to original facial asymmetry and shape; and (2) volumetric rejuvenation to the face via selective fat compartment filling of deep malar and high malar locations and nasolabial fold to precisely control facial contouring. Various SMAS manipulation techniques have been described. However, to date, a single technique has not been shown to be superior to another.7,10 Therefore, more emphasis is given to creation of smooth contour and highlights through deep and superficial volume augmentation and less to the exact method of tissue reposition.

Basic science/disease process

Using a combination of standardized preoperative and topographic visual analysis to target fat grafting to specific areas that have undergone deflation, and doing so before SMAS alteration, allows for better control in facial recontouring and results in successful correction of the aging face. In-depth understanding of the anatomy of distinct facial fat compartments and a systematic method to assess areas of fat atrophy and volume depletion, alongside recognition of vascular danger zones, are therefore essential to optimizing patient outcomes and maintaining safety during facelift procedures.11 This chapter provides an outline for the basic principles that have set the standard for the modern facelift. Based on both existing literature and clinical experience this chapter provides overviews of the principles of the lift-and-fill facelift while still allowing the experienced clinician ample flexibility in treatment strategy. In addition to a detailed text, broad reference base, instructional videos, and anatomic illustrations, we provide two clinical patient scenarios that demonstrate the key concepts of the lift-and-fill facelift technique.

Basic science/disease process Facial aging is a multifactorial process governed by both intrinsic (genetic) and extrinsic (environmental) factors that is the result of a complex interplay between the underlying craniofacial skeleton, mimetic musculature, compartmentalized facial fat, facial retaining ligaments, and the skin envelope.12–16 An understanding of facial aging is fundamental to properly restoring natural, youthful and harmonious facial characteristics in facial rejuvenation procedures. Collagen and elastin are the primary components of the skin. Toxic injury to these components,17 as well as atrophy of skin appendages and decreased extracellular matrix of the skin, contribute substantially to the process of aging through epidermal thinning, collagen loss and dermal elastosis over time.18 With age, the facial skeleton undergoes clockwise rotation of the midface in relation to the cranial base. The maxilla increases in size and becomes posterior displaced, the orbital aperture enlarges, and the mandible decrease in size in both horizontal and vertical planes.13 Prior computed tomography (CT) studies have demonstrated that the relative prominence and position of facial soft tissues are substantially influenced by the morphologic changes of the facial bony skeleton,19–21 shifting the face’s overlying retaining ligaments and soft tissue, which in turn causes deflation of distinct facial fat compartments and gives the appearance of increased skin laxity and prominent folds in the nasolabial, periorbital, and jowl regions.22,23 These volumetric changes to both the facial bones and fat compartments further influence the facial mimetic muscles’ laxity and tension.21,24,25 The concept of facial volume restoration has long been advocated as an important principle in facial rejuvenation8,22,26–41 with facial fat atrophy directly influencing both volume and shape of the aging face. The senior author (RJR) has extensively studied facial fat compartment anatomy and the role of facial fat atrophy in facial aging.22,33,42–45 Once thought of as an anatomically continuous structure, the subcutaneous fat of the face has been shown to be highly compartmentalized in a multidimensional fashion.22,33,46,47

283

Both volume deflation and distributional changes in these fat compartments contribute to the distinct morphology of the aging face, with volume deflation often preceding changes in volume distribution.12 Evidence for deflation as a primary component of facial aging has been clearly elucidated by Lambros,31 who has popularized the volumetric theory in his observations of midface and periorbital aging. In a photographic analysis of 130 subjects, he showed that the true descent of soft tissues might not be as profound as once thought, noting that the eyelid–cheek junction remained stable between the younger and older cohorts and therefore does not descend with age. Furthermore, skin landmarks such as moles and wrinkles in the periorbital and upper midface areas did not descend with time.7,22,31 These findings further support fat compartment deflation as the main cause for undesirable and aged facial contour. The lift-and-fill facelift approach addresses volume deflation, the root cause of facial aging, allowing for less manipulation of the stable surface landmarks for a more natural facial appearance. A series of dye-partition anatomic studies performed by Rohrich et al.22,33,42–44 elucidated the anatomy of superficial and deep facial fat compartments (see Fig. 9.9.1). They described the distinct fibrous septa separating the superficial and deep compartments extending from the fascial layer to the dermis. In 2014, in a cadaveric study comparing the adipocytes of the deep and superficial facial fat compartments, Wan et al.40 demonstrated a significant difference in size between the smaller adipocytes of the deep medial cheek compartment and those in the superficial nasolabial fat compartment, suggesting accelerated deflation in the deep compartments and further confirming the volumetric theory. Another major force of facial aging is volume distribution and the formation of separations between the already defined fat compartments. In a youthful face the transition between subcutaneous compartments is smooth, whereas in aging individuals there are abrupt contour changes between regions.10 Our understanding of the interplay between the deep and superficial fat compartments was further refined by introducing the concept of superficial fat “pseudoptosis”. Pseudoptosis results from the loss of support from deflation of deep compartments in conjunction with loss of support of the facial ligaments, resulting in anatomical descent of the superficial fat compartments and consecutive volume redistribution.48 In a study comparing MRIs of older and younger faces, Gosain37 demonstrated relative descent in the position of the cheek fat. These findings were confirmed by Stuzin et al.49 who suggested that descent of the midfacial soft tissues, resulting clinically with soft tissue sagging described as radial expansion, is caused by age-related elastosis and attenuation of the fibrous attachments between the skin, fat, and deep fascia. In the senior author’s experience, facial fat atrophy in facial aging carries greater significance than soft tissue laxity and osseous changes. To demonstrate these findings, Rohrich et al.33 showed volume augmentation of the deep cheek fat compartments provided improved anterior cheek projection and reduced nasolabial crease. It is with these findings that facial fat grafting gained a high value in facial rejuvenation. Age-associated soft tissue changes and loss of midface volume, particularly in the malar and submalar areas

284

SECTION II

CHAPTER 9.9  • The lift-and-fill facelift

Figure 9.9.1  Fat compartments. The superficial fat compartments of the cheek include the superficial middle and lateral malar fat. The deep midfacial fat compartments include the deep medial malar fat and the nasolabial fat. (Courtesy of Stav Brown, MD.)

require both volume restoration, as well as repositioning of ptotic tissue and removal of redundant tissue.50 Anatomic studies have provided a topographic map of the superficial and deep facial fat compartments allowing an accurate and precise augmentation of deflated facial areas in conjunction with selective SMAS-shaping techniques.4,7,8,22,33 Based on these principles, the lift-and-fill facelift has revolutionized the approach to the aging face in aesthetic surgery.7,51,52 The senior author routinely utilizes this powerful combination and selective fat compartment augmentation of the deep malar, nasolabial and oral commissures in every facelift.4,7,8,22,33,46,53

Anatomy In-depth understanding of the anatomy of the superficial and deep facial fat compartments is critical for precision in preoperative analysis and successful rejuvenation of the aging face. Fat compartments of the face are outlined in Table 9.9.1 and illustrated in Fig. 9.9.1.7,22

Retaining ligaments of the face The fat compartments and retaining ligaments of the face are intimately related. Retaining ligaments are soft-tissue support

Anatomy

Table 9.9.1  Fat compartments of the face

Fat compartments

Anatomical landmarks45

Superficial compartments Forehead – central compartment

Midline of forehead, bordered inferiorly by nasal dorsum

Forehead – middle temporal compartment

Bordered medially/laterally by central forehead fat, inferiorly by orbicularis retaining ligament

Forehead-lateral temporal malar compartment

Connects temporal fat to cervical fat, superficial to parotid gland

Periorbital – supraorbital compartment

Supraorbital, bordered superiorly and laterally by orbicularis retaining ligament

Periorbital – infraorbital compartment

Bordered inferiorly by orbicularis retaining ligament, immediately inferior to inferior lid tarsus

Periorbital – lateral orbital compartment

Bordered superiorly by inferior temporal septum, inferiorly by superior cheek septum

Cheek – middle malar compartment

Superiorly adherent to zygomaticus major, anterior and superficial to parotid gland

Cheek – high malar (lateral) compartment

Superior to middle malar fat

Jowl compartment

Bordered medially by lip depressor and inferiorly by platysma

Deep compartments Cheek – medial malar compartment

Bordered superiorly by orbicularis retaining ligament and lateral orbital compartment, lateral to nasolabial fold

Nasolabial fat compartment

Overlapping jowl fat, anterior to medial cheek fat

structures of the face arising from the underlying facial skeleton or deep fascia and are important landmarks in identifying the danger zones of facelift dissection.48 The three major retaining ligaments of the face include the zygomatic ligament, the mandibular ligament, and the masseteric cutaneous ligaments (Figs. 9.9.2 & 9.9.3, Table 9.9.2).54–56

Superficial fat compartments There are 23 superficial facial fat compartments. These encompass the forehead, periorbital, midface and lower face regions (see Fig. 9.9.1 & Table 9.9.1). The superficial fat compartments of the cheek are separated by septal barriers arising from the SMAS (see Fig. 9.9.2).22,33,48,57,58 In the midface, these include part of the nasolabial fat and the lateral, middle, and medial cheek fat. Transition areas between compartments clinically correlate with zones of fixation that are encountered when dissecting a hemiface from lateral to medial and typically have some vascular component.22,47

285

The nasolabial compartment is located medial to the deeper fat of the suborbicularis oculi fat (SOOF) compartment. It is bordered superiorly by the orbicularis retaining ligament and adherent to the lower border of the zygomaticus major muscle. In the cheek area, there are three distinct fat compartments: the medial, middle, and lateral-temporal cheek fat. Lateral to the nasolabial fold lies the medial cheek fat, bordered superiorly by the orbicularis retaining ligament and the lateral orbital compartment. The jowl fat can be found inferior to the medial cheek compartment. Anterior and superficial to the parotid gland the middle cheek fat can be found, partially adherent to the zygomaticus major in its superior portion. The zygomatic ligament can be noted in the confluence of these three superficial compartments. The parotidomasseteric ligaments are found where the medial fat compartment meets the middle cheek compartment.22,47 The most lateral compartment of cheek fat is the lateraltemporal cheek compartment. When advancing medially from the pre-auricular incision during a facelift, the first transition zone encountered corresponds with a true septum located anterior to this compartment.22,47 The lateral-temporal cheek compartment lies just superficial to the parotid gland, connecting the temporal fat to the cervical subcutaneous fat.

Deep fat compartments The deep compartments were later described and are found deep to the facial mimetic muscles overlying the maxilla (see Fig. 9.9.1 & Table 9.9.1). They influence anterior malar projection, blend the anterior cheek with the lateral cheek and provide structural support to the midface and the superficial fat compartments. Understanding the anatomy and the spectrum of their changes is vital for an individualized and tailored management strategy in facial rejuvenation.13,14,16 Unlike the superficial fat compartments that can be altered by SMAS manipulation, the deep fat of the midface is primarily manipulated using volume restoration (see Fig. 9.9.2).59,60 Deep fat compartments include the deep malar (medial) compartment, middle malar, nasolabial fold and superior cheek. Located under the orbicularis oculi muscle, the deep malar (medial) compartment is bordered laterally by the capsule of the buccal fat pad and the zygomaticus major muscle. Its medial boundary is formed by the pyriform ligament surrounding the nasal base and its superior border by the orbital retaining ligament. The deep medical cheek fat is supplied mainly by the infraorbital artery.7,22,47 The most inferior fat on the face is the jowl fat compartment. It is bordered medially by the depressor anguli oris muscle, superiorly by nasolabial fat and medial fat, and inferiorly by the membranous fusion of the platysma muscle.22

Blood supply Septal boundaries separating facial compartments are composed of a vascularized fibrous membrane carrying an identifiable perforator supplying the skin.22,47 The nasolabial fat is the most medial of the major cheek compartments. It is separated from the upper lip fat by the nasolabial septum which contains perforator vessels from the angular artery. The lateral-temporal cheek fat, which is the most lateral fat

286

SECTION II

CHAPTER 9.9  • The lift-and-fill facelift

Figure 9.9.2  Cross-section illustrating the superficial and deep malar fat compartments relative to the SMAS layer. The superficial cheek fat pads are separated by septal barriers arising from the SMAS, whereas the deep malar fat pads lie deep to and separate from the SMAS. (Courtesy of Stav Brown, MD.)

compartment, is supplied by perforators arising from the branches of the superficial temporal artery. Medial to the lateral-temporal cheek compartment is the middle cheek fat. The medial limit of this compartment is formed by the middle cheek septum, which contains perforating branches from the transverse facial artery to the overlying skin. The medial fat compartment is located in between the middle cheek fat and nasolabial fat and supplied by perforators of the facial and infraorbital arteries.22,47

Chronology of compartmental fat deflation Understanding the chronology of compartmental fat deflation with aging is integral to volumetric rejuvenation.12 Aging features that may be addressed with fat grafting are outlined in Table 9.9.3.20,41,61–67 The superficial lateral and medial, along with the deep medial, cheek compartments are classically affected early, followed by superficial malar deflation in the sixth decade. Inferior orbital rim becomes visible, as well as a centromedial cheek hollow below the tear trough, termed the V-deformity results. These findings can begin as early as the 40 s and are addressed by fat augmentation of the deep medial cheek, deep lateral cheek, and medial suborbicularis (SOOF). Cheek projection and a smooth transition between the anterior and lateral cheek can be achieved by deep lateral cheek augmentation. The jowl and nasolabial compartments witness less volume loss and become more prominent as supporting, deeper compartments start deflating.68 Volume loss in the deep lateral cheek, lateral temporal and forehead areas, which are also amenable to fat augmentation, is witnessed in the later decades.

Danger zones The danger zones of the face are encountered in transition points between fat compartments or areas of dense retaining ligaments where transitions between tissue planes may occur and facial nerve branches are especially vulnerable to injury (see Fig. 9.9.3).22,69–71 The four danger zones encountered in facelift dissection are outlined in Table 9.9.4.72,73

Patient selection, evaluation and planning A wide variety of patients can be considered candidates for surgical facial rejuvenation procedures; however, a history of smoking, bleeding disorders, or surgical infections requires caution.74 Optimal facial rejuvenation results require a multifaceted, patient-specific treatment plan that addresses skin, soft tissue support and fat atrophy.12 When tailoring a patient’s treatment, both facial volume and facial shape should be addressed. Symmetry assessment is a critical component of the preoperative evaluation. Described by Rohrich et al.,8 the individualized-component facelift takes into account regional asymmetries and applies the concepts of lifting and filling for facial rejuvenation. Fig. 9.9.4 demonstrates the technical sequence in the lift-and-fill facelift. Differential fat augmentation is performed to treat volume asymmetry in conjunction with differential manipulations of the selective SMAS performed to each side to treat volume distributional asymmetry. A preoperative discussion about the patient’s desired aesthetic goals and examination of photographs from the patient’s

Patient selection, evaluation and planning

287

Zygomatic ligament Superficial middle cheek fat Upper masseteric ligament Masseteric cutaneous ligaments Superficial lateral cheek fat Lower masseteric ligament Mandibular ligament

Figure 9.9.3  Retaining ligaments and danger zones. The three major retaining ligaments of the face are the zygomatic ligament, the mandibular ligament, and the masseteric cutaneous ligaments. Four danger zones are encountered in facelift dissection where facial nerve branches are especially vulnerable to injury. These danger zones occur in transition points between superficial fat compartments or in areas of dense retaining ligaments. (1) The first danger zone lies between the region of the zygomatic and the upper masseteric ligaments. The zygomatic branch of the facial nerve becomes relatively superficial here and is vulnerable to injury. (2) The second danger zone lies anterior to the parotid, in the transition from the superficial lateral to middle cheek fat compartment. The buccal branch of the facial nerve is vulnerable to injury in this loose areolar plane. (3) The third danger zone lies in the region of the lower masseteric ligaments. The marginal mandibular branch of the facial nerve is vulnerable to injury here as it exits the tail of the parotid. (4) The fourth danger zone is in the region of the mandibular ligament. Dissection past the cheek–chin junction should proceed with caution in this highly vascular zone. (Courtesy of Stav Brown, MD.)

Table 9.9.2  Retaining ligaments of the face

Ligament

Origin

Zygomatic ligament

Zygomatic eminence at the superior junction of the middle cheek and infraorbital fat

54

Mandibular ligament58,64

Tubercle of the mandible at the cheek–chin junction

Masseteric cutaneous ligaments

48,55,56

Masseteric fascia

288

SECTION II

CHAPTER 9.9  • The lift-and-fill facelift

Table 9.9.3  Aging features that may be addressed with fat grafting

Facial area

Anatomical landmarks

Upper third

Brows Upper eyelids Temples22

Middle third

Lower eyelid Tear trough Malar region

Aging features

Management

Lateral forehead hollowing

Fat grafting to the temples and forehead61

Descended lateral brow secondary to atrophy of temporal fat pads Deep tear trough deformity due to hollowing of the infraorbital region, laxity of the orbital retaining ligament, and loss of volume in the anterior cheek

Upper lid blepharoplasty in patients with brow ptosis Fractionated fat injection following blepharoplasty62 Blepharoplasty (prior fat transfer) in patients with fat herniation at the inferior orbital rim123 Fractionated fat grafting for blending of the lid–cheek junction and correction of orbital hollowing90 Volume augmentation of the malar region: the deep malar (medial) compartment, deep nasolabial malar compartment, the high lateral superficial malar compartment, and the middle superficial malar compartment

Injection site (volume required)45 Forehead – crease in the midforehead or within the hairline (10–15 mL) Temples – within temporal hairline (2–7 mL) Tear trough and periorbital region – inferior to medial orbit in midcheek (3 mL) Cheek (nasolabial and deep malar compartments, superficial superior and inferior malar compartments) Adjacent to alar base (1–3 mL per compartment)

Buccal fat reconstitution after malar augmentation66,123 Lower third

Nasolabial fold Labiomandibular fold (marionette lines) Prejowl sulcus (geniomandibular groove) Labiomental sulcus Lips Chin

Deepening of the nasolabial fold Loss of dentate mandible expansion and prejowl concavity63–65

Malar and the nasolabial fold augmentation (filling of the malar fat compartments effectively lifts the nasolabial fold and is performed before any nasolabial augmentation to avoid overcorrection)

Fat grafting along the lateral mandible Thinning of lips and loss posterior to the jowl of crispness along the philtral columns along Surgical cervicofacial rhytidectomy in with subcutaneous fat patients with significant jowling22 atrophy – perioral rhytids Fat grafting to the geniomandibular groove52 Loss of chin projection Fat grafting to superficial compartments and vertical height near the vermillion–cutaneous junction and deepening of the labiomental crease Injectables to the white roll and vermillion53

Nasolabial fold – adjacent to alar base (1–3 mL per compartment) Buccal region – intraoral or medial lower cheek (2–5 mL) Geniomandibular groove –over mandibular border (1–3 mL) Chin – intersection of the oral commissure and lateral canthus (1–3 mL) Perioral region –adjacent to oral commissures (1–2 mL) Mandible –anterior to mandibular angle (1–3 mL)

Fat grafting to the chin67/chin implants in patients who require more than 3 mL of augmentation per side52

youth should be included as part of the preoperative planning in conjunction with a meticulous facial analysis. Indications for specific fat compartment augmentation are based on preoperative analysis of the topographic deflation. Accurate preoperative planning of selective fat compartment grafting is the first step in the lift-and-fill facelift. Three basic parameters should be addressed as part of facial analysis: midface width, facial length and facial fullness.8

Midface width and facial length evaluation An individualized-component facelift technique not only allows varying vectors of pull but also serves in better tailoring differing techniques of SMAS manipulation to each face.

The deep volumetric foundation influences the extent and type of SMAS and skin manipulation. Management of the SMAS after fat grafting will be determined through assessment of the patient’s midface width and facial length. Each side of a patient’s face may benefit from a different technique in cases of significant asymmetry.7 SMAS stacking is typically indicated for facial sides that are long and narrow and require more fullness, while SMASectomy is indicated for facial sides that are short and wide face to decrease facial fullness. SMAS stacking performed superficial to the augmented deeper malar fat compartments not only allows differential augmentation in the exact topographic location that is indicated but also serves as a “contour bridge”

Treatment/surgical technique

Filling of fat compartments

Table 9.9.4  Facial danger zones

Danger zone

289

Location

Facial nerve branch

1

Between the region of the zygomatic and the upper masseteric ligaments, inferior and lateral to the zygomatic eminence59,73,76,77,79

Zygomatic branch (become relatively superficial, may course over the zygomaticus major muscle origin to innervate the orbicularis oculi)59,72,73

2

Anterior to the parotid, in the transition from the superficial lateral to middle cheek fat compartment

Buccal branch (in deep buccal fat pad)64,73

3

Inferior masseteric border, Marginal mandibular where lower masseteric branch (exits the tail of the ligaments arise parotid)70

4

Mandibular ligament or cheek–chin junction

Marginal mandibular branch58

between the deep medial and lateral superficial malar compartments.4,7,8,22,33,46,75 In the setting of a fuller and/or wider facial side, where SMASectomy would be preferred, fat transfer volumes may be less indicated in the high lateral malar compartment to enhance the desired contour.7,8,46

Facial fullness evaluation Evaluation of facial fullness will guide areas to be addressed with fat grafting, either alone or in conjunction with surgical techniques. The face is divided into anatomical thirds and key features are systematically assessed. Transition points between the subcutaneous and deep fat compartments will manifest as visible folds in the aging face and areas of soft tissue redundancy. Assessing the capacity of the recipient site is highly important in any fat grafting procedure. However, it is important to note that unlike breast and buttock tissue, the primary goal in facial fat grafting is not augmentation per se but “customized facial tissue mobilization”, and therefore precise assessment of the capacity of the recipient site is less critical. Superficial ligamentous release of tethered skin points is not necessary in facial fat grafting and may be required only at the lid/cheek junction or when dimpling occurs during closure.41

Treatment/surgical technique As previously discussed, the lift-and-fill facelift combines precise volume augmentation with individualized alteration of the SMAS. The technical sequence in the lift-and-fill facelift is outlined in (Algorithm Fig. 9.9.1).

Preoperative marking The patient’s face should be preoperatively marked with the patient in an upright position, allowing dependent tissues to fully accentuate facial highlights and shadows.23

As previously discussed in detail, facial fat compartments directly influence both facial volume and facial shape through their anatomic relation with the retaining ligaments. Thus, deep compartment volume restoration with fat grafting is a critical component in facial rejuvenation. The main benefits of fat grafting compared with non-autologous injectables include better integration with native facial tissues to create a more seamless, natural, and long-lasting improvement in contour as well as improvement in quality of overlying facial tissues due to the regenerative potential of adipose-derived stem cells.52,74 Fat grafting is a safe and effective method to improve the midface without increasing surgical morbidity. The midface, including the malar mound and nasolabial folds, has historically been a difficult region to treat with surgical rhytidectomy.4,7,59 “High” SMAS suspension above the level of the zygomatic arch is usually required for effective elevation of the malar mound; however, it carries the risk of frontal branch injury.59,76–78 Furthermore, improving the nasolabial fold required extensive cheek dissection past the nasolabial groove, which resulted in increased perioral distortion and edema without providing significant aesthetic improvement. 4,59,76,78–81

Fat grafting sequence Fat grafting is usually completed in the beginning of the procedure, prior to any skin incisions, to decrease the chance of fat environmental contamination and allow for accurate tailoring of the SMAS manipulation over the augmented fat compartments (exception to this sequence is when concurrent transconjunctival blepharoplasty is being performed). Video 9.9.1 demonstrates adjunctive fat grafting during facelift. The deep compartments are generally filled first, starting with the deep medial cheek, the most critical compartment to be filled.7,82 This creates the foundation to build on with further fat augmentation of more superficial compartments, with SMAS modification bridging the two. Deflation of the deep medial cheek fat plays a major part in the aging process and it is considered the foremost workhorse compartment in effective volume restoration.7,22,46 Due to the smaller fat lobule size in this area and accelerated rate of deflation, it should always be augmented first.40 Improved anterior cheek projection, diminished nasolabial fold prominence, and improved tear trough appearance can all be achieved by selective augmentation of this compartment alone, resulting in a more youthful cheek.7,22,33,36,40,46 The nasolabial fat is volumized first from a proximal access point, with additional fat placed deep on the pyriform in patients with especially thick proximal nasolabial folds. Next, the superficial high lateral cheek is addressed. Although this serves to accentuate malar highlights in women, it should be omitted in men to avoid potential feminizing effects.7,75 Augmentation of the middle and lateral superficial malar compartments can aid in blending the lower cheek junction and nasojugal crease.7,22,46 Superficial fat augmentation may also be performed during or after SMAS manipulation and is recommended for the oral commissures, surrounding labial aesthetic units, and

290

SECTION II

CHAPTER 9.9  • The lift-and-fill facelift

Figure 9.9.4  Facelift classifications. Short-scar and mini-lifts use limited skin incisions in the pre-auricular area (black solid line). Traditional facelifts use full-length skin incisions that extend into the temporal and occipital scalp (black dotted line). The extent of dissection performed in the mini-lift is minimal in the face and typically does not involve the neck (green striped area). The extent of dissection in the short-scar lift is somewhat greater in the cheek and may extend partially into the neck (red line). The extent of dissection in the traditional facelift typically involves the full face and neck (purple line). (Courtesy of Stav Brown, MD.)

paramenton (lateral chin depressions). The superficial perioral compartments can help augment the inferior nasolabial region and diminish the appearance of perioral rhytides.53,60 However, superficial fat augmentation is more difficult in areas where skin has been undermined.7 The deep volumetric foundation created with fat grafting will determine the extent and type of SMAS and skin alteration.8 SMAS stacking is performed superficial to the augmented deeper malar fat compartments. In a fuller and/or wider face/facial side, where SMASectomy might be indicated according to preoperative analysis, fat grafting of the high lateral malar compartment may be less indicated to enhance the desired contour.

The contour and volume of the subSMAS fat grafting is based on the preoperative shape of the malar bone and native distribution of facial fullness, considering the anticipated results of SMAS alternation.

Fat harvesting, preparation and injection technique Donor site selection Donor site aesthetics, patient preference, surgical positioning, quantity of fat needed, and quantity of fat available are the

Treatment/surgical technique

291

Algorithm 9.9.1 Technical sequence in the lift-and-fill facelift. Meticulous preoperative facial analysis: (1) midface width, (2) facial length, (3) facial fullness

Preoperative marking

Fat grafting to deep and superficial fat compartments: the deep malar (medial) compartment and nasolabial fold are fat grafted first, the high lateral (superficial) compartment and nasolabial fold are augmented last

Skin incisions and local anesthetic infiltration

Selective skin undermining

Platysma manipulation

Anterior platysmaplasty in patients with platysmal banding

Lateral platysma window in patients without platysmal banding

SMAS manipulation

SMAS stacking for facial sides that are narrower and require more fullness

SMASectomy for facial sides that are wider and fuller

Redraping of skin and closure

Blepharoplasty (if indicated)

Skin resurfacing procedures (if indicated): erbium laser, trichloroacetic acid peel and microneedling

major factors in donor site selection.83 The lower abdomen and inner thighs are the preferred harvesting sites for facial rejuvenation procedures due to the high concentration of stromal vascular cells and small cell size.84

Fat harvesting technique Various fat harvesting and preparation techniques have been described in the literature.85,86 The Coleman technique is a popular fat grafting technique that has been applied since the early 1990s. This technique involves gentle fat harvesting to preserve parcel structure, fat refinement through centrifugation for concentration of the adipose tissue and removal of non-viable components, and delivery

of the fat in small aliquots to ensure sufficient blood supply and graft take.87,88 Fat harvesting is performed using syringe aspiration with a 10-mL Luer-Lok syringe attached to a harvesting cannula. A modified multihole Coleman cannula increases harvesting efficiency by creating a negative pressure when the plunger of the syringe is pulled back.23,74 The senior author uses a small cannula (12-gauge) with small holes (1-mm) for manual low-pressure lipoaspiration of the inner thigh to ensure that appropriately sized lobules of fat are harvested.89 Entry sites for cannula insertion should be made in discrete areas such as the umbilicus for harvest from the lower abdomen or inguinal line for harvest from the medial thigh. Cannula passage should be kept superficial to prevent damage to the

292

SECTION II

CHAPTER 9.9  • The lift-and-fill facelift

rectus fascia and fat should be harvested uniformly to ensure a smooth donor site contour.

Fat refinement and purification Centrifugation is our preferred method of fat refinement for separation and concentration of ruptured fat cells (the oil fraction), blood and local anesthetic (the water fraction) from intact fat cells.23 The lipoaspirate should fill approximately half of the 10-mL syringe and be placed in a centrifuge for no longer than 1 min (2250 revolutions/min) at low pressure.52,87 After discarding blood-tinged water and oil fractions, a Telfa strip (Telfa Strip, Cardinal Health, Dublin, OH, USA) or Codman neuropad (Codman Neuro, Raynham, MA, US) is placed inside of the barrel for residual oil absorbent.74 Following centrifugation, mechanical emulsification is performed by pushing fat between two syringes connected by a Luer-Lok connecter.90

Fat injection An average of 30 mL of fat is required for most facial rejuvenation and contouring cases.91 Approximately 10–12 mL of yellow fat is injected into the two deep central facial fat compartments. Depending on the augmentation desired, another 10–20 mL is then distributed in between the nasolabial compartment and lateral compartments.7,33,46 Processed fat can be transferred into 1-mL syringes for precise injection. Higher-density fat should be preferred over lower-density fat as it demonstrates better graft take.92 A 16-gauge needle is used to introduce a blunt-tipped Coleman cannula for deep compartment injection. A 21-gauge needle directly attached to the syringe can be used for injection of the superficial compartments, which allows more precise injection and minimizes vascular trauma when injecting thicker subdermal tissue.7,33,46 A small volume of fat should be administered with each injection for maximal precision and control of fat delivery and to minimize risk of complications (including fibrosis, calcification, infections, or oil cyst formation).91 Injected volumes should be limited to no more than 0.5–1 mL of fat per second with each pass, and injections should be performed within multiple tissue planes and in multiple directions, with awareness of the cannula tip at all times to avoid injury to nearby vessels and nerves.50,93,94 If fibrotic adhesions, a tight skin envelope or other volume-restrictive factors are encountered, dissection with an 18-gauge needle or forked-tip cannula may be indicated.90,91 The depth of fat injection should be tailored to achieve desired patient outcomes, proceeding from deep to superficial. The appearance of wrinkles, overall facial complexion, and overall skin quality can be improved via fat placement in the intradermal or subdermal layers.95 However, superficial fat placement should be cautiously performed as irregularities can be more apparent. Deep compartments can be accessed just lateral to the alar– cheek junction.96 Placement of fat against the bony periosteum can change how the overlying soft tissue envelope wraps the facial bony structure.74 Ensuring that there is no molding of placed fat

is critical to prevent fat necrosis and minimize resorption. After grafting is complete, the infusion sites can be closed with interrupted sutures. Incisional healing can be facilitated by placing small, concentrated volumes of approximately 0.2–0.3 mL into the closed incisions.74 Subsequent superficial fat grafting may be performed on the forehead, temples, tear trough, oral commissure, chin, and any other regions requiring volume restoration. However, overcorrection should be avoided as expansion of the overlying tissue is not reliant on the fat grafts alone and therefore large volumes may create an unnaturally overfilled facial contour.7 Intercompartmental membranes are elastic and can accommodate the graft volume. Therefore, it is best to graft less primarily and discuss with patients the possibility of needing to perform future fat grafting or use fillers for maintenance.7 Video 9.9.1 demonstrates fat harvesting, preparation and injection.

Facelift classifications Although the surgical principles of rhytidectomy have remained largely the same, the wide variety of marketing names has made the classification of facelift techniques increasingly complex. Wan et al.11 described a systematic classification based on three technical components: skin incision, face/neck dissection, and SMAS treatment. According to this classification, most facelift procedures performed today can be classified as “traditional,” “short-scar,” or “mini” (see Fig. 9.9.4).

Skin incisions Before local anesthetic infiltration, incision placement is planned. Skin incisions and flap undermining are identical in both SMASectomy and SMAS stacking.97 Optimal placement of facelift incisions is subject to nuances and varies by patient.11 Pre-auricular incisions can be placed in the pre-auricular skin crease (pretragal) or in the posterior margin of the tragus (intratragal/post-tragal) (Fig. 9.9.5). Due to its superior scar concealment, the senior author utilizes an intratragal incision that extends perpendicular to the pre-auricular incision along the infratemporal hairline anteriorly. Beveling of the blade is required to minimize chances of alopecia. Proper vertical redraping of the elevated skin flap is achieved by the latter extension of the incision. The inferior portion of the incision always extends around the base of the ear lobule and around the conchal cartilage. To avoid bringing hair-bearing skin onto the ear in men with heavy beards, hair follicles should be resected or cauterized with low energy from the undersurface of the tragus flap.59,75 Tragus inset must preserve sharp, distinct transitions, especially at the incisura, to avoid blunting the inferior tragal border.59,81 Retroauricular incisions are placed directly within the auriculomastoid groove in men or slightly (2 mm) onto the posterior conchal skin in women (Fig. 9.9.6).59,75 Incision placement in the posterior ear is performed a few millimeters above the postauricular sulcus since this scar to tends to descend after healing. The incision then extends superiorly along the hairline, and its length is tailored according to the amount of skin excess that is being removed.4,7,8,75

Treatment/surgical technique

Figure 9.9.5  Pre-auricular incision. Intratragal/post-tragal incisions (solid line) are most commonly used and are hidden in the posterior margin of the tragus. Pretragal incisions placed in the pre-auricular skin crease (dashed line) are more visible but may be useful in patients with obvious cheek-tragal skin color mismatch or a prominent tragal cartilage. (Courtesy of Stav Brown, MD.)

Temporal and occipital incisions can be placed within the hair-bearing scalp or along the hairline, or a combination of both (Fig. 9.9.7). Potentially more visible, occipital incisions placed along the posterior hairline may be necessary to avoid unaesthetic posterior hairline displacement in patients with significant neck skin excess or massive-weight-loss patients. Video 9.9.2 demonstrates facelift incision planning.

Local anesthetic infiltration technique Once placement of the incision has been marked, local anesthetic infiltration is performed. The superwet technique used for infiltration is defined as having a volume greater than 50–100 mL per hemiface. Hydrodissection with this technique has proved particularly useful in secondary facelifts. The solution is mixed preoperatively and consists of 30 mL of 0.5% lidocaine and 1.5 mL of epinephrine 1:1000, all mixed in 300 mL of normal saline. Using a 22-gauge spinal needle on an autofill syringe, it is injected in the subcutaneous plane where skin flap dissection is planned. A long spinal needle inserted only along the incision line allows for uniform hydrodissection in a plane between the skin flap and SMAS, avoiding trauma to the skin flap. The total volume injected is determined by the evidence of moderate skin turgor without

293

Figure 9.9.6  Postauricular incision. Retroauricular incisions can be placed slightly (2 mm) onto the posterior conchal skin in women for better scar concealment and to prevent inferior scar migration. (Courtesy of Stav Brown, MD.)

skin blanching. Skin elevation is performed 15 minutes after injection time in order to maximize the vasoconstrictive effects of the epinephrine and the incision site is reinjected before final closure.8,98

Selective skin undermining The final blending of facial contour through fat transfer of the deep malar fat compartment and the high superficial (lateral) malar compartment is achieved by the overlying SMAS manipulation. Individualized SMAS treatment coalesces the deep malar and superficial lateral fat compartments in a seamless manner, serving as the “contour bridge”. Skin flap undermining in traditional facelifts is illustrated in Fig. 9.9.8. The senior author uses a two-layer approach that separates the skin and SMAS layers for bidirectional vector movement and more natural skin redraping. In the past, skin flap undermining used to extend medially to the nasolabial groove, which carries the risk of nasal groove effacement, oral commissure distortion, and compromising vascularity. An individualized approach dictated by the shape and width of the patient’s face serves to limit skin undermining to either the lateral canthus or just medial to the zygomaticus major muscle. While skin undermining does not need to be extensive in patients with minimal skin laxity and in faces with a wide malar width (since advancing the medial SMAS laterally may not be necessary), wider undermining may be required in

294

SECTION II

CHAPTER 9.9  • The lift-and-fill facelift

Figure 9.9.7  Temporal and occipital incisions. Incisions in the temporal and occipital regions can be placed within the scalp or along the hairline. Scalp incisions (red lines) are placed well within the hair-bearing scalp for better scar concealment. Hairline incisions (blue lines) are potentially more visible but avoid objectionable hairline displacement. The temporal hairline incision is made as an inverted-L in the temporal sideburn to avoid sideburn elevation. The occipital hairline incision can be made in the junction of the thick and thin nape hair in the neck for better concealment. (Courtesy of Stav Brown, MD.)

patients with narrow faces that need volume recruited cephalad toward the zygomatic arch.4,8 The skin flap is sharply dissected off the underlying SMAS through three zones97: 1. First zone – composed of two lines: the first from the alar base to the tragus and the second from the tragus down to the anterior border of the sternocleidomastoid. 2. Second zone – extends from posterior to the sternocleidomastoid to the postauricular neck area. 3. Third zone – extends cephalically from a line drawn from the alar base to the lobule.

SMAS and platysma manipulation Despite their favorable safety profile and relatively short operative time, skin-based techniques do not retain the same viscoelastic properties as SMAS-based approaches. Greater longevity is achieved when the SMAS bears the load of the subcutaneous mass and overall soft-tissue tension.4,99 However, the importance of varying specific SMAS vectors,

depth/extent of dissection, amount of tissue mobilization and other factors continually changes. The superiority of one specific method of tissue (SMAS) manipulation over another has not been clearly determined. 100–102 Accurate preoperative analysis is crucial in the decision-making process for how the SMAS is shaped and lifted. Techniques that center on SMASectomy and SMAS stacking with wide skin undermining allow for excellent outcomes without the need for an extended subSMAS dissection.7,8,49,78,80,100,101,103–107 As previously discussed, preoperative evaluation of facial length and fullness dictates the orientation or angle of SMAS shaping and direction of SMAS manipulation.8,46,76,103 The direction of SMAS pull is dictated via identification of the long side of the face, with long faces necessitating a horizontal vector of pull, which allows for malar fullness while correcting for excess facial length, and short faces requiring a more oblique vector to maintain facial length while correcting for excess malar fullness. As discussed, facial fullness is another important factor to consider when deciding between SMAS plication (or SMAS

Treatment/surgical technique

295

Figure 9.9.8  Skin flap undermining in traditional facelifts. The extent of skin flap dissection in traditional facelifts varies depending on the SMAS technique and dictates the degree of skin-SMAS separation. Minimal skin undermining (to green line) is performed in deep-plane composite facelifts to preserve all retaining ligaments between the cheek skin and SMAS. This allows the skin and SMAS layers to be suspended as a composite flap. Limited skin undermining (to red dotted line) is performed in lamellar SMAS flap techniques. The zygomatic ligaments are divided but the masseteric ligaments are preserved to maintain connections between the anterior cheek skin and SMAS. This allows for the inferior cheek skin to be vertically suspended along with SMAS flap rotation. Extended skin flap dissection (to purple line) is performed in SMAS plication techniques. All skin-SMAS connections are released into the midcheek to allow for untethered access to the medial SMAS. (Courtesy of Stav Brown, MD.)

stacking) versus SMASectomy. While SMAS stacking influences the facial rejuvenation process by synergistic augmentation, SMASectomy provides subtractive effects.7 SMAS stacking allows for differential augmentation and creates more fullness in the malar region; the augmentative effects will be most significant when the stacked region is located directly over a grafted fat compartment. SMASectomy may be indicated in faces with excess facial fullness that will benefit from volume removal, for a more balanced facial structure.

In the SMAS-stacking technique, the SMAS is carefully incised, undermined proximally and distally, and then advanced toward a central axis line for a three-layered stacking effect. Enhanced malar projection and cheek fullness are achieved when the undermined edges are brought over the remaining SMAS base. The central preservation of the SMAS island and creation of a bilaminar construct make stacking a more powerful augmentative maneuver than plication.4,7,8,22,33,46,75

296

SECTION II

CHAPTER 9.9  • The lift-and-fill facelift

The exact location where augmentation occurs is determined by the SMAS incision, and the extent of the augmentation can be tailored by the amount of SMAS incorporated in each stitch bite. Furthermore, the amount of SMAS stacking required is determined by the underlying skeletal support. Patients with a greater inter-zygomatic width and more prominent malar eminences are likely to benefit more from a horizontally-directed SMAS layering or SMASectomy that mobilizes tissue in a vertical vector and not require as much SMAS stacking over the lateral malar region.4,7,8,22,33,46,75 A well-defined neck contour is an integral part in facial rejuvenation. In patients without platysmal banding, the senior author utilizes a lateral platysma window to address the neck. Incision for the platysma window is marked anterior to the lobule at one fingerbreadth below the angle of the mandible and one fingerbreadth in front of the anterior border of the sternocleidomastoid muscle. The platysma is then elevated using forceps and electrocautery to create a platysma window that is 2 cm in vertical length. Dissection continues until enough of a flap has been elevated and good traction power is achieved. Using two figure-of-eight 4-0 Mersilene sutures (Ethicon, Inc., Raritan, NJ, US), it is then sutured to the posterior mastoid fascia spanning the area where the great auricular nerve is located.4,8,58,108 When platysmal banding is present, an anterior platysmaplasty is also performed using a submental incision. Anterior platysmaplasty allows correction of medial platysmal laxity as well as resection of subplatysmal fat under direct visualization. Medial platysmaplasty (if indicated) is performed after fixation of the SMAS to allow maximal malar elevation without having an opposing pull if the midline plication is performed first. In order to prevent excessive deepening of the submental crease, submental incision is placed posterior to the crease. Skin flap elevation in this area is done slightly above the platysma, keeping most of the fat attached to the skin. Wide skin undermining is performed to communicate with the previously dissected lateral skin flaps. The medial borders of the platysma are defined using electrocautery, followed by removal of excess fat. Platysmaplasty is then performed from inferior to superior using interrupted figureof-eight sutures. The muscle is then transected transversely right above the thyroid cartilage inferiorly, in order to highlight the cervicomental angle.4,8,58,108

Postoperative bruising and swelling reduction Postoperative bruising, swelling, and total drain output can be minimized by utilizing platelet-rich plasma (PRP) before closure of the skin incision.109 Using a 60-mL syringe containing 6 mL of anticoagulant, venous blood is drawn while the patient is being prepped and then centrifuged. A 10-mL dual-port sprayer syringe is used to draw up the PRP, which is then sprayed in between the skin flap and the underlying SMAS.7,8,75,109 The senior author also uses tranexamic acid (TXA), topically, blended in local anesthesia and intravenously to minimize intra-operative bleeding, postoperative hematoma, bruising and edema. TXA has emerged as a promising antifibrinolytic agent in a variety of surgical fields and its use has recently expanded to plastic reconstructive surgery. In addition to its antifibrinolytic effects, TXA’s promising role in aesthetic procedures can be mainly attributed to its anti-inflammatory

properties.110,111 The senior author uses TXA routinely in all facelift patients without history of venous/arterial thromboembolism, or pre-existing thromboembolic disorders/ hypercoagulable states. A bolus of 1 g of TXA is administered intravenously after induction: 1 g of TXA is added to the wetting solution infiltrate (300 mL of saline with 300 mL of 0.5% lidocaine with epinephrine). For topical administration, TXA is diluted to a 2%–3% concentration (10–15 g TXA in 500 mL saline) and applied directly to the open wound areas using irrigation and pledgets/soaked sponges for 3–5 minutes at the end of surgery. The senior author has never experienced any TXA-related complications in facelift surgery.111

Superficial versus deep-plane dissection Careful subcutaneous skin flap dissection under direct vision in a known subSMAS plane is preferred over blind dissection since deflection into deeper planes can easily occur, especially if consistent skin flap thickness is not ensured. Precise skin flap thickness can be evaluated using transillumination with the contralateral operating room light during subcutaneous flap elevation.70 However, the incidence of facial nerve injuries in subSMAS techniques has not been reported to be higher than superficial-plane dissection.6,70,76,112–114 After redraping the skin properly, the shaping effects of deeper fat grafting and SMAS manipulation will translate effectively to the surface appearance. Adjunctive skin resurfacing procedures can create superior results without adding to patient morbidity when performed judiciously in selected patients. Their benefits include improved overall skin quality and dermal rhytids in areas such as the perioral and glabellar regions, which are not typically reached with facelift dissection. Skin resurfacing techniques are typically used after all skin incisions are closed and include erbium laser, trichloroacetic acid peel, and microneedling. 11,115–122

Postoperative care After facial fat grafting, patients should be guided to apply cool compresses to minimize bruising, swelling and discomfort. Since any shear force or trauma to the area may compromise graft survival, deep massage should be avoided to prevent fat migration or necrosis.74 Counseling should also include an approximate timeline of expected outcomes. Patients should be counseled prior to their initial fat grafting operation that bruising and swelling may persist for up to 6 weeks postoperatively.74,123 Additionally, pigmentation of the lower eyelids, or “tea staining”, is expected for up to a year until the overlying skin thickens.74 Overlying skin thickening and softening, scar improvement, and wrinkle reduction take place gradually. Improved complexion of aging or sun-damaged skin may be noted after a year.74 Patients should also be aware that additional procedures are almost always necessary to achieve an ideal result since grafted volume can decrease by up to 50%–90% and volume loss secondary to facial aging is expected to continue regardless of graft take.74,123 However, repeat facial fat grafting operations should not be performed until at least 6 months to a year after the initial operation to allow for resolution of the

Outcome, prognosis, complications

inflammatory response and proper assessment of the surgical outcome.74,123

Outcome, prognosis, complications Minor complications Minor aesthetic irregularity or asymmetry is the most common complication after fat grafting. Palpable lumps may occur if fat is placed too superficially or in large aliquots that result in fat necrosis. These minor irregularities can be treated using suction lipectomy, direct open excision, or the use of Lipodissolve.74 Fat can be addressed with simple excision if the patient desires.91 Other complications include infection, fat embolism, hematoma, seroma, ischemia and nerve injury.

297

As preoperative administration of oral or transdermal clonidine in the morning of surgery was demonstrated to decrease postoperative hypertension and hematoma rates in rhytidectomy patients with and without pre-existing hypertension.75,124,126,130,134–137 Anti-aggregants (e.g. aspirin) and nonsteroidal anti-inflammatory agents should be stopped at least 2 weeks before surgery for hematoma prevention.125,126,130,138

Infection To minimize the risk of infection, patients with history of cold sores should receive prophylactic acyclovir and areas that may be contaminated with oral flora (such as the lips) should be injected last.74

Fat embolism Intravascular fat injection and subsequent fat embolism can be prevented using pre-injection of planned recipient sites with 1% lidocaine with 1:200,000 epinephrine.91

Hematoma The incidence of hematoma following rhytidectomy ranges from 0.9% to 4%.124–130 Men are at increased risk due to their thicker and more vascular skin.75,126 Hematomas require prompt treatment to prevent skin slough, fibrosis, or infection. Early acute hematomas caused by generalized oozing rather than a specific vessel may be addressed at the bedside by opening the postauricular incision under local anesthesia and inserting a small suction catheter for drainage and irrigation.131 Reaccumulating or large hematomas require surgical exploration with intra-operative hemostasis under normotension, as hypotensive anesthesia may mask potential bleeding sites.124,130,132 Perioperative hypertension is the single most important modifiable risk factor in hematoma prevention126,133 with early postoperative hypertension (systolic blood pressure >140 mm Hg) being the most strongly correlated with hematoma, over preoperative or pre-existing hypertension.124,130,134 A strict antihypertensive protocol should be started in all patients regardless of medical history. Routine medications should be continued perioperatively in patients with pre-existing hypertension with the exception of diuretics, which should be held for 1 to 2 days after surgery.126,130 Potential contributory causes such as postoperative pain, anxiety, and nausea/vomiting should be aggressively treated for postoperative hypertension prevention.124,126,130,134–136 Breakthrough hypertension can be managed with oral antihypertensive agents such as labetalol or nicardipine.124,126,130,134–136 Clonidine, a long-acting alpha-2 agonist, can be used as a prophylactic antihypertensive measure in routine rhytidectomy patients or higher-risk individuals.75,124,126,130,134–137

Figure 9.9.9  Case study 9.9.1: lift-and-fill facelift with individualized-component facelift to address facial asymmetry. (From Rohrich RJ, Ghavami A, Constantine FC, et al. Lift-and-fill facelift: integrating the fat compartments. Plast Reconstr Surg. 2014;133(6):763e; with permission.)

298

SECTION II

CHAPTER 9.9  • The lift-and-fill facelift

Seroma Effective strategies for seroma prevention include the use of closed neck drains via a stab incision in the occipital scalp and chin straps for dead-space closure. When developed, seromas are managed with serial aspiration until resolved. In refractory cases or when a seroma cannot be aspirated, injections of Kenalog 10 mg/mL diluted with 1% lidocaine are utilized.139

Ischemia The most likely causes of necrosis in facelift surgery include nicotine product use, thin skin flaps, excess skin tension on wound closure and unrecognized seromas and hematomas. Therefore, ischemia in facelift surgery can be prevented with proper patient selection, maintaining at least 3 mm of fat on the skin flap undersurface, skin closure with minimal tension, and hematoma and seroma prevention. Intraoperative application of topical nitroglycerin ointment over less well-perfused areas can improve blood flow. While areas of necrosis in the postoperative period are conservatively managed with daily cleaning and triple antibiotic ointment application, subsequent scar revision might be needed for areas that have healed by secondary intention.139

Sensory nerve injury Facial numbness, tingling, or sensitivity are some of the most common complaints reported by patients at 6 months.104,140 While most of these sensory changes are transient and expected to self-resolve within 6–12 months, injury to the great auricular nerve, which provides sensory innervation to the posterior auricle and ear lobule, can be much more destructive. With an estimated incidence of 6%, it is the most commonly injured nerve in rhytidectomy.71,141 It is most vulnerable to injury 6.5 cm inferior to the external auditory canal (McKinney point) where it crosses the midbelly of the

sternocleidomastoid muscle.107 Great auricular nerve injury can be prevented by performing postauricular skin flap dissection under direct vision over the sternocleidomastoid muscle, keeping down the fascia over the muscle. Skin flap dissection should remain relatively thin directly under the ear lobule. In case platysmal suspension sutures are placed, they should span the location of the great auricular nerve.142 Suture plication or partial severance of the great auricular nerve can cause painful neuroma with early surgical exploration required in severe cases of persistent pain.

Motor nerve injury The incidence of permanent facial nerve injury after rhytidectomy is extremely low with an estimated incidence of less than 1%.70,71,127 Even slight recovery of some degree of motion early on indicates incomplete injury, and gradual resolution can often be expected within 6 months.

Case study 9.9.1 A 60-year-old woman underwent a lift-and-fill facelift with individualized-component facelift to address facial asymmetry (Figs. 9.9.9 & 9.9.10). Fat transfer volumes were as follows (labeled in Fig. 9.9.10): 3 cc in the right deep malar fat compartment and 2 cc in the left, and 2 cc in the right superficial lateral (high) malar compartment and 1 cc in the left side. In addition, the prejowl area received 2 cc bilaterally. SMAS stacking was performed bilaterally, using a more oblique vector on the right and with more undermining to address the shorter/wider facial side; on the left (the longer side), SMAS tacking was performed in a horizontal vector with less skin undermining for recruitment of more vertical pull. The patient also underwent medial platysmaplasty through an anterior open approach.7

Figure 9.9.10 Case study 9.9.1: Fat transfer volumes. (From Rohrich RJ, Ghavami A, Constantine FC, et al. Lift-and-fill facelift: integrating the fat compartments. Plast Reconstr Surg. 2014;133(6):763e; with permission.)  

Outcome, prognosis, complications

299

Figure 9.9.11  Case study 9.9.2: lift-and-fill facelift with individualized-component facelift to treat facial asymmetry along with an open neck lift. (From Rohrich RJ, Ghavami A, Constantine FC, et al. Lift-and-fill facelift: integrating the fat compartments. Plast Reconstr Surg. 2014;133(6):763e; with permission.)

300

SECTION II

CHAPTER 9.9  • The lift-and-fill facelift

Figure 9.9.12  Case study 9.9.2: fat transfer volumes. (From Rohrich RJ, Ghavami A, Constantine FC, et al. Lift-and-fill facelift: integrating the fat compartments. Plast Reconstr Surg. 2014;133(6):763e; with permission.)

The buccal branch is the most commonly injured facial nerve branch during facelift. Noticed as diminished or asymmetric upper lip elevation while smiling, buccal branch weakness, often recovers relatively quickly due to significant arborization between the buccal and zygomatic branches.71 Unlike the buccal branch, the paucity of interconnections of the mandibular and temporal branches hinders their respective recoveries if injured.70,71,127 Marginal mandibular branch palsy causes weakness of the lower lip depressors and presents as permanent elevation of the lower lip on the affected side during smiling.71 Temporal branch injury manifests as weakened eyebrow elevation and diminished transverse forehead rhytides on the affected side. Neurotoxin can be utilized for chemoparalysis on the contralateral side to improve symmetry while waiting for complete recovery.

Access the reference list online at   Elsevier eBooks+

Case study 9.9.2 A 62-year-old woman underwent a lift-and-fill facelift with individualized-component facelift to treat facial asymmetry along with an open neck lift (Figs. 9.9.11 & 9.9.12). Fat transfer volumes were as follows (labeled in Fig. 9.9.12): 3 cc in the nasolabial fold on the left and 2 cc on the right. In addition, the deep malar fat compartment received 2 cc bilaterally. The superficial high (lateral) malar compartment received 2 cc bilaterally. SMASectomy was performed bilaterally to decrease facial fullness. On the left, the longer side, SMASectomy was oriented horizontally; on the right, the shorter side, SMASectomy was performed in a more oblique vector with more skin undermining.7

References

References 1. American Society of Plastic Surgeons. 2020 National Plastic Surgery Statistics, Cosmetic Surgical Procedures. Available at: https://www.plasticsurgery.org/documents/News/ Statistics/2020/plastic-surgery-statistics-report-2020.pdf. Accessed June 20, 2021. 2. Jacono AA, Malone MH, Lavin TJ. Nonsurgical facial rejuvenation procedures in patients under 50 prior to undergoing facelift: habits, costs, and results. Aesthet Surg J. 2017;37:448453. 3. Sundine MJ, Kretsis V, Connell BF. Longevity of SMAS facial rejuvenation and support. Plast Reconstr Surg. 2010;126:229–237. 4. Rohrich RJ, Narasimhan K. Long-term results in face lifting: observational results and evolution of technique. Plast Reconstr Surg. 2016;138:97–108. 5. Liu TS, Owsley JQ. Long-term results of face lift surgery: patient photographs compared with patient satisfaction ratings. Plast Reconstr Surg. 2012;129:253–262. 6. Rammos CK, Mohan AT, Maricevich MA, Maricevich RL, Adair MJ, Jacobson SR. Is the SMAS flap facelift safe? A comparison of complications between the sub-SMAS approach versus the subcutaneous approach with or without SMAS plication in aesthetic rhytidectomy at an academic institution. Aesthetic Plast Surg. 2015;39:870–876. 7. Rohrich RJ, Ghavami A, Constantine FC, Unger J, Mojallal A. Lift-and-fill face lift: integrating the fat compartments. Plast Reconstr Surg. 2014;133:756e–767e. 8. Rohrich RJ, Ghavami A, Lemmon JA, Brown SA. The individualized component face lift: developing a systematic approach to facial rejuvenation. Plast Reconstr Surg. 2009;123:1050–1063. 9. Kappos EA, Temp M, Schaefer DJ, Haug M, Kalbermatten DF, Toth BA. Validating facial aesthetic surgery results with the FACE-Q. Plast Reconstr Surg. 2017;139:839–845. 10. Rohrich RJ, Durand PD, Dayan E. The lift-and-fill facelift: superficial musculoaponeurotic system manipulation with fat compartment augmentation. Clin Plast Surg. 2019;46:515–522. 11. Wan D, Dayan E, Rohrich RJ. Safety and adjuncts in face lifting. Plast Reconstr Surg. 2019;144:471e–484e. 12. Rohrich RJ, Avashia YJ, Savetsky IL. Prediction of facial aging using the facial fat compartments. Plast Reconstr Surg. 2021;147:38s–42s. 13. Farkas JP, Pessa JE, Hubbard B, Rohrich RJ. The science and theory behind facial aging. Plast Reconstr Surg. Global Open. 2013:1. 14. Gonzalez-Ulloa M, Flores ES. Senility of the face – basic study to understand its causes and effects. Plast Reconstr Surg. 1965;36:239–246. 15. Wan D, Amirlak B, Rohrich R, Davis K. The clinical importance of the fat compartments in midfacial aging. Plast Reconstr Surg Glob Open. 2013;1:e92. 16. Wulc AE, Sharma P, Czyz CN. The anatomic basis of midfacial aging. In: Hartstein M, Wulc A, Holck D, eds. Midfacial Rejuvenation. New York: Springer; 2012. 17. Fisher GJ, Varani J, Voorhees JJ. Looking older: fibroblast collapse and therapeutic implications. Arch Dermatol. 2008;144:666–672. 18. Pessa JE, Nguyen H, John GB, Scherer PE. The anatomical basis for wrinkles. Aesthet Surg J. 2014;34:227–234. 19. Pessa JE. An algorithm of facial aging: verification of Lambros’s theory by three-dimensional stereolithography, with reference to the pathogenesis of midfacial aging, scleral show, and the lateral suborbital trough deformity. Plast Reconstr Surg. 2000;106:479–488. discussion 489–490. 20. Shaw Jr RB, Katzel EB, Koltz PF, et al. Aging of the facial skeleton: aesthetic implications and rejuvenation strategies. Plast Reconstr Surg. 2011;127:374–383. 21. Rohrich RJ, Pessa JE. Discussion. Aging of the facial skeleton: aesthetic implications and rejuvenation strategies. Plast Reconstr Surg. 2011;127:384–385.

300.e1

22. Rohric R, Pess JE. The fat compartments of the face: anatomy and clinical implications for cosmetic surgery. Plast Reconstr Surg. 2007;119:2219–2227. 23. Glasgold R, Lam GM. S. Complementary fat grafting. In: Shiffman M, Mirrafati S, Lam S, Cueteaux C, eds. Master Techniques in Facial Rejuvenation. Berlin: Springer; 2018. 24. Pessa JE, Zadoo VP, Mutimer KL, et al. Relative maxillary retrusion as a natural consequence of aging: combining skeletal and soft-tissue changes into an integrated model of midfacial aging. Plast Reconstr Surg. 1998;102:205–212. 25. Le Louarn C, Buis J, Buthiau D. Treatment of depressor anguli oris weakening with the face recurve concept. Aesthet Surg J. 2006;26: 603–611. 26. Coleman SR. Structural fat grafting. Aesthet Surg J. 1998; 18(386):388. 27. Coleman SR. Facial augmentation with structural fat grafting. Clinics Plast Surg. 2006;33:567–577. 28. Stuzin JM. Restoring facial shape in face lifting: the role of skeletal support in facial analysis and midface soft-tissue repositioning. Plast Reconstr Surg. 2007;119:362–376. 29. Owsley JQ. Lifting the malar fat pad for correction of prominent nasolabial folds. Plast Reconstr Surg. 1993;91:463–474. discussion 475–466. 30. Hamra ST. A study of the long-term effect of malar fat repositioning in face lift surgery: short-term success but long-term failure. Plast Reconstr Surg. 2002;110:940–951. discussion 952–949. 31. Lambros V. Observations on periorbital and midface aging. Plast Reconstr Surg. 2007;120:1367–1376. 32. Little JW. Volumetric perceptions in midfacial aging with altered priorities for rejuvenation. Plast Reconstr Surg. 2000;105:252–266. discussion 266–269. 33. Rohrich RJ, Pessa JE, Ristow B. The youthful cheek and the deep medial fat compartment. Plast Reconstr Surg. 2008;121:2107–2112. 34. Rohrich RJ, Arbique GM, Wong C, Brown S, Pessa JE. The anatomy of suborbicularis fat: implications for periorbital rejuvenation. Plast Reconstr Surg. 2009;124:946–951. 35. Pessa JE, Rohrich RJ. Discussion: aging changes of the midfacial fat compartments: a computed tomographic study. Plast Reconstr Surg. 2012;129:274–275. 36. Gierloff M, Stöhring C, Buder T, Gassling V, Açil Y, Wiltfang J. Aging changes of the midfacial fat compartments: a computed tomographic study. Plast Reconstr Surg. 2012;129:263–273. 37. Gosain AK, Klein MH, Sudhakar PV, Prost RW. A volumetric analysis of soft-tissue changes in the aging midface using high-resolution MRI: implications for facial rejuvenation. Plast Reconstr Surg. 2005;115:1143–1152. discussion 1153–1155. 38. Bucky LP, Kanchwala SK. The role of autologous fat and alternative fillers in the aging face. Plast Reconstr Surg. 2007;120:89s–97s. 39. Gierloff Stöhring C, Buder T, Wiltfang J. The subcutaneous fat compartments in relation to aesthetically important facial folds and rhytides. J Plast Reconstr Aesthet Surg. 2012;65:1292–1297. 40. Wan D, Amirlak B, Giessler P, et al. The differing adipocyte morphologies of deep versus superficial midfacial fat compartments: a cadaveric study. Plast Reconstr Surg. 2014;133:615e–622e. 41. Rohrich RJ, Ghavami A, Mojallal A. The five-step lower blepharoplasty: blending the eyelid-cheek junction. Plast Reconstr Surg. 2011;128:775–783. 42. Reece EM, Pessa JE, Rohrich RJ. The mandibular septum: anatomical observations of the jowls in aging – implications for facial rejuvenation. Plast Reconstr Surg. 2008;121:1414–1420. 43. Rohrich RJ, Pessa JE. The subplatysmal supramylohyoid fat. Plast Reconstr Surg. 2010;126:589–595. 44. Rohrich RJ, Pessa JE. The retaining system of the face: histologic evaluation of the septal boundaries of the subcutaneous fat compartments. Plast Reconstr Surg. 2008;121:1804–1809. 45. Schultz KP, Raghuram A, Davis MJ, Abu-Ghname A, Chamata E, Rohrich RJ. Fat grafting for facial rejuvenation. Semin Plastic Surg. 2020;34:30–37.

300.e2

SECTION II

CHAPTER 9.9  • The lift-and-fill facelift

46. Pezeshk RA, Small KH, Rohrich RJ. Filling the facial compartments during a face lift. Plast Reconstr Surg. 2015;136: 704–705. 47. Schaverien MV, Pessa JE, Rohrich RJ. Vascularized membranes determine the anatomical boundaries of the subcutaneous fat compartments. Plast Reconstr Surg. 2009;123:695–700. 48. Stuzin JM, Baker TJ, Gordon HL. The relationship of the superficial and deep facial fascias: relevance to rhytidectomy and aging. Plast Reconstr Surg. 1992;89:441–449. discussion 450–451. 49. Stuzin JM, MOC-PSSM CME. article: face lifting. Plast Reconstr Surg. 2008;121:1–19. 50. Coleman SR. Structural fat grafting: more than a permanent filler. Plast Reconstr Surg. 2006;118:108s–120s. 51. DeFatta RJ, Williams 3rd EF. Fat transfer in conjunction with facial rejuvenation procedures. Facial Plast Surg Clin North Am. 2008;16:383–390. 52. Marten TJ, Elyassnia D. Fat grafting in facial rejuvenation. Clin Plast Surg. 2015;42:219–252. 53. Pezeshk RA, Stark RY, Small KH, Unger JG, Rohrich RJ. Role of autologous fat transfer to the superficial fat compartments for perioral rejuvenation. Plast Reconstr Surg. 2015;136:301e–309e. 54. Alghoul M, Codner MA. Retaining ligaments of the face: review of anatomy and clinical applications. Aesthet Surg J. 2013;33:769–782. 55. Ozdemir R, Kilinç H, Unlü RE, Uysal AC, Sensöz O, Baran CN. Anatomicohistologic study of the retaining ligaments of the face and use in face lift: retaining ligament correction and SMAS plication. Plast Reconstr Surg. 2002;110:1134–1147. discussion 1148–1149. 56. Seo YS, Song JK, Oh TS, Kwon SI, Tansatit T, Lee JH. Review of the nomenclature of the retaining ligaments of the cheek: frequently confused terminology. Arch Plast Surg. 2017;44: 266–275. 57. Mitz V, Peyronie M. The superficial musculo-aponeurotic system (SMAS) in the parotid and cheek area. Plast Reconstr Surg. 1976;58:80–88. 58. Narasimhan K, Stuzin JM, Rohrich RJ. Five-step neck lift: integrating anatomy with clinical practice to optimize results. Plast Reconstr Surg. 2013;132:339–350. 59. Marten TJ. High SMAS facelift: combined single flap lifting of the jawline, cheek, and midface. Clinics Plast Surg. 2008;35:569–603. 60. Sinno S, Mehta K, Reavey PL, Simmons C, Stuzin JM. Current trends in facial rejuvenation: an assessment of ASPS members’ use of fat grafting during face lifting. Plast Reconstr Surg. 2015;136:20e–30e. 61. Chiu CH. Objective evaluation of eyebrow position after autologous fat grafting to the temple and forehead. Aesthetic Plast Surg. 2017;41:1342–1350. 62. Rohrich RJ, Villanueva NL, Afrooz PN. Refinements in upper blepharoplasty: the five-step technique. Plast Reconstr Surg. 2018;141:1144–1146. 63. Pecora NG, Baccetti T, McNamara Jr. JA. The aging craniofacial complex: a longitudinal cephalometric study from late adolescence to late adulthood. Am J Orthod Dentofacial Orthop. 2008;134:496–505. 64. Mendelson B, Wong CH. Changes in the facial skeleton with aging: implications and clinical applications in facial rejuvenation. Aesthetic Plast Surg. 2012;36:753–760. 65. Shaw Jr RB, Katzel EB, Koltz PF, Kahn DM, Girotto JA, Langstein HN. Aging of the mandible and its aesthetic implications. Plast Reconstr Surg. 2010;125:332–342. 66. Cohen SR, Fireman E, Hewett S, Saad A. Buccal fat pad augmentation for facial rejuvenation. Plast Reconstr Surg. 2017;139:1273e–1276e. 67. Rohrich RJ, Sanniec K, Afrooz PN. Autologous fat grafting to the chin: a useful adjunct in complete aesthetic facial rejuvenation. Plast Reconstr Surg. 2018;142:921–925. 68. Yousif NJ, Gosain A, Sanger JR, Larson DL, Matloub HS. The nasolabial fold: a photogrammetric analysis. Plast Reconstr Surg. 1994;93:70–77.

69. Pessa JE, Rohrich RJ. Facial Topography: Clinical Anatomy of the Face. St. Louis: Quality Medical; 2012. 70. Roostaeian J, Rohrich RJ, Stuzin JM. Anatomical considerations to prevent facial nerve injury. Plast Reconstr Surg. 2015;135:1318–1327. 71. Baker DC, Conley J. Avoiding facial nerve injuries in rhytidectomy. Anatomical variations and pitfalls. Plast Reconstr Surg. 1979;64: 781–795. 72. Mendelson BC, Muzaffar AR, Adams Jr. WP. Surgical anatomy of the midcheek and malar mounds. Plast Reconstr Surg. 2002;110:885–896. discussion 897–911. 73. Stuzin JM, Baker TJ, Gordon HL, Baker TM. Extended SMAS dissection as an approach to midface rejuvenation. Clin Plastic Surg. 1995;22:295–311. 74. Coleman SR, Katzel EB. Fat grafting for facial filling and regeneration. Clin Plastic Surg. 2015;42:289–300. vii. 75. Rohrich RJ, Stuzin JM, Ramanadham S, Costa C, Dauwe PB. The modern male rhytidectomy: lessons learned. Plast Reconstr Surg. 2017;139:295–307. 76. Barton Jr. FE. Rhytidectomy and the nasolabial fold. Plast Reconstr Surg. 1992;90:601–607. 77. Connell BF, Marten TJ. The trifurcated SMAS flap: three-part segmentation of the conventional flap for improved results in the midface, cheek, and neck. Aesthetic Plast Surg. 1995;19:415–420. 78. Barton Jr FE, Hunt J. The high-superficial musculoaponeurotic system technique in facial rejuvenation: an update. Plast Reconstr Surg. 2003;112:1910–1917. 79. Hamra ST. The deep-plane rhytidectomy. Plast Reconstr Surg. 1990;86:53–61. discussion 62–53. 80. Baker DC. Lateral SMASectomy. Plast Reconstr Surg. 1997;100: 509–513. 81. Stuzin JM, Baker TJ, Baker TM. Refinements in face lifting: enhanced facial contour using vicryl mesh incorporated into SMAS fixation. Plast Reconstr Surg. 2000;105:290–301. 82. Wang W, Xie Y, Huang RL, et al. Facial contouring by targeted restoration of facial fat compartment volume: the midface. Plast Reconstr Surg. 2017;139:563–572. 83. Khan HA, Keyhan SO. Fat grafting in facial aesthetic units. Atlas Oral Maxillofac Surg Clin North Am. 2018;26:15–23. 84. Geissler PJ, Davis K, Roostaeian J, Unger J, Huang J, Rohrich RJ. Improving fat transfer viability: the role of aging, body mass index, and harvest site. Plast Reconstr Surg. 2014;134:227–232. 85. Hsu VM, Stransky CA, Bucky LP, Percec I. Fat grafting’s past, present, and future: why adipose tissue is emerging as a critical link to the advancement of regenerative medicine. Aesthet Surg J. 2012;32:892–899. 86. Bucky LP, Percec I. The science of autologous fat grafting: views on current and future approaches to neoadipogenesis. Aesthet Surg J. 2008;28:313–321. quiz 322–314. 87. Coleman SR. Long-term survival of fat transplants: controlled demonstrations. Aesthetic Plast Surg. 1995;19:421–425. 88. Coleman S. The technique of periorbital lipoinfiltration. Operat Tech Plast Reconstr Surg. 1994;1:120–126. 89. Del Vecchio D, Rohrich RJ. A classification of clinical fat grafting: different problems, different solutions. Plast Reconstr Surg. 2012;130:511–522. 90. Rohrich RJ, Mahedia M, Shah N, Afrooz P, Vishvanath L, Gupta RK. Role of fractionated fat in blending the lid-cheek junction. Plast Reconstr Surg. 2018;142:56–65. 91. Pu LLQ. Fat grafting for facial rejuvenation and contouring: a rationalized approach. Annals of Plastic Surgery. 2018;81:S102–s108. 92. Allen Jr RJ. Canizares O Jr, Scharf C, et al. Grading lipoaspirate: is there an optimal density for fat grafting? Plast Reconstr Surg. 2013;131:38–45. 93. Lee JH, Kirkham JC, McCormack MC, Nicholls AM, Randolph MA, Austen Jr. WG. The effect of pressure and shear on autologous fat grafting. Plast Reconstr Surg. 2013;131:1125–1136. 94. Xie Y, Zheng DN, Li QF, et al. An integrated fat grafting technique for cosmetic facial contouring. J Plast Reconstr Aesthet Surg. 2010;63:270–276.

References

95. Mojallal A, Lequeux C, Shipkov C, et al. Improvement of skin quality after fat grafting: clinical observation and an animal study. Plast Reconstr Surg. 2009;124:765–774. 96. Rohrich RJ, Afrooz PN. Finesse in face lifting: the role of facial fat compartment augmentation in facial rejuvenation. Plast Reconstr Surg. 2019;143:98–101. 97. Pezeshk RA, Sieber DA, Rohrich RJ. Refinements in tailoring the lift-and-fill facelift. Plast Reconstr Surg Global Open. 2020;8:e2827. 98. Costa CR, Ramanadham SR, O’Reilly E, Coleman JE, Rohrich RJ. The role of the superwet technique in face lift: an analysis of 1089 patients over 23 years. Plast Reconstr Surg. 2015;135:1566–1572. 99. Saulis AS, Lautenschlager EP, Mustoe TA. Biomechanical and viscoelastic properties of skin, SMAS, and composite flaps as they pertain to rhytidectomy. Plast Reconstr Surg. 2002;110:590–598. discussion 599–600. 100. Guyuron B, Rowe DJ, Weinfeld AB, Eshraghi Y, Fathi A, Iamphongsai S. Factors contributing to the facial aging of identical twins. Plast Reconstr Surg. 2009;123:1321–1331. 101. 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. 1996;98:1135–1143. discussion 1144–1147. 102. Webster RC, Smith RC, Papsidero MJ, Karolow WW, Smith KF. Comparison of SMAS plication with SMAS imbrication in face lifting. Laryngoscope. 1982;92:901–912. 103. Barton Jr. FE. The “high SMAS” face lift technique. Aesthet Surg J. 2002;22:481–486. 104. Fleury CM, Schwitzer JA, Hung RW, Baker SB. Adverse event incidences following facial plastic surgery procedures: incorporating FACE-Q Data to improve patient preparation. Plast Reconstr Surg. 2018;141:28e–33e. 105. Baker DC. Minimal incision rhytidectomy (short scar face lift) with lateral SMASectomy. Aesthet Surg J. 2001;21:68–79. 106. Baker DC. Lateral SMASectomy, plication and short scar facelifts: indications and techniques. Clin Plast Surg. 2008;35:533–550. 107. Wan D, Small KH, Barton FE. Face lift. Plast Reconstr Surg. 2015;136:676e–689e. 108. Pezeshk RA, Sieber DA, Rohrich RJ. Neck rejuvenation through the lateral platysma window: a key component of face-lift surgery. Plast Reconstr Surg. 2017;139:865–866. 109. Brown SA, Appelt EA, Lipschitz A, Sorokin ES, Rohrich RJ. Platelet gel sealant use in rhytidectomy. Plast Reconstr Surg. 2006;118:1019–1025. 110. Brown S, Yao A, Taub PJ. Antifibrinolytic agents in plastic surgery: current practices and future directions. Plast Reconstr Surg. 2018;141:937e–949e. 111. Rohrich RJ, Cho MJ. The role of tranexamic acid in plastic surgery: review and technical considerations. Plast Reconstr Surg. 2018;141:507–515. 112. Hamra ST. Composite rhytidectomy. Plast Reconstr Surg. 1992;90:1–13. 113. Kamer FM. One hundred consecutive deep plane face-lifts. Arch Otolaryngol Head Neck Surg. 1996;122:17–22. 114. Swanson E. Outcome analysis in 93 facial rejuvenation patients treated with a deep-plane face lift. Plast Reconstr Surg. 2011;127:823–834. 115. Scheuer 3rd JF, Costa CR, Dauwe PB, Ramanadham SR, Rohrich RJ. Laser resurfacing at the time of rhytidectomy. Plast Reconstr Surg. 2015;136:27–38. 116. Baker TJ. Chemical face peeling and rhytidectomy. A combined approach for facial rejuvenation. Plast Reconstr Surg Tranplant Bull. 1962;29:199–207. 117. Dingman DL, Hartog J, Siemionow M. Simultaneous deep-plane face lift and trichloroacetic acid peel. Plast Reconstr Surg. 1994;93:86–93. discussion 94–95. 118. Schwartz RJ, Burns AJ, Rohrich RJ, Barton Jr FE, Byrd HS. Long-term assessment of CO2 facial laser resurfacing: aesthetic results and complications. Plast Reconstr Surg. 1999;103:592–601. 119. Graf RM, Bernardes A, Auerswald A, Noronha L. Full-face laser resurfacing and rhytidectomy. Aesthetic Plast Surg. 1999;23:101–106.

300.e3

120. Chen K-H, Tam K-W, Chen I-F, et al. A systematic review of comparative studies of CO2 and erbium:YAG lasers in resurfacing facial rhytides (wrinkles). J Cosmet Laser Ther. 2017;19:199–204. 121. Herbig K, Trussler AP, Khosla RK, Rohrich RJ. Combination Jessner’s solution and trichloroacetic acid chemical peel: technique and outcomes. Plast Reconstr Surg. 2009;124:955–964. 122. Ramaut L, Hoeksema H, Pirayesh A, Stillaert F, Monstrey S. Microneedling: where do we stand now? A systematic review of the literature. J Plast Reconstr Aesthet Surg. 2018;71:1–14. 123. Glasgold M, Glasgold R, Lam S. Autologous fat grafting for midface rejuvenation. Clin Plast Surg. 2015;42:115–121. 124. Trussler AP, Hatef DA, Rohrich RJ. Management of hypertension in the facelift patient: results of a national consensus survey. Aesthet Surg J. 2011;31:493–500. 125. Abboushi N, Yezhelyev M, Symbas J, Nahai F. Facelift complications and the risk of venous thromboembolism: a single center’s experience. Aesthet Surg J. 2012;32:413–420. 126. Baker DC, Stefani WA, Chiu ES. Reducing the incidence of hematoma requiring surgical evacuation following male rhytidectomy: a 30-year review of 985 cases. Plast Reconstr Surg. 2005;116:1973–1985. discussion 1986–1987. 127. Baker TJ, Gordon HL, Mosienko P. Rhytidectomy: a statistical analysis. Plast Reconstr Surg. 1977;59:24–30. 128. Feldman JJ. Neck lift my way: an update. Plast Reconstr Surg. 2014;134:1173–1183. 129. Gupta V, Winocour J, Shi H, Shack RB, Grotting JC, Higdon KK. Preoperative risk factors and complication rates in facelift: analysis of 11,300 patients. Aesthet Surg J. 2016;36:1–13. 130. Ramanadham SR, Mapula S, Costa C, Narasimhan K, Coleman JE, Rohrich RJ. Evolution of hypertension management in face lifting in 1089 patients: optimizing safety and outcomes. Plast Reconstr Surg. 2015;135:1037–1043. 131. Baker DC, Chiu ES. Bedside treatment of early acute rhytidectomy hematomas. Plast Reconstr Surg. 2005;115:2119–2122. discussion 2123. 132. Man D. Premedication with oral clonidine for facial rhytidectomy. Plast Reconstr Surg. 1994;94:214–215. 133. Berner RE, Morain WD, Noe JM. Postoperative hypertension as an etiological factor in hematoma after rhytidectomy. Prevention with chlorpromazine. Plast Reconstr Surg. 1976;57:314–319. 134. Ramanadham SR, Costa CR, Narasimhan K, Coleman JE, Rohrich RJ. Refining the anesthesia management of the face-lift patient: lessons learned from 1089 consecutive face lifts. Plast Reconstr Surg. 2015;135:723–730. 135. Richards BG, Schleicher WF, Zins JE. Putting it all together: recommendations for improving pain management in plastic surgical procedures – surgical facial rejuvenation. Plast Reconstr Surg. 2014;134:108s–112s. 136. Rees TD, Lee YC, Coburn RJ. Expanding hematoma after rhytidectomy. A retrospective study. Plast Reconstr Surg. 1973;51:149–153. 137. Beninger FG, Pritchard SJ. Clonidine in the management of blood pressure during rhytidectomy. Aesthet Surg J. 1998;18:89–94. 138. Grover R, Jones BM, Waterhouse N. The prevention of haematoma following rhytidectomy: a review of 1078 consecutive facelifts. Br J Plast Surg. 2001;54:481–486. 139. Rohrich RJ, Sinno S, Vaca EE. Getting better results in facelifting. Plast Reconstr Surg. Global Open. 2019;7:e2270. 140. Klassen AF, Cano SJ, Schwitzer JA, Scott AM, Pusic AL. FACE-Q scales for health-related quality of life, early life impact, satisfaction with outcomes, and decision to have treatment: development and validation. Plast Reconstr Surg. 2015;135:375–386. 141. Brown DL, Dellon AL. Surgical approach to injuries of the cervical plexus and its peripheral nerve branches. Plast Reconstr Surg. 2018;141:1021–1025. 142. Rohrich RJ, Taylor NS, Ahmad J, Lu A, Pessa JE. Great auricular nerve injury, the “subauricular band” phenomenon, and the periauricular adipose compartments. Plast Reconstr Surg. 2011;127:835–843.

 

SECTION II •  Aesthetic Surgery of the Face

9.10 Neck rejuvenation James E. Zins and Jacob Grow

Access video and video lecture content for this chapter online at Elsevier eBooks+ 

SYNOPSIS

ƒ Aging is a global phenomenon affecting the entirety of the face. Therefore, the gold standard for neck rejuvenation is formal facelift surgery with both direct and ancillary techniques that address the neck concurrently. ƒ Improvement in neck contour is predicated upon skin release from retaining ligaments, appropriate alteration of the soft tissue in the intermediate or subplatysmal plane including subplatysmal fat, digastric muscles and submandibular glands when indicated, as well as appropriate skin redraping. ƒ In select patients, the neck can be effectively treated in isolation through submental liposuction, an open submental-only approach (anterior lipectomy and platysmaplasty), or direct excision of neck skin with Z-plasty. ƒ Minimally invasive injectables and energy-based modalities may result in moderate improvements in neck contour through skin tightening or fat reduction, but cannot replace formal surgical interventions.

Introduction Neck laxity is one of the earliest signs of facial aging and is, therefore, commonly present when patients present for facial rejuvenation. The gold standard for correcting the neck is through formal facelift surgery with a dedicated portion of the procedure focused on the cervical area (Video Lecture 9.10.1 ). Components of the facelift portion of the procedure also improves the aesthetics of the neck. This global approach to facial aging is the best option for most patients. However, under appropriate circumstances, as detailed in this chapter, the neck can be treated effectively in isolation.1–3 Improvement in neck contour and overall aesthetics is predicated upon: (1) skin release from retaining ligaments and septae; (2) appropriate fat removal from the subcutaneous (superficial) and subplatysmal plane; (3) alteration of the platysma and digastric muscles; and (4) submandibular gland alteration when appropriate. As a general principle, skin tension should be avoided in facelift/necklift procedures. It results in poor scar quality at best and skin slough at worst. Excessive tension adds little to

further the correction and enhances creep, which leads to early return of skin laxity. When appropriately addressing the skin, fat and platysma, neck surgery results are long-lasting. In fact, neck correction when performed as described, is generally the longest-lasting component of the face/necklift procedure.

Access the Historical Perspective section online at Elsevier eBooks+

Anatomy and the effect of aging The critical anatomical areas in the neck are the cervicomental angle, the submental/submandibular triangles, and the gonial angles. The paired anterior bellies of the digastric muscles extend from the lesser cornu of the hyoid bone to the posterior surface of the mandible on each side of the symphysis. The motor innervation of the anterior belly of the digastric muscle is the mandibular division of the trigeminal nerve, acting as weak depressors of the mandible. Excision produces no noticeable functional deficit but does cause retro-positioning of the hyoid bone, resulting in a favorable deepening of the cervicomental angle.31 The borders of the submandibular triangles are formed by the anterior and posterior bellies of the digastric muscles and the inferior border of the mandibular body. These bilateral triangles each contain the submandibular salivary gland, facial artery and vein, lingual nerve, and the marginal mandibular branch of the facial nerve. The submandibular gland may produce a bulge in the submandibular triangle if it is hypertrophied and/or ptotic and can be unmasked postoperatively by skin tightening (Fig. 9.10.1). In the lower face, the marginal mandibular nerve exits from under the anterior–inferior portion of the parotid gland. In this location, the course is deep to the parotid-masseteric fascia. It runs horizontally along the lower border of the mandible passing from deep to the parotid-masseteric fascia into the subSMAS

301.e1

SECTION II

CHAPTER 9.10  • Neck rejuvenation

Historical perspective   1966:

Pitanguy – anatomical description of the facial nerve.4   1978: Connell – contouring the neck by lipectomy and a muscle sling.5   1979: Aston – the platysma muscle in rhytidoplasty.6   1980: de Castro – the anatomy of the platysma muscle.7   1980: Ellenbogen and Karlin – visual criteria for restoring the youthful neck.8   1985: Courtiss – suction lipectomy of the neck.9   1989: Furnas – the retaining ligaments of the cheek.10   1989: Stuzin – anatomy of the frontal branch of the facial nerve.11   1990: Feldman – corset platysmaplasty.12   1991: De Pina and Quinta – aesthetic resection of the submandibular gland.13   1992: Hamra – deep plane rhytidectomy.14   1992: Stuzin – the relationship of the superficial and deep facial fascias.15   1995: Giampapa and Di Bernardo – neck recontouring with suture suspension and liposuction.16   1996: Biggs – excision of neck redundancy with single Z-plasty closure.17   1998: Knize – limited incision submental lipectomy and platysmaplasty.18

  1997:

Connell and Shamoun – the significance of digastric muscle contouring.19   1997: Baker – short scar facelift .20   2002: Tonnard – minimal access cranial suspension (MACS) lift.21   2005: Zins and Fardo – the anterior-only approach to neck rejuvenation.22   2006: Sullivan et al. – neck contouring with submandibular gland suspension.23   2008: Mendelson et al. – surgical anatomy of the lower face: the premasseter space, the jowl, and the labiomandibular fold.24   2011: Martén et al. – the safety of facelift in the elderly.25   2013: Alghoul et al. – relationship of the zygomatic facial nerve to the retaining ligaments of the face.26   2014: Feldman – necklift my way: an update.27   2015: Food and Drug Administration (FDA) approves the use of deoxycholic acid for treatment of supraplatysmal submental adiposity.   2017: Pelle-Ceravolo – lateral skin-platysma displacement neck lift.28   2019: Sinno and Thorne – cervical branch of the facial nerve following various platysmaplasty maneuvers.29   2021: Kochuba et al. – effect of tranexamic acid in facelift hemostasis.30

302

SECTION II

CHAPTER 9.10  • Neck rejuvenation

B

A

C

Figure 9.10.1  Fresh cadaver dissection demonstrating anatomy of the platysma muscle. This specimen shows complete separation of the muscle in the midline without decussation. Black arrows represent the anterior muscle borders.

(SMAS = superficial musculo-aponeurotic system) cleavage plane at the level of the facial vessels and continues superficial to the facial vessels to innervate the depressor anguli oris and mentalis muscles.32 Anteriorly at this transition point over the facial artery and vein, the marginal mandibular branch is most prone to injury during facelift surgery. Recovery after complete transection is unlikely since it most often exists as a single branch with infrequent cross-innervation from buccal branches of the facial nerve.33 Dingman and Grabb demonstrated in their landmark study that the marginal mandibular nerve traveled at or above the lower jaw border in 81% of cadaver specimens posterior to the facial vessels and was found above the lower jaw border in 100% of specimens anterior to the facial vessels. Although the exact course of the marginal mandibular nerve in relation to the mandibular border remains an area of controversy, what is not controversial is its relative location superficial to deep (Fig. 9.10.2).35,36 Huettner also demonstrated in a cadaveric study that the mandibular cutaneous ligament is located in the parasymphyseal region 67.8 ± 3.3 mm from the horizontal line constructed from the gonial angle along the inferior border of the mandible (Fig. 9.10.3). The marginal mandibular nerve passes 9.7 ± 1.2 mm superior to the mandibular ligament in the subSMAS plane.34 Injury to the nerve can therefore only occur by platysma violation or through conduction injury from electrocautery. Both the lingual and hypoglossal nerves lie deep to the submandibular gland. Therefore, intracapsular resection of the gland minimizes the risk of both bleeding and nerve injury. The cervical branch of the facial nerve supplies innervation to the platysma muscle, acting to depress the lateral commissure. It exits the parotid gland within 1.5 cm of the gonial angle deep to the deep parotid-masseteric fascia and then quickly transitions to the subplatysmal plane. Cadaveric studies suggest that a single cervical branch root is present proximal to the facial vessels. The nerve then divides into multiple rami anteriorly from 1.75 cm to 4.5 cm caudal to the lower mandibular border.37,38 Sinno and Thorne have shown persistent continuity of this cervical branch trunk following simulated platysmaplasty techniques, demonstrating that innervation to the platysma remains intact after surgical intervention.29

Figure 9.10.2  Fresh cadaver dissection demonstrating the marginal mandibular nerve (large arrows) coursing superficial to the facial vessels (small arrows) but deep to the SMAS. It is here, where the marginal mandibular nerve passes from deep to the parotid-masseteric fascia into the subSMAS cleavage plane and superficial to the facial vessels, that it is most prone to injury during facelift surgery. The dotted line represents lower mandibular border. “A” represents the masseter muscle; “B” represents platysma muscle reflected anteriorly; “C” represents the submandibular gland. Rectangle seen at the lower mandibular border of the full face fresh cadaver orients the reader to close-up view of cadaver dissection.

Although not a motor nerve, the most commonly injured nerve in facelift/necklift surgery is the great auricular nerve (GAN). The GAN is a purely sensory nerve that supplies the earlobe, antitragus, scapha, helical crus, and lower posterior auricle. Historically, the most common method for locating the GAN, where it is most superficial and vulnerable to injury, is at McKinney’s point, defined as a point 6.5 cm inferior to the external auditory canal as it crosses the midbelly of the sternocleidomastoid muscle.39 Since that time, other authors have found greater variation in the location of the GAN than initially reported. In a cadaveric study, Ozturk et al. described a danger zone of injury for the GAN, which can be defined by drawing a vertical line through the midlobule perpendicular to the Frankfort’s horizontal, followed by a 30° angle constructed posteriorly from the midlobule.40 Ozturk et al. found that the superior course of the GAN fell within this triangle 100% of the time (Fig. 9.10.4, Video 9.10.1 ). Remaining in a superficial dissection plane over this danger zone above the cervical fascia can greatly decrease incidence of GAN injury. Three important planes exist in the neck: the superficial plane between the skin and the platysma; the intermediate plane deep to the platysma containing the subplatysmal fat, the anterior belly of the digastric muscles, and the submandibular glands; and the deep plane deep to the deep fascia.41 Several authors have described the fat compartments in the neck and detailed the anatomy of subplatysmal fat.42,43 Rohrich  et al. described central, medial, and lateral compartments which form a V-shaped adipose tissue mass that extends from the lateral third of the mandible to the thyroid cartilage.44 In contrast, Larson et al. only identified central and lateral compartments. They found that the supraplatysmal fat represented 44% of the total neck fat, subplatysmal fat contributed to 30.7%, and the submandibular glands 24.5% of neck volume. The contribution from fat deep to the deep fascia was 30 cc in 24 h), the drain remains in place until the output has subsided. Drainage is likely to be significant in heavier necks or

if unipolar electrocautery was used to raise flaps. Therefore, scissor dissection and bipolar cautery is favored for skin flap elevation. A chinstrap is worn continuously for 5 days and then at night for an additional 2 weeks for those undergoing platysmaplasty with fat resection. Patients are instructed to sleep with their heads elevated and necks gently extended. A single pillow positioned behind the head should be avoided. Cervical flexion can increase edema through venous obstruction, place excess tension on postauricular closures, and diminish adherence of the skin flap to the underlying wound bed. There should be no heavy lifting or bending in the immediate postoperative period. NSAIDs and anticoagulants are best avoided for at least 1 week after neck rejuvenation. Finally, good communication between the surgeon and patient increases cooperation and helps achieve a better surgical outcome. It is routine for our patients to send photos of themselves in the immediate postoperative period. This allows for early identification of complications, and also gives the patients reassurance, thus improving their postoperative experience.154

Complications Complications following neck rejuvenation surgery are similar to those seen with standard facelift surgery. Early complications include the following:   Hematoma.   Seroma.   Sialocele.   Injury to the marginal mandibular branch of the facial nerve.

Late complications include the following:   Contour

irregularities. fat removal.   Inadequate reduction.   Overcorrection.   Recurrence of platysmal bands.   Asymmetrical

318

SECTION II

CHAPTER 9.10  • Neck rejuvenation

The incidence of hematoma following facelift in general or the wide variety of necklift procedures described in this chapter vary greatly, ranging from as low as 1% to significantly higher depending upon the study cited.155 The occurrence of hematoma can be minimized by performance of a careful history, making certain that anticoagulants and antiplatelet medications are avoided for 1–2 weeks preoperatively, which includes a wide array of herbal medications known to increase bleeding risk. Careful attention to detail must also be carried out intraoperatively to avoid a surgical error that leads to a postoperative bleed. Other means of reducing the incidence of hematoma include the avoidance of postoperative hypertension, nausea and vomiting. Other adjuncts such as platelet-rich plasma156 and fibrin glue have been cited as effective in some hands, while others have found these ancillary-type techniques ineffective.157–159 As discussed previously, the use if TXA has transformed our practice in achieving thorough hemostasis and decreasing operative times while also minimizing postoperative drain output.150 While a hematoma may occur, the significant error comes from not recognizing it promptly. Clearly, early evacuation of both small and large hematomas minimizes postoperative morbidity and mortality. An expanding hematoma is a surgical emergency due to the potential for airway compromise and skin flap necrosis. Small hematomas, however, can also be troublesome postoperatively. They are frequently missed because of facial swelling and may lead to long-term irregularities. Large hematomas need to be evacuated in the operating room. However, small hematomas can often be aspirated, milked out through the drains, or evacuated with a suction cannula. If a small hematoma goes unrecognized in the early postoperative period, it can be drained percutaneously 7–14 days following surgery when the clot lyses. Seromas are most frequent in the neck area and can also be troublesome postoperatively. Unrecognized seromas lead to neck contour irregularities, which are difficult and at times nearly impossible to correct. While not universal, most surgeons drain the neck postoperatively. Our preference is to use suction drains to obliterate dead space and minimize seroma fluid collections. Drains are removed when output is minimal.

Access the reference list online at   Elsevier eBooks+

This may require drainage for 24 hours or more, but usually removal occurs on postoperative day 1. Should a seroma occur in the neck following drain removal, repeat aspiration is indicated until the seroma subsides. Sialocele is a rare but well-documented face/necklift complication. This may occur following subSMAS surgery or submandibular gland resection. It should be suspected when clear fluid is found in the drain, or aspiration yields this same clear, turbid fluid. The diagnosis of parotid fistula is confirmed by measuring the amylase level in the aspirate. In the case of parotid fistulas, the amylase level will be quite high. Classically, suction drains that obliterate dead space rather than repeat aspirations appear to be the most effective means of resolving the fistula. In the absence of distal obstruction, the fistula will close. More recently, injection of botulinum toxin has replaced internal drainage.160,161 Facial nerve injury is also rare, most commonly involving the marginal mandibular branch of the facial nerve when operating in the neck and jawline. Most injuries are relatively distal and resolve without the need for intervention. However, marginal mandibular branch injury may be permanent due to its peculiar anatomy. Re-exploration for facial nerve injury is generally not indicated since injury is most likely distal with the presence of redundancy. The use of botulinum toxin A to weaken the contralateral muscles is a reasonable temporizing measure while waiting for the nerve injury to resolve. Late complications of face and neck rejuvenation are generally aesthetic and include recurrence of platysmal banding, contour abnormalities due to the irregular resection of fat, unmasking of ptotic submandibular glands, pixie ears, and abnormalities of scar formation. Recurrent platysmal banding is the most common aesthetic deformity of the neck requiring reoperation after initial surgery.162 It is a particularly challenging problem, as its specific etiology remains controversial.163 Thin, long necks are most prone to this phenomenon. Conservative subcutaneous defatting of the neck is the best means for prevention. In treating these patients during secondary face/necklift procedures, the need for further midline tightening is nearly universal, as laxity recurs following the initial plication and plays a major factor in the bands reforming.

References

References 1. Abdollahi H, Lao W, Matarasso A. Chapter X: Managing the components of the aging neck: from liposuction to submentalplasty, to neck lift. In: Shiffman MA, Di Giuseppe A, eds. Liposuction: Principles and Practice. Berlin: Springer; 2016. 2. Matarasso A, Smith D. Necklift techniques. In: Evans G, ed. Operative Plastic Surgery. 2nd edn Oxford: Oxford University Press; 2019. 3. Matarasso A, Sinno S. Isolated necklift. In: Chung K, Thorne C, Sinno S, eds. Operative Techniques in Facial Aesthetic Surgery. Philadelphia: Lippincott Williams & Wilkins; 2019:238–241. 4. Pitanguy I, Ramos AS. The frontal branch of the facial nerve: the importance of its variations in face lifting. Plast Reconstr Surg. 1966;38(4):352–356. 5. Connell BF. Contouring the neck in rhytidectomy by lipectomy and a muscle sling. Plast Reconstr Surg. 1978;61(3):376–383. 6. Aston SJ. Platysma muscle in rhytidoplasty. Ann Plast Surg. 1979;3(6):529–539. 7. de Castro CC. The anatomy of the platysma muscle. Plast Reconstr Surg. 1980;66(5):680–683. 8. Ellenbogen R, Karlin JV. Visual criteria for success in restoring the youthful neck. Plast Reconstr Surg. 1980;66(6):826–837. 9. Courtiss EH. Suction lipectomy of the neck. Plast Reconstr Surg. 1985;76(6):882–889. 10. Furnas DW. The retaining ligaments of the cheek. Plast Reconstr Surg. 1989;83(1):11–16. 11. Stuzin JM, Wagstrom L, Kawamoto HK, Wolfe SA. Anatomy of the frontal branch of the facial nerve: the significance of the temporal fat pad. Plast Reconstr Surg. 1989;83(2):265–271. 12. Feldman JJ. Corset platysmaplasty. Plast Reconstr Surg. 1990;85(3):333–343. 13. de Pina DP, Quinta WC. Aesthetic resection of the submandibular salivary gland. Plast Reconstr Surg. 1991;88(5):779–788. 14. Hamra ST. Composite rhytidectomy. Plast Reconstr Surg. 1992;90(1):1–13. 15. Stuzin JM, Baker TJ, Gordon HL. The relationship of the superficial and deep facial fascias: relevance to rhytidectomy and aging. Plast Reconstr Surg. 1992;89(3):441–451. 16. Giampapa VC, Di Bernardo BE. Neck recontouring with suture suspension and liposuction: an alternative for the early rhytidectomy candidate. Aesthetic Plast Surg. 1995;19(3):217–223. 17. Biggs TM. Excision of neck redundancy with single Z-plasty closure. Plast Reconstr Surg. 1996;98(6):1113–1114. 18. Knize DM. Limited incision submental lipectomy and platysmaplasty. Plast Reconstr Surg. 1998;101(2):473–481. 19. Connell BF, Shamoun JM. The significance of digastric muscle contouring for rejuvenation of the submental area of the face. Plast Reconstr Surg. 1997;99(6):1586–1590. 20. Baker TJ, Stuzin JM. Personal technique of face lifting. Plast Reconstr Surg. 1997;100(2):502–508. 21. Tonnard P, Verpaele A, Monstrey S, et al. Minimal access cranial suspension lift: a modified S-lift. Plast Reconstr Surg. 2002;109(6):2074–2086. 22. Zins JE, Fardo D. The "anterior-only" approach to neck rejuvenation: an alternative to face lift surgery. Plast Reconstr Surg. 2005;115(6):1761–1768. 23. Sullivan PK, Freeman MB, Schmidt S. Contouring the aging neck with submandibular gland suspension. Aesthet Surg J. 2006;26(4):465–471. 24. Mendelson BC, Freeman ME, Wu W, Huggins RJ. Surgical anatomy of the lower face: the premasseter space, the jowl, and the labiomandibular fold. Aesthetic Plast Surg. 2008;32(2):185–195. 25. Martén E, Langevin CJ, Kaswan S, Zins JE. The safety of rhytidectomy in the elderly. Plast Reconstr Surg. 2011;127(6):2455–2463. 26. Alghoul M, Bitik O, McBride J, Zins JE. Relationship of the zygomatic facial nerve to the retaining ligaments of the face: the Sub-SMAS danger zone. Plast Reconstr Surg. 2013;131(2):245e–252e.

318.e1

27. Feldman JJ. Neck lift my way: an update. Plast Reconstr Surg. 2014;134(6):1173–1183. 28. Pelle-Ceravolo M, Angelini M, Silvi E. Treatment of anterior neck aging without a submental approach: lateral skin-platysma displacement, a new and proven technique for platysma bands and skin laxity. Plast Reconstr Surg. 2017;139(2):308–321. 29. Sinno S, Thorne CH. Cervical branch of facial nerve: an explanation for recurrent platysma bands following necklift and platysmaplasty. Aesthet Surg J.. 2019;39(1):1–7. 30. Kochuba AL, Coombs DM, Kwiecien GJ, Sinclair NR, Zins JE. Prospective study assessing the effect of local infiltration of tranexamic acid on facelift bleeding. Aesthet Surg J. 2021;41(4):391–397. 31. Guyuron B. Problem neck, hyoid bone, and submental myotomy. Plast Reconstr Surg. 1992;90:830–840. 32. Mendelson BC, Freeman ME, Wu W, et al. Surgical anatomy of the lower face: the premasseter space, the jowl, and the labiomandibular fold. Aesthetic Plast Surg. 2008;32:185–195. 33. Baker DC, Conley J. Avoiding facial nerve injuries in rhytidectomy. Anatomical variations and pitfalls. Plast Reconstr Surg. 1979;64:781–795. 34. Huettner F, Rueda S, Ozturk CN, et al. The relationship of the marginal mandibular nerve to the mandibular osseocutaneous ligament and lesser ligaments of the lower face. Aesthet Surg J. 2015;35:111–120. 35. Dingman RO, Grabb WC. Surgical anatomy of the mandibular ramus of the facial nerve based on the dissection of 100 facial halves. Plast Reconstr Surg. 1962;29:266–272. 36. Marolt C., Freed B., Coker C., et al. Key anatomical clarifications for the marginal mandibular branch of the facial nerve: clinical significance for the plastic surgeon. Aesthet Surg J. 2011;41(11): 1223–1228. 37. Salinas NL, Jackson O, Dunham B, Bartlett SP. Anatomical dissection and modified Sihler stain of the lower branches of the facial nerve. Plast Reconstr Surg. 2009;124(6):1905–1915. 38. Chowdhry S, Yoder EM, Cooperman RD, Yoder VR, Wilhelmi BJ. Locating the cervical motor branch of the facial nerve: anatomy and clinical application. Plast Reconstr Surg. 2010;126(3):875–879. 39. McKinney P, Gottlieb J. The relationship of the great auricular nerve to the superficial musculoaponeurotic system. Ann Plast Surg. 1985;14:310–314. 40. Ozturk CN, Ozturk C, Huettner F, et al. A failsafe method to avoid injury to the great auricular nerve. Aesthet Surg J. 2014;34:16–21. 41. Nahai F. Neck lift. In: Nahai F, editor. The Art of Aesthetic Surgery: Principles and Techniques. Vol. 2. St. Louis: Quality Medical Publishing; 2005:1239–1284. 42. Raveendran SS, Anthony DJ, Ion L. An anatomic basis for volumetric evaluation of the neck. Aesthet Surg J. 2012;32: 685–691. 43. Larson JD, Tierney WS, Ozturk CN, et al. Defining the fat compartments in the neck: a cadaver study. Aesthet Surg J. 2014;34:499–506. 44. Rohrich RJ, Pessa JE. The subplatysmal supramylohyoid fat. Plast Reconstr Surg. 2010;126:589–595. 45. Orra S, Tadisina K, Charafeddine A, et al. The effect of age on fat distribution in the neck using volumetric computed tomography. Plast Reconstr Surg. 2021;147(1):49–55. 46. Aston SJ. Platysma muscle in rhytidoplasty. Ann Plast Surg. 1979;3:529–539. 47. De Castro CC. Anatomy of the neck and procedure selection. Clin Plast Surg. 2008;35:625–642. 48. Reece EM, Pessa JE, Rohrich RJ. The mandibular septum: anatomical observations of the jowls in aging-implications for facial rejuvenation. Plast Reconstr Surg. 2008;121:1414–1420. 49. Fogli AL. Skin and platysma muscle anchoring. Aesthetic Plast Surg. 2008;32:531–541. 50. de Castro CC. The anatomy of the platysma muscle. Plast Reconstr Surg. 1980;66:680–683. 51. Connell BF. Contouring the neck in rhytidectomy by lipectomy and a muscle sling. Plast Reconstr Surg. 1978;61:376–383.

318.e2

SECTION II

CHAPTER 9.10  • Neck rejuvenation

52. Connell BF. Neck contour deformities. The art, engineering, anatomic diagnosis, architectural planning, and aesthetics of surgical correction. Clin Plast Surg. 1987;14:683–692. 53. Connell BF, Gaon A. Surgical correction of aesthetic contour problems of the neck. Clin Plast Surg. 1983;10:491–505. 54. Connell BF, Shamoun JM. The significance of digastric muscle contouring for rejuvenation of the submental area of the face. Plast Reconstr Surg. 1997;99:1586–1590. 55. Ellenbogen R, Karlin JV. Visual criteria for success in restoring the youthful neck. Plast Reconstr Surg. 1980;66:826–837. 56. Ellenbogen R, Karlin JV. Regrowth of platysma following platysma cervical lift: etiology and methodology of prevention. Plast Reconstr Surg. 1981;67:616–623. 57. Knize DM. Limited incision submental lipectomy and platysmaplasty. Plast Reconstr Surg. 1998;101:473–481. 58. Knize DM. Limited incision submental lipectomy and platysmaplasty. Plast Reconstr Surg. 2004;113:1275–1278. 59. Furnas DW. The retaining ligaments of the cheek. Plast Reconstr Surg. 1989;83:11–16. 60. Robbins LB, Brothers DB, Marshall DM. Anterior SMAS plication for the treatment of prominent nasomandibular folds and restoration of normal cheek contour. Plast Reconstr Surg. 1995;96:1279–1288. 61. Baker DC. Lateral SMASectomy. Plast Reconstr Surg. 1997;100:509–513. 62. Stuzin JM, Feldman JJ, Baker DC, et al. Cervical contouring in face lift. Aesthet Surg J.. 2002;22:541–548. 63. Owsley Jr. JQ. Platysma-fascial rhytidectomy: a preliminary report. Plast Reconstr Surg. 1977;60:843–850. 64. Owsley Jr. JQ. SMAS-platysma face lift. Plast Reconstr Surg. 1983;71:573–576. 65. Owsley JQ. Mechanical properties and microstructure of the superficial musculoaponeurotic system. Plast Reconstr Surg. 1996;98:59–73. 66. Hamra ST. Composite rhytidectomy. Plast Reconstr Surg. 1992;90:1–13. 67. Hamra ST. Composite Rhytidectomy. St. Louis: Quality Medical Publishing; 1993. 68. Little JW. Three-dimensional rejuvenation of the midface: volumetric resculpture by malar imbrication. Plast Reconstr Surg. 2000;105:267–269. 69. Stuzin J., pers. comm. 2004. 70. Zins J, Morrison C. Aesthetic surgery of the aging face and neck. In: Siemionow M, Eisenmann-Klein M, eds. Plastic and Reconstructive Surgery. London: Springer; 2009: 379–392. 71. Flowers RS. Tear trough implants for correction of tear trough deformity. Clin Plast Surg. 1993;20:403–415. 72. Yaremchuk MJ. Infraorbital rim augmentation. Plast Reconstr Surg. 2001;107:1585–1595. 73. Yaremchuk MJ, Israeli D. Paranasal implants for correction of midface concavity. Plast Reconstr Surg. 1998;102:1676–1685. 74. Bartlett SP, Grossman R, Whitaker LA. Age-related changes of the craniofacial skeleton: an anthropometric and histologic analysis. Plast Reconstr Surg. 1992;90:592–600. 75. Pessa JE, Zadoo VP, Mutimer KL, et al. Relative maxillary retrusion as a natural consequence of aging: combining skeletal and soft-tissue changes into an integrated model of midfacial aging. Plast Reconstr Surg. 1998;102:205–212. 76. Whitaker LA. Biological boundaries: a concept in facial skeletal restructuring. Clin Plast Surg. 1989;16:1–10. 77. Whitaker LA, Bartlett SP. Skeletal alterations as a basis for facial rejuvenation. Clin Plast Surg. 1991;18:197–203. 78. Rosen HM. Surgical correction of the vertically deficient chin. Plast Reconstr Surg. 1988;82:247–256. 79. Rosen HM. Aesthetic guidelines in genioplasty: the role of facial disproportion. Plast Reconstr Surg. 1995;95:463–472. 80. Feldman JJ. Corset platysmaplasty. Plast Reconstr Surg. 1990;85:333–343.

81. Feldman JJ. Corset platysmaplasty. Clin Plast Surg. 1992;19:369–382. 82. Feldman JJ My approach to neck lift. Denver: Colorado Society of Plastic Surgeons; 1995. 83. Feldman JJ. Lesser lifts and ancillary procedures. Orlando, FL: Annual Meeting of the American Society of Aesthetic Surgery; 1996. 84. Feldman JJ. The isolated neck lift. Vail, CO: Massachusetts General Hospital Aesthetic Symposium; 1996. 85. Feldman JJ. Face or neck lift without a postauricular incision. Orlando FL: 33rd Annual Meeting of the American Society of Aesthetic Surgery; 2000. 86. Feldman JJ. Approach to face-neck-brow-periorbital lift. Instructional course. San Antonio, TX: Annual Meeting of the American Society of Plastic Surgeons; 2002. 87. Feldman JJ. Small incision necklift. Instructional course. Vancouver, Canada: Annual Meeting of the American Society of Aesthetic Surgery; 2004. 88. Zins JE, Fardo D. The “anterior-only” approach to neck rejuvenation: an alternative to face lift surgery. Plast Reconstr Surg. 2005;115:1761–1768. 89. Zins JE, Menon N. Anterior approach to neck rejuvenation. Aesthet Surg J. 2010;30:477–484. 90. Matarasso A, Matarasso SL, Brandt FS, Bellman B, Botulinum A. Exotoxin for the Management of Platysma Bands. Plast Reconstr Surg. 1999;103(2):645–652. (Cited in Yearbook of Plastic, Reconstructive, and Aesthetic Surgery 2000. Mosby; 2000: 121.). 91. Agarwal A, Dejoseph L, Silver W. Anatomy of the jawline, neck, and perioral area with clinical correlations. Facial Plast Surg. 2005;21:3–10. 92. Sclafani AP. Soft tissue fillers for management of the aging perioral complex. Facial Plast Surg. 2005;21:74–78. 93. Goldman MP, Marchell NL. Laser resurfacing of the neck with the combined CO2/Er:YAG laser. Dermatol Surg. 1999;25:923–925. 94. Weiss RA, Weiss MA, Beasley KL. Rejuvenation of photoaged skin: 5 years results with intense pulsed light of the face, neck, and chest. Dermatol Surg. 2002;28:1115–1119. 95. Hayashi K, Thabit 3rd G, Massa KL, et al. The effect of thermal heating on the length and histological properties of the glenohumeral joint capsule. Am J Sports Med. 1997;25:107–112. 96. Ferraro GA, De Francesco F, Nicoletti G, et al. Histologic effects of external ultrasound-assisted lipectomy on adipose tissue. Aesthetic Plast Surg. 2008;32:111–115. 97. Fabi SG. Noninvasive skin tightening: focus on new ultrasound techniques. Clin Cosmet Investig Dermatol. 2015;8:47–52. 98. Fabi SG, Few JW, Moinuddin S. Practical guidance for optimizing patient comfort during microfocused ultrasound with visualization and improving patient satisfaction. Aesthet Surg J. 2020;40(2):208–216. 99. Oni G, Hoxworth R, Teotia S, et al. Evaluation of a microfocused ultrasound system for improving skin laxity and tightening in the lower face. Aesthet Surg J. 2014;34:1099–1110. 100. Fabi SG, Goldman MP. Retrospective evaluation of micro-focused ultrasound for lifting and tightening the face and neck. Dermatol Surg. 2014;40:569–575. 101. MacGregor JL, Tanzi EL. Microfocused ultrasound for skin tightening. Semin Cutan Med Surg. 2013;32:18–25. 102. Dayan SH, Schlessinger J, Beer K, et al. Efficacy and safety of ATX-101 by treatment session: pooled analysis of data from the phase 3 REFINE trials. Aesthet Surg J. 2018;38(9):998–1010. 103. Grow JN, Holding J, Korentager R. Assessing the efficacy of deoxycholic acid for the treatment of submental fat: a threedimensional study. Aesthet Surg J. 2019;39(12):1400–1411. 104. Cunha KS, Lima F, Cardoso RM. Efficacy and safety of injectable deoxycholic acid for submental fat reduction: a systematic review and meta-analysis of randomized controlled trials. Expert Rev Clin Pharmacol. 2021;14(3):383–397. 105. Tonnard P, Verpaele A. The MACS-lift short scar rhytidectomy. Aesthet Surg J. 2007;27:188–198.

References

106. Tonnard P, Verpaele A, Morrison C. MACS facelift. In: Aston SJ, Steinbrech DS, Walden JL, eds. Aesthetic Plastic Surgery. New York: Saunders Elsevier; 2009:137–148. 107. Guerrerosantos J. Surgical correction of the fatty fallen neck. Ann Plast Surg. 1979;2:389–396. 108. Castro C.C. Transactions of the VIII International Congress of Plastic and Reconstructive Surgery, Montreal, Canada, 1983. 109. Souther SG, Vistnes LM. Medial approximation of the platysma muscle in the treatment of neck deformities. Plast Reconstr Surg. 1981;67:607–613. 110. Fuente del Campo A. Midline platysma muscular overlap for neck restoration. Plast Reconstr Surg. 1998;102:1710–1715. 111. Cruz RS, O’Reilly EB, Rohrich RJ. The platysma window: an anatomically safe, efficient, and easily reproducible approach to neck contour in the face lift. Plast Reconstr Surg. 2012;129:1169–1172. 112. Guerrerosantos J, Sandoval M, Salazar J. Long-term study of complications of neck lift. Clin Plast Surg. 1983;10:563–572. 113. Giampapa VC, Di Bernardo BE. Neck recontouring with suture suspension and liposuction: an alternative for the early rhytidectomy candidate. Aesthetic Plast Surg. 1995;19:217–223. 114. Ramirez OM. Advanced considerations determining procedure selection in cervicoplasty. Part two: surgery. Clin Plast Surg. 2008;35:691–709. viii. 115. Feldman JJ. Neck lift my way: an update. Plast Reconstr Surg. 2014;134:1173–1183. 116. Nahai F. Reconsidering neck suspension sutures. Aesthet Surg J.. 2004;24:365–367. 117. Giampapa V, Bitzos I, Ramirez O, et al. Suture suspension platysmaplasty for neck rejuvenation revisited: technical fine points for improving outcomes. Aesthetic Plast Surg. 2005;29:341–352. 118. Giampapa V, Bitzos I, Ramirez O, et al. Long-term results of suture suspension platysmaplasty for neck rejuvenation: a 13-year follow-up evaluation. Aesthetic Plast Surg. 2005;29:332–340. 119. Ramirez OM. Advanced considerations determining procedure selection in cervicoplasty. Part two: surgery. Clin Plast Surg. 2008;35:691–709. 120. Ramirez OM. Advanced considerations determining procedure selection in cervicoplasty. Part one: anatomy and aesthetics. Clin Plast Surg. 2008;35:679–690. 121. Ramirez OM, Robertson KM. Comprehensive approach to rejuvenation of the neck. Facial Plast Surg. 2001;17:129–140. 122. Ramirez OM. Cervicoplasty: nonexcisional anterior approach. Plast Reconstr Surg. 1997;99:1576–1585. 123. Tonnard P. Short-Scar Face Lift: Operative Strategies and Techniques. Vol. II. St. Louis: Quality Medical Publishing;; 2007. 124. Courtiss EH. Suction lipectomy of the neck. Plast Reconstr Surg. 1985;76:882–889. 125. Goddio AS. Skin retraction following suction lipectomy by treatment site: a study of 500 procedures in 458 selected subjects. Plast Reconstr Surg. 1991;87:66–75. 126. Sinclair NR, Kochuba A, Coombs DM, et al. Face lift practice patterns: an American Society of Plastic Surgeons member survey, 2000 and 2020. How much have we changed? Plast Reconstr Surg. 2022;149(6):1096e–1105e. 127. Grotting JC, Beckenstein MS. Cervicofacial rejuvenation using ultrasound-assisted lipectomy. Plast Reconstr Surg. 2001;107:847–855. 128. de Souza Pinto EB, Abdala PC, Maciel CM, et al. Liposuction and VASER. Clin Plast Surg. 2006;33:107–115. 129. Jewell ML, Fodor PB, de Souza Pinto EB, et al. Clinical application of VASER-assisted lipoplasty: a pilot clinical study. Aesthet Surg J.. 2002;22:131–146. 130. Collawn SS. Skin tightening with fractional lasers, radiofrequency, Smartlipo. Ann Plast Surg. 2010;64:526–529. 131. Prado A, Andrades P, Danilla S, et al. A prospective, randomized, double-blind, controlled clinical trial comparing laser-assisted lipoplasty with suction-assisted lipoplasty. Plast Reconstr Surg. 2006;118:1032–1045.

318.e3

132. Cook J, DiBernardo BE, Pozner JN. Bipolar Radiofrequency as an adjunct to face and body contouring: a 745-patient clinical experience. Aesthet Surg J. 2021;41(6):685–694. 133. Dayan E, Rovatti P, Aston S, Chia CT, Rohrich R, Theodorou S. Multimodal radiofrequency application for lower face and neck laxity. Plast Reconstr Surg Glob Open. 2020 Aug 26;8(8):e2862. 134. Cohen S, Dominsky O, Artzi O, Dayan E, Eckstein J. Deep layer radiofrequency thermo-coagulative technology for cervicofacial contouring: sonographic and clinical results. Plast Reconstr Surg Glob Open. 2020;8(12):e3286. 135. Doolabh V, Ruff P. A Retrospective chart review of subdermal neck coagulation using helium plasma technology. Dermatol Rev. 2020;1:143–150. 136. Ruff PG, Doolabh V, Zimmerman EM, Gentile RA. Safety and efficacy of helium plasma for subdermal coagulation. Dermatol Rev. 2020;1:108–114. 137. Kam J, Frost A, Bloom JD. Radiofrequency rejuvenation of the “tweener” patient: under, over, or through the skin. Facial Plast Surg. 2021;37(2):240–248. 138. Biggs TM. Excision of neck redundancy with single Z-plasty closure. Plast Reconstr Surg. 1996;98:1113–1114. 139. Biggs TM, Koplin L. Direct alternatives for neck skin redundancy in males. Clin Plast Surg. 1983;10:423–428. 140. Biggs TM, Koplin L. Concepts of neck lift. Clin Plast Surg. 1983;10:367–378. 141. Cronin TD, Biggs TM. The T-Z-plasty for the male “turkey gobbler” neck. Plast Reconstr Surg. 1971;47:534–538. 142. Hamilton JM. Submental lipectomy with skin excision. Plast Reconstr Surg. 1993;92:443–448. 143. Adamson JE, Horton CE, Crawford HH. The surgical correction of the “turkey gobbler” deformity. Plast Reconstr Surg. 1964;34:598–605. 144. Gradinger GP. Anterior cervicoplasty in the male patient. Plast Reconstr Surg. 2000;106:1146–1155. 145. de Pina DP, Quinta WC. Aesthetic resection of the submandibular salivary gland. Plast Reconstr Surg. 1991;88:779–788. 146. Singer DP, Sullivan PK. Submandibular gland I: an anatomic evaluation and surgical approach to submandibular gland resection for facial rejuvenation. Plast Reconstr Surg. 2003;112:1150–1156. 147. Bravo FG. Submandibular and parotid gland reduction in facelift surgery. Plast Reconstr Surg. 2013 Oct;132(4S):95–96. 148. Mendelson BC, Tutino R. Submandibular gland reduction in aesthetic surgery of the neck: review of 112 consecutive cases. Plast Reconstr Surg. 2015;136(3):463–471. 149. Jung GS, Cho IK, Sung HM. Submandibular gland reduction using botulinum toxin type a for a smooth jawline. Plast Reconstr Surg Glob Open. 2019;7(4):e2192. 150. Kochuba AL, Coombs DM, Kwiecien GJ, Sinclair NR, Zins JE. Prospective study assessing the effect of local infiltration of tranexamic acid on facelift bleeding. Aesthet Surg J. 2021;41(4):391–397. 151. Couto RA, Charafeddine A, Sinclair NR, Nayak LM, Zins JE. local infiltration of tranexamic acid with local anesthetic reduces intraoperative facelift bleeding: a preliminary report. Aesthet Surg J. 2020;16;40(6):587–593. 152. Chornenki NLJ, Um KJ, Mendoza PA, et al. Risk of venous and arterial thrombosis in non-surgical patients receiving systemic tranexamic acid: a systematic review and meta-analysis. Thromb Res. 2019 Jul;179:81–86. 153. Rohrich RJ, Cho MJ. The role of tranexamic acid in plastic surgery: review and technical considerations. Plast Reconstr Surg. 2018;141(2):507–515. 154. Pozza ED, D’Souza GF, DeLeonibus A, Fabiani B, Gharb BB, Zins JE. Patient satisfaction with an early smartphone-based cosmetic surgery postoperative follow-up. Aesthet Surg J. 2017;38(1):101–109. 155. Jones BM, Grover R. Avoiding hematoma in cervicofacial rhytidectomy: a personal 8-year quest. Reviewing 910 patients. Plast Reconstr Surg. 2004;113:381–390.

318.e4

SECTION II

CHAPTER 9.10  • Neck rejuvenation

156. Man D, Plosker H, Winland-Brown JE. The use of autologous platelet-rich plasma (platelet gel) and autologous platelet-poor plasma (fibrin glue) in cosmetic surgery. Plast Reconstr Surg. 2001;107:229–239. 157. Marchac D, Brady JA, Chiou P. Face lifts with hidden scars: the vertical U incision. Plast Reconstr Surg. 2002;109:2539–2554. 158. Marchac D, Greensmith AL. Early postoperative efficacy of fibrin glue in face lifts: a prospective randomized trial. Plast Reconstr Surg. 2005;115:911–918. 159. Marchac D, Sandor G. Face lifts and sprayed fibrin glue: an outcome analysis of 200 patients. Br J Plast Surg. 1994;47:306–309. 160. Capaccio P, Cuccarini V, Benicchio V, Minorati D, Spadari F, Ottaviani F. Treatment of iatrogenic submandibular sialocele with

botulinum toxin. Case report. Br J Oral Maxillofac Surg. 2007;45(5):415–417. 161. Lawson 3rd GA, Kreymerman P, Nahai F. An unusual complication following rhytidectomy: iatrogenic parotid injury resulting in parotid fistula/sialocele. Aesthet Surg J. 2012;32(8):1040. 162. Citarella ER, Condé-Green A, Janne Hasbun S. Secondary neck lift and the importance of midline platysmaplasty: review of 101 cases. Plast Reconstr Surg. 2017;139(2):564e–566e. 163. Knipper P, Mitz V. Platysma bands: is a change needed in the surgical paradigm? Plast Reconstr Surg. 2017;140(5):755e.

 

SECTION II •  Aesthetic Surgery of the Face

9.11 Male facelift Timothy Marten and Dino Elyassnia

Access video lecture content for this chapter online at Elsevier eBooks+ 

Introduction Over the past few decades increased numbers of men have sought facial rejuvenation as prevailing attitudes regarding aging and appearance have shifted. During this time plastic surgeons have recognized that a diminished margin for error arguably exists in male patients due to the fact that men have fewer options to conceal their scars or a mediocre result. Plastic surgeons have also come to recognize that in most cultures male facial aesthetics differ from those thought desirable in females and attractive masculinity is not as closely equated with youth and beauty as is femininity. Men generally seek a somewhat different outcome from facial rejuvenation surgery, and this has led to a rethinking of techniques that have evolved mainly to treat facial aging in women. New approaches, modified techniques, and aesthetic goals have subsequently emerged that allow attractive rejuvenation of the male face while preserving a natural, masculine, unoperated appearance.1–20

Aging of the male face and male facial aesthetics Treatment strategies in men will be different from those in women and it is not appropriate to arbitrarily apply concepts and techniques that evolved largely for treating the female face to that of a man. The male face is arguably more nuanced than that of a woman, whom we have come to accept as having a more contrived and made-up appearance, and certain aspects of male facial aging are often regarded as signs of experience, wisdom, and power that many men wish not to lose. In these and other ways men often have different goals than women when seeking rejuvenation of their faces, with the man arguably more concerned about a natural appearance free of signs that a surgical procedure has been performed. If we see a woman

whose face looks younger that the rest of her body, or if her face has visible signs that a facelift might have been performed, we smile and tell ourselves “she might have had something done”. If we see a man with an overdone or unnatural appearance, or tell-tale signs that surgery has been performed, however, we are often more judgmental and disapproving. Women, who typically wear longer hairstyles and make-up, also have more ways to hide signs that surgery has been performed than a man. In this sense, there is perhaps less room for error, both technically and artistically, when a male facelift is performed. In the time since history has been recorded female beauty has been closely associated with smooth skin, the absence of wrinkles, and youth – whereas male attractiveness often encompasses a certain weathered ruggedness, and even a certain disdain for an overly perfected appearance. These conventions and attitudes are indeed changing, but nonetheless are a consideration when performing male facelift procedures. In our current cultural climate, female attractiveness is seen as correlated with smooth skin, a wrinkleless forehead, an arched eyebrow, a stylized eye appearance, a high cheek profile, a tight jawline, and overall inverted oval facial shape. Male attractiveness, on the other hand, rests more in a bottom-heavy rectangular facial shape, a heavier and bolder jawline, a strong athletic neckline, a lower and more horizontal eyebrow, a flatter cheek profile, and less meticulously maintained skin. When these differences are considered it can be seen that a different endpoint is typically sought by men seeking facelift surgery, and the goals of the procedure and accompanying technique must be modified accordingly. Men typically seek and desire a bold, athletic neck and jawline, and more subtle and less dramatic changes in other areas of the face. All things considered, a surgeon who can deliver a good result in the neck and jawline, provide well-concealed scars, and exercise restraint when operating on the forehead, eyes and mouth is likely to be successful when treating male patients. In contrast, surgeons who over-treat the orbital area, do not provide well-concealed scars, and do not deliver a good result in the neck are likely to have more unhappy patients.

320

SECTION II

CHAPTER 9.11  • Male facelift

Recognizing the components of the aging deformity of the face Recognizing the components of the aging deformity of the face and appreciating the underlying anatomical abnormalities is essential to properly advising patients and fundamental to the planning of any surgical procedure. Careful analysis will reveal that most patient problems will fall into three broad categories: (1) aging and breakdown of the skin surface; (2) facial sagging, skin redundancy, and loss of youthful facial contour; and (3) facial hollowing, atrophy and/or age-related lipodystrophy. Proper treatment will depend upon the types of problems present, the patient’s priorities, and the time, trouble and expense he is willing to endure to obtain the desired improvement. Male patients primarily concerned with surface aging of their face do not require formal surgical procedures and may achieve the type of improvement they desire through dermatologic surface treatments of the skin. These treatments include skin peels, skin resurfacing, chemodenervation (neuromodulator injections), and other treatments designed to remove or reduce age-related skin surface imperfections. In our experience, few men have this as a primary concern. Men primarily concerned with facial sagging, skin excess and loss of facial contour will achieve minimal ultimate improvement, however, if surface treatments only are employed, and will require formal surgical lifts in which sagging tissue is repositioned and redundant tissue is excised if these problems are to be properly corrected and an attractive and natural-appearing improvement is to be obtained. Most men’s concerns fall solidly in this category. The misapplication of surface treatments of the skin to the sagging face with excess tissue will produce little more than a smooth, saggy face with no improvement in contour. This sort of “smoothsaggy look”, typically seen in older patients who have undergone laser resurfacing or deep skin peels, is inconsistent with a natural appearance as patients with loss of facial contour generally also have concomitant skin surface aging. It is arguably more masculine and natural-appearing to have youthful facial shape with a few wrinkles and surface imperfections, than a smooth but saggy face. Many, if not most, of the changes associated with loss of facial contour in men represent primarily "deep layer" problems that will be inadequately corrected if traditional “skinonly” techniques are used. Regrettably, many surgeons unfamiliar with deep layer techniques, and other physicians insufficiently trained to perform then, often employ a variety of conceptually flawed procedures including skin-only “minilifts”, “suture lifts”, “thread lifts”, and “short scar” lifts and resort to other misguided and misapplied ancillary procedures to overcome the shortcomings of these methods in men. These procedures include facial liposuction, buccal fat extraction, malarplasty, submalarplasty, and PTFE (“Gortex”) implantation. Although some of these ancillary procedures are at times indicated in male patients, they will be unnecessary in the majority of cases if a superficial musculo-aponeurotic system (SMAS) facelift and deep layer rejuvenation is performed (Fig. 9.11.1). Male patients with significant facial atrophy and age-related facial hollowing will generally achieve suboptimal improvement from both surface treatments of facial skin and surgical lifts. Smoothing skin will not hide a drawn appearance due

to loss of facial volume, and it is difficult to create natural and healthy masculine contours by lifting and repositioning tissues that have abnormally thinned and deflated with age. Restoring lost facial volume with autologous fat grafting is a powerful

A

B

Figure 9.11.1  High SMAS facelift and related procedures in a male patient. (A) Before surgery view of patient, age 59. He can be seen to have combined surface aging of his skin, tissue sagging and redundancy, and facial atrophy. Note heavily wrinkled forehead, hollow cheeks and midface, deep cheek folds and sagging facial tissues. (B) Same patient, 1 year and 6 months after facelift, necklift, forehead lift, upper blepharoplasty with levator reinsertion, lower blepharoplasty, and partial facial fat grafting. Note improvement in forehead wrinkling, brow position, eye appearance, lower eyelid fullness, posture of perioral tissues, and overall facial sagging. Increased facial fullness following fat grafting is also evident particularly in the midface. The patient has a more rested, youthful, healthy, virile, and masculine appearance without a tight, pulled, or “facelifted” look. All surgical procedures performed by Timothy Marten, MD, FACS. (Photos courtesy of Timothy Marten, MD, FACS, used with permission.)

Treatment strategies in the male patient

technique that has gained widespread acceptance in treating the aging face. Properly performed, the addition of fat to areas of the male face that have atrophied due to age or disease can produce a significant and sustained improvement in appearance unobtainable by other means (see Figs. 9.11.1, 9.11.37 & 9.11.39). In addition, autologous fat grafting may represent the first true anti-aging therapy plastic surgeons have to offer our patients in that there is a growing body of evidence that adult stem cells transferred with fat exert a rejuvenating effect on tissues in areas adjacent to areas where fat is injected. Age-related facial atrophy rarely exists as an isolated event in the healthy patient, however, and thus male patients troubled by it are not always logically or appropriately treated by fat grafting alone. Isolated fat grafting is also arguably of questionable benefit to the patient troubled by significant facial sagging and skin redundancy. Although aggressive filling of the sagging face with fat can produce improved contour and a smoother appearance, it generally results in an unusually large, overfilled face that appears unnatural. Such an overfilled face can be hard to correct in an attractive manner at a later date, and it is both more logical and practical to perform fat grafting in conjunction with formal surgical lifts if needed, or sometime after ptotic tissue has been repositioned and redundant tissue has been removed. When a SMAS facelift technique is used in conjunction with fat grafting, both loss of facial contour and facial atrophy can be corrected and optimal improvement in the patient’s appearance can be obtained.

321

A

Treatment strategies in the male patient There are a number of situations one encounters in treating men in which a somewhat different strategy than one would use in women can be employed.

The bald man and the man with short hair The bald man or the man with short hair, while often regarded by some as a significant challenge above and beyond that of the typical patient, can in reality be treated largely in the same way as a man or woman with abundant hair. Even sparse, short hair provides good cover for the temple and occipital incisions if properly planned as the short hair worn by most men falls over them and conceals them. This is the case even in the man who wears a “military-style” haircut. In these patients the basic facelift incision plan need not be specifically modified (Fig. 9.11.2; see also Fig. 9.11.39). Small incision and endoscopic foreheadplasty (see Fig. 9.11.26) is also usually possible in these patients if indicated as incisions can be sited on the temple scalp and at the superior-most spot that hair is present (see Fig. 9.11.39). Alternatively, a forehead lift can be performed by excising forehead skin along a transverse forehead crease (see Fig. 9.11.28), or by using a supraciliary incision (see Fig. 9.11.29). Both these strategies result in inconspicuous scars and represent a worthwhile trade-off in most men in the facelift age group.

Man with shaved head Although once uncommonly seen, the shaved head has gradually become a near cultural norm and an increasingly common

B

Figure 9.11.2  (A,B) Occipital hairline scar in men with short hair. The bald man or the man with short hair, while often regarded by some as a significant challenge above and beyond that of the typical patient, can be treated in the same way as a man or woman with abundant hair. Even sparse, short hair provides good cover for the temple and occipital scars if properly planned as the short hair worn by most men falls over the scars and conceals them. This is the case even in the man who wears a “military-style” haircut. All surgical procedures performed by Timothy Marten, MD, FACS. (Photos courtesy of Timothy Marten, MD, FACS, used with permission.)

fashion statement, and this has resulted in plastic surgeons encountering a growing number of these men seeking facelifts and related procedures. Although these patients may initially present a quandary and are often mistakenly turned away by some surgeons, they are very good candidates for “facelift” surgery if a thoughtful surgical plan is employed. In treating the man with the shaved head one can exploit the fact that a key and quintessential feature of an attractive, athletic appearing man is a good neckline. Unlike women – for whom optimal appearances are more closely tied to youth, an inverted oval facial shape, high cheek contour, and a tight jawline – the male face is more tolerant of a rectangular shape, a lower cheek profile, and a lax jawline. As such, a short scar

322

SECTION II

CHAPTER 9.11  • Male facelift

A

B

C

D

E

Figure 9.11.3  Facial rejuvenation strategy in the man with the shaved head. In treating the man with the shaved head one can exploit the fact that a quintessential feature of an attractive, athletic appearing man is a good neckline. As such, a short scar necklift performed in conjunction with ancillary procedures, as indicated, such as facial fat grafting, superciliary eyebrow lift, nasolabial fold excision, and conservative eyelid surgery, can result in quite satisfactory improvement without the need for a full facelift and periauricular scars. (A,C) Male patient with shaved head seen preoperatively. On casual consideration it seems treating him would be difficult. (B,D,E) Same patient following short scar necklift (note: no scar is present around the ear), facial fat grafting, and conservative eyelid surgery. The patient appears remarkably rejuvenated even though a periauricular incision was not used and no periauricular scar is present (see also Fig. 9.11.4). All surgical procedures performed by Timothy Marten, MD, FACS. (Photos courtesy of Timothy Marten, MD, FACS, used with permission.)

necklift performed in conjunction with ancillary procedures such as fat grafting, superciliary eyebrow lift, nasolabial fold excision, and conservative eyelid surgery, can result in quite satisfactory improvement without the need for a full facelift and periauricular scars (Fig. 9.11.3). In a short scar necklift16 a submental incision only is used and improved neck contour is obtained by modification of deep layer neck structures and not the excision of neck skin. These modifications include subplatysmal lipectomy, submandibular gland reduction, partial digastric myectomy, and platysma­plasty. Skin is then allowed to redrape over the deeper and geometrically longer concave surface created and this, in effect, “takes up” “loose” neck skin. Short scar necklift can be productive in men well into their 60 s in most cases (Fig. 9.11.4). If a man with a shaved head feels excess skin is present that needs to be removed an “extended necklift”5 incision plan can be used (typical periauricular facelift incision with no temporal portion Fig. 9.11.5) modified by shortening or eliminating the occipital portion of the incision. Typically men needing and requesting this are older (in their 60 s or 70 s) and the scar is less of an issue and better concealed on their more aged skin than in the typical “short scar” candidate (40s–60 s).

The “facelift” phobic man Many men are simply put off by the word “facelift” and even when their typical fears of “looking different”, “having a pulled or tight appearance”, or “having obvious scars” are countered with explanations as to how those occurrences can be avoided, it can be difficult to convince them to undergo the procedure. Often it seems that they want the improvement afforded by the facelift but just cannot get past the name of the procedure. In such cases an accord can usually be struck by simply calling the procedure an “extended necklift” and modifying the facelift incision plan slightly accordingly. In the extended necklift, a typical periauricular facelift incision is employed but no temporal portion of the incision is made (see Fig. 9.11.5). Such a plan places the incision and resulting scar in a well-concealed location but negates the possibility of a poorly concealed scar in the temporal (around the sideburn) area. This incision plan will allow a limited low cheek SMAS flap to be elevated (or a low cheek SMAS plication to be performed) as part of the procedure that provides improvement in the lower face and along the jawline that would not otherwise be obtained if an isolated necklift (short

Preoperative planning in the male facelift patient

A

323

scar necklift) only was performed. In addition, it allows the excision of a significant amount of skin from the lower face, jawline, and neck that would not otherwise be removed. It should be noted that the extended necklift encompasses certain compromises however, including the fact that no upper cheek or midface improvement is obtained. While this is often an unacceptable compromise when operating on the female face, it can be a very acceptable trade-off in the male patient. The extended necklift can be combined with fat grafting2–4 to offset some of its limitations and to obtain improvement on the upper face. Conservatively performed forehead and eyelid surgery, as discussed above and in following sections, can further enhance the outcome.12–14

Short scar facelifts in men

B

Figure 9.11.4  Short scar necklift. (A) patient before surgery. (B) Same patient after short scar necklift. A submental incision only is used and improved neck contour is obtained by modification of deep layer neck structures and not the excision of neck skin. Skin is then allowed to redrape and redistribute itself over the deeper and geometrically longer concave surface created and this takes up “loose” neck skin. No scar is present around or behind the ear. All surgical procedures performed by Timothy Marten, MD, FACS. (Photos courtesy of Timothy Marten, MD, FACS, used with permission.)

A traditional short scar incision plan offers little benefit for most men and can in reality be problematic in many cases. The basic premise of shifting facial skin strongly in a vertical direction is conceptually flawed and typically results in the need for aggressive temple or forehead lifts and tedious gathering of redundancy along a temporal hairline incision that might not otherwise be required. Gathering of tissue, and the often resulting puckering and bunching of skin along incisions in the temple and post-lobular areas that typically occurs when short scar incision plans are used, can be concealed to some extent by women who typically wear longer hairstyles, but can be a significant source of embarrassment to men (Fig. 9.11.6). Vertical skin shifts can also move deep cervical wrinkles up onto the lower face, a problem not encountered when a postauricular incision is used and a proper more posteriorly directed vector for skin shift is employed. And because neck improvement is of paramount importance in men, it could be argued that shortening the scar in the postauricular area where it should be well concealed (see Figs. 9.11.2–9.11.5 and Fig. 9.11.17A), even in a man with short hair and compromising overall result in the cervicosubmental region, is of dubious value. Shortening the occipital portion of the facelift incision somewhat may be useful in the man with the shaved head however (see previous discussion).

Preoperative planning in the male facelift patient It is not possible to design or use a "universal" male facelift technique as each male patient will present with a unique set of problems that require precise anatomic diagnosis and an appropriately planned and individualized surgical repair. Committed study, careful planning, and avoiding the use of a “formula technique” will maximize improvement, limit complications, and minimize secondary deformities. Figure 9.11.5  Extended necklift incision plan. The incision plan for an “extended necklift” is similar to the typical periauricular facelift incision plan without the temporal portion of the incision. This incision plan allows some lower facial skin to be excised and a “low” superficial musculo-aponeurotic system (SMAS) flap to be elevated and advanced (or low SMAS plication or SMAS stacking to be performed) that provides improvement in the lower face and along the jawline that would not otherwise be obtained if an isolated necklift (short scar necklift) only was performed. (Illustration courtesy of Timothy Marten, MD, FACS, used with permission.)

Planning incisions in the male facelift patient Planning the temple incision The temporal portion of the facelift incision has traditionally been placed within the temporal scalp in a well-intended, but all too frequently counterproductive attempt to hide the resulting scar. When cheek skin redundancy is small and

324

SECTION II

CHAPTER 9.11  • Male facelift

A

Figure 9.11.7  Temple scalp temporal incision plan. When cheek skin redundancy is small and abundant temple and sideburn hair is present, an incision hidden in the temple scalp (red dotted line) can be used without producing objectionable sideburn and temporal hairline displacement. Note sideburn and bearded skin in front of the ear (area between black arrows) have been moved posteriorly closer to the ear but not objectionably so (retrotragal pre-auricular incision plan has been used; (see Fig. 9.11.12). Procedure performed by Timothy Marten, MD, FACS. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

B

Figure 9.11.6  Flawed “short scar” facelift incision plans. (A,B) A short scar incision plan offers little benefit to most men and can be problematic in many cases. Gathering of tissue, and the often resulting puckering and bunching of skin along incisions in the temple and postauricular areas, that typically occurs when short scar incision plans are used can be concealed to some extent by women who typically wear longer hairstyles, but can be a significant source of embarrassment to men. Procedures performed by unknown surgeons. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

abundant temple and sideburn hair is present, such a plan can be used without producing objectionable sideburn elevation and temporal hairline displacement (Fig. 9.11.7). This, however, is often seldom the case for male patients, who typically present for facelifts at a later age. Patients best suited for this incision plan are usually young men and women who are troubled by mild to moderate cheek laxity only. In many men, however, skin shifts and the presence of sparse temple hair can result in unnatural, tell-tale, and effeminate-appearing displacement of the temporal hairline and sideburn if such a plan is used. Proper analysis, careful planning and the use of an incision along the hairline, when indicated, can avert this problem without compromising the overall outcome of the procedure (Fig. 9.11.8).

This incision will accommodate large posterior-superior skin flap shifts and allows maximum improvement in the upper lateral face to be made. If it is made with care and closed under no tension, the resulting scar is usually inconspicuous and will be far less troublesome for the patient than a displaced hairline. This is particularly true for men whose temple hair is generally kept cut short and usually falls forward and over the scar, as opposed to women who typically wear their hair long and tuck it up over their ear, exposing the scar. The length (extent superiorly) of the temple-sideburn incision can be varied depending on the amount of redundant skin in the upper lateral cheek, and the amount of midface improvement obtained (Fig. 9.11.9).

Planning the pre-auricular incision Open to inspection, the pre-auricular region exists as a frequent point of reference for those seeking to identify a facelift patient. Traditionally, incisions in this area in men are made well anterior to the anterior border of the helix and continued inferiorly, anterior to the tragus in a “pretragal” location (Fig. 9.11.10). This plan, however, works well only for the unusual male patient with cheek and tragal skin of similar characteristics who, in addition, exhibits favorable healing. Unfortunately, most male patients have a marked gradient of color, texture, and surface irregularities over these areas and a tell-tale

Preoperative planning in the male facelift patient

325

B

A

Figure 9.11.8  (A,B) Temporal hairline incision in the male patient. In many male patients skin shifts and the presence of sparse temple hair can result in unnatural, tell-tale, and effeminate-appearing displacement of the temporal hairline and sideburn if such a plan is used. Placing the incision along the hairline prevents this problem and results in a well-concealed scar if the incision is closed properly. (A) Plan for temple hairline incision in the male patient. Note that unlike the incision plan in a female patient that is made as a soft curve, the incision in men should be planned in a more angular fashion, echoing the shape of the male sideburn. (B) Close-up of healed incision. Hairline displacement has been avoided and the scar is well concealed. The sideburn has an angular masculine shape and has not been retrodisplaced or diminished in size (note slight shift of bearded skin below the sideburn can be seen). Surgical procedures performed by Timothy Marten, MD, FACS. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

A

B

C

Figure 9.11.9  (A–C) Length of the temple hairline incision. The superior extent of the temporal hairline incision will vary depending upon the amount of cheek skin shift predicted (and whether a forehead lift is to be concomitantly performed) if puckering and gathering is to be avoided in this area. (A) Superior extent of temple hairline incision when modest cheek skin displacement is predicted (white dotted line). (B) Superior extent of temple hairline incision when moderate cheek skin displacement is predicted (white dotted line). The incision must be made higher to accommodate the cheek skin shift, but still is situated in a well-concealed location. (C) Superior extent of temple hairline incision when large cheek skin displacement is predicted (white dotted line). This incision should be made no higher than the junction of the temporal hairline with the frontotemporal hairline, however (point shown by white arrow). If it is carried more superiorly along the frontotemporal hairline (area designated by red X) the resulting scar will usually be visible as hair tends to grow posteriorly in that area. Procedure performed by Timothy Marten, MD, FACS. (Illustration courtesy of Timothy Marten, MD, FACS, used with permission.)

mismatch will be evident, even in the presence of an inconspicuous scar (Fig. 9.11.11). For these reasons, and in all but the unusual case, the pre-auricular portion of the facelift incision in men is usually best placed along the posterior margin of the tragus, rather than in the pretragal sulcus (Fig. 9.11.12). In this location a mismatch of color, texture, or surface irregularities will not be noticed and the scar, if visible, will appear to be a tragal highlight (Fig. 9.11.13).

In addition, if properly planned and executed, an incision along the margin of the tragus will not produce tragal retraction or other anatomical irregularity (Fig. 9.11.14A–C). If tissue repositioning is achieved using SMAS advancement and not excessive skin tension, as it rightly should be, modest displacement of skin will occur in many male patients and no bearded skin will be advanced onto the tragus (see Fig. 9.11.14A). In the male patient in whom large skin flap shifts occur, beard growth on the tragus can be reduced by

326

SECTION II

CHAPTER 9.11  • Male facelift

intra-operative destruction of beard follicles from the underside of the tragal flap (see Fig. 9.11.35). Because beard hair grows in three phases, “beard shift” encroachment on the tragus cannot usually be completely eliminated at the time of surgery. However, most mature men in the facelift age group have some stray hair growth on the tragal area naturally, and some visible hair growth on the tragus is not necessarily seen as a sign that a facelift has been performed in the eyes of most casual observers and in typical social situations (see Fig. 9.11.14B,C; also Figs. 9.11.7, 9.11.8

& 9.11.13). To obtain the most natural appearance, some men may wish to undergo electrolysis following their surgery in the relatively rare case that bearded skin is advanced onto the tragus and intra-operative epilation is not adequate. In general, it is prudent to wait 4–6 months after surgery before that is done. The superior portion of the pre-auricular incision should be planned as a soft curve paralleling the curve of the anterior border of the helix. This will result in a natural-appearing "width" to the helix in keeping with the rest of the ear, and the resultant scar, if visible, will appear to be a helical highlight. As the tragus is approached, the mark for incision is carried into the depression superior to it and then continued along its posterior margin. In this location the scar, if visible, will appear to be a natural highlight (see Figs. 9.11.8, 9.11.12–9.11.14). At the inferior portion of the tragus the incision must turn anteriorly and then again inferiorly, into the crease between anterior lobule and cheek. If a more relaxed “lazy S” plan is made, or if a straight line incision is used, skin settling and scar contraction will result in crowding of the incisura, obliteration of the inferior tragal border and a tell-tale elongated and "chopped off" tragal appearance.

Planning the perilobular incision

Figure 9.11.10  Traditional location of the pre-auricular incision. This places the scar in most men in an area open to inspection by others and “brands” the male patient as having had facelift surgery. Gradients of color and texture between smooth, pale auricular skin and coarse, red cheek skin draw additional attention to the scar (see Figs. 9.11.11A–C).

B

A

To obtain a natural perilobular appearance, and to facilitate shaving in men, it is essential to preserve the natural sulcus of beard-free skin naturally present between the earlobe and the cheek and to avoid destruction of, or excision of, this functionally and aesthetically important anatomic subunit. This is accomplished by marking the perilobular incision 2 or 3 mm inferior to the lobular-facial sulcus and slightly lower than it would be made in a woman (see Fig. 9.11.15B). All other factors being equal, a superior result will be obtained when such a plan is used, in comparison to any plan in which the incision is placed directly in the sulcus and an attempt is subsequently made to directly join thin, soft earlobe with coarse,

C

Figure 9.11.11 Typical irregularities seen when a pretragal incision is used in male patients. (A) An unknown surgeon has mistakenly tried to “hide” the pre-auricular incision along the posterior border of bearded skin. The scar is easily seen in the exposed location. A gradient of color and texture on each side of it draws additional attention to it, and the patient’s attempt to hide it by growing a long sideburn has failed. Retro-displacement of bearded skin against the scar has resulted in a thin, spindly, unnatural, and unmasculine-appearing sideburn. (B,C) An unknown surgeon failed to recognize the difference in color and texture of the ear (tragal) and cheek skin and the use of a pretragal incision has resulted in an obvious irregularity even though the scar itself is well healed. The difference in color and texture on each side of the scar would be better concealed along anatomic interfaces if a retrotragal (see Figs. 9.11.10–9.11.14) incision plan had been used. Procedures performed by unknown surgeons. (Illustration courtesy of Timothy Marten, MD, FACS, used with permission.)  

Preoperative planning in the male facelift patient

327

A

A

B B

Figure 9.11.12  “Retrotragal” plan for the pre-auricular portion of the facelift incision. (A,B) Placing the incision along natural anatomic contours conceals the scar and disguises differences in color and skin texture on each side of it (see also Figs. 9.11.13 & 9.11.14). (Illustration courtesy of Timothy Marten, MD, FACS, used with permission.)

thick, bearded cheek (Fig. 9.11.15A). Preserving the lobular-facial sulcus will also make it significantly easier for the patient to shave in the perilobular area.

Planning the postauricular incision Traditionally, the postauricular portion of the facelift incision has been made in both men and women up over the posterior surface of the concha. This was done as part of a well-intended, but conceptually flawed, effort to offset inevitable descent of the postauricular flap and inferior migration of the resulting scar that occurred when skin was tightened in an

Figure 9.11.13  Retrotragal incision plan of the pre-auricular incision and resulting scar. (A) “Retrotragal” plan for concealed pre-auricular incision. The incision is planned along natural anatomic interfaces to disguise gradients of color and texture typically seen between the ear and cheek. (B) Healed retrotragal scar in a male facelift patient. The scar is situated along anatomic interfaces concealing gradients of color and texture that would be obvious if a pretragal incision plan had been used. In this location the scar, if seen, fools the eye and appears to be a reflected highlight. Procedure performed by Timothy Marten, MD, FACS. (Illustration courtesy of Timothy Marten, MD, FACS, used with permission.)

attempt to improve neck contour. Many surgeons have come to realize that such a plan embodies erroneous assumptions and can result in undesirable effects and problematic including hypertrophic scarring, postauricular webbing, and obliteration of the auriculomastoid sulcus. If such a plan is used in men, bearded skin from the neck can also be moved up into the auriculomastiod sulcus, or even onto the posterior surface of the ear resulting in considerable difficulty in shaving. The postauricular portion of the facelift incision should instead be marked 2–3 mm posterior to the existing auriculomastoid sulcus with the ear pulled forward as little as possible,

328

SECTION II

A

CHAPTER 9.11  • Male facelift

B

C

Figure 9.11.14  Healed “retrotragal” facelift scars in male patients. A retrotragal placement of the pre-auricular portion of the facelift incision has resulted in inconspicuous and well-concealed scars. In the upper third, the scar sits in the interface between the helix and the cheek and the scar appears to be a reflected highlight of the anterior helical border. In the middle third, the scar sits along the poster margin of the tragus and cannot be seen. Some coarse and bearded skin has been shifted up against and onto the tragus in (B) and (C), but this is less obvious than the presence of a pretragal scar with a gradient of color and texture on each side of it (see Fig. 9.11.11). In the lower third, the scar sits in a well-concealed location 2–3 mm outside the lobular-facial sulcus but far enough away from it that shaving in that area is not difficult. Note that the patient seen in (C) has a shaved head. All surgical procedures performed by Timothy Marten, MD, FACS. (Photos courtesy of Timothy Marten MD, FACS, used with permission.)

A

B

Figure 9.11.15  Erroneous elimination of the lobular-facial sulcus and proper perilobular incision plan. (A) The perilobular incision has been placed too close to the earlobe and the lobular-facial sulcus eliminated. The thin, soft earlobe has been inserted into coarse, thick, bearded cheek skin resulting in an unnatural transition between the two structures and a “facelifted” appearance. Failure to preserve a cuff of lobular-facial sulcus also makes it difficult for men to shave. (procedure performed by unknown surgeon). (B) To obtain a natural perilobular appearance, and to facilitate shaving in men, it is essential to mark the perilobular incision 2–3 mm inferior to the lobular-facial sulcus and slightly more inferior than it would be made in a woman. All other factors being equal, a superior result will be obtained when such a plan is used, in comparison to any plan in which the incision is placed directly in the sulcus and an attempt is subsequently made to directly join thin, soft earlobe with coarse, thick cheek. (Photos courtesy of Timothy Marten, MD, FACS, used with permission.)

and the mark turned posteriorly to cross the mastoid at the approximate level of the divergence of the anterior and superior crus of the antihelix. Such a plan places the scar at a natural anatomical interface where it will be difficult to detect, even on close inspection (see Figs. 9.11.16 & 9.11.2) but facilitates shaving of beard hair that might be advanced onto this area.

Planning the transmastoid portion of the postauricular incision Considerable confusion exists among surgeons performing facelift procedures as to what level the transmastoid part of the postauricular facelift incision (see Fig. 9.11.16, black

Preoperative planning in the male facelift patient

dotted line) should cross over to the occipital scalp and as a result this part of the incision is often not placed strategically and in a manner that best conceals it, or in a way that allows optimal excision of skin from the anterior neck. If it is placed too low it will be visible in the male patient who typically wears a short hairstyle. If it is placed too high the defect created will force an overly vertical shift of the postauricular skin flap and compromise improvement in the anterior neck and submental region. A useful guide in siting the transmastoid part of the postauricular incision is to envision a horizontal line through the point at which the anterior and superior crus of the antihelix diverge (red dot in Fig. 9.11.17A). Typically at that level the rim of the helix extends posteriorly back to the occipital hairline

Figure 9.11.16  Planning the postauricular incision. The postauricular incision (red dotted line) should be made 2–3 mm posterior to the existing auriculomastoid groove and the mark turned posteriorly to cross the mastoid at the approximate level of the anterior crus of the antihelix (see Fig. 9.11.17). Such a plan places the postauricular scar along a natural anatomical interface where it will be difficult to detect but facilitates shaving of beard hair that might be advanced into this area. (Illustration courtesy of Timothy Marten, MD, FACS, used with permission.)

A

B

329

to the so-called “helix-hairline touch point” (see Fig. 9.11.17B) and a transmastoid incision placed at that level will be hidden behind the ear in the lateral view (see Fig. 9.11.17C,D).

Planning the occipital incision Planning the location for the occipital portion of the facelift incision is conceptually similar to that of the temple region and the incision plan must address similar concerns of hairline displacement and scar visibility. Traditionally this incision is placed transversely extending into the occipital scalp, in a well-intended but usually counterproductive attempt to hide the resultant scar (Fig. 9.11.18). For patients in whom neck skin redundancy is small and excision of postauricular skin is unnecessary, such a plan may be acceptable and will result in a well-concealed scar. Male patients in this category are usually young and troubled by mild neck deformity only, and in these situations the incision is used for access to the lateral neck only, and not as a means to remove postauricular skin. Mistakenly using this incision to excise skin will predictably result in the advancement of neck skin into the occipital scalp and "notching" of the occipital hairline (Fig. 9.11.19B,C). Although women sometimes can hide such an irregularity due to the presence of longer hair, creating a step-off and hairline displacement on a male patient can result in a problem that is difficult to conceal. Proper analysis, careful planning, and the use of an incision along the hairline (Fig. 9.11.20A,B) when indicated, and carried out in a technically correct manner, will prevent this problem, allow skin to be excised along a correct posterior-superior vector, while simultaneously producing a well-concealed scar (see Fig. 9.11.2). The length of the occipital portion of the postauricular incision will necessary vary depending on the quality of the patient’s tissues and the amount of redundant skin present in the anterior neck and submental area (size of “wattle”), and “small”, “medium” and “long” (length of incision along the occipital hairline) incision plans are used as indicated (Fig. 9.11.21). In patients with good tissue quality and minimal

C

D

Figure 9.11.17 Planning the position of the transmastoid part of the postauricular incision. Strategically placing the transmastoid part of the postauricular incision conceals it and allows optimal excision of skin from the anterior neck. If it is placed too low it is visible. If it is placed too high the defect created will force an overly vertical shift of the postauricular skin flap and compromise improvement in the neck. (A) The point of divergence of the anterior and superior crus of the helix provides a useful guide as to how high the transmastoid part of the postauricular incision should be placed (red dot). (B) At this horizontal level (red line) the rim of the helix will typically “touch” the occipital hairline in the lateral view. (C) A transmastoid scar placed at this level will cross over to the occipital scalp in a hidden location. Note that if the incision were placed lower the resulting scar would show. (D) Typical plan for the postauricular incision showing the transmastoid component (red line) to be concealed (gray dotted line shows location of the auriculomastoid component incision hidden behind the ear and white dotted line the occipital incision hidden along the occipital hairline). (Note: the male patient shown has undergone a previous facelift and it can be seen that his scars are well concealed despite his very short “military-style” haircut). (Procedure performed by Timothy Marten, MD, FACS.) (Illustration courtesy of Timothy Marten MD, FACS, used with permission.)  

330

SECTION II

CHAPTER 9.11  • Male facelift

A

Figure 9.11.18  Traditional (but incorrect) plan for the occipital portion of the facelift incision. In traditional facelift incision plans the incision is placed transversely on the occipital scalp in a well-intended but usually counterproductive attempt to hide the resultant scar. This incision plan does not allow for the excision of neck skin along an appropriate vector without resulting in notching and displacement of the occipital hairline (see Fig. 9.11.19) and is only applicable to young men with minimal neck skin excess who need little or no neck skin excised.

anterior neck and submental skin excess (“small wattle”), a “short” incision along the hairline will be indicated (see Fig. 9.11.21A). In patients with modest loss of skin quality and modest anterior neck and submental skin excess (“medium wattle”) a “medium” length incision is made along the occipital hairline (see Fig. 9.11.21B). In elderly patients with poor skin elasticity and a large anterior neck and submental skin excess (“large wattle”) a “long” incision along the occipital hairline will be needed (see Fig. 9.11.21C).

B

Planning the submental incision Optimal improvement in the neck can generally not be obtained in most male patients unless a submental incision is made owing to the near universal presence of excess subplatysmal fat, large submandibular glands, and hypertrophy and/or malposition of the anterior bellies of the digastric muscles typically seen in most men presenting for facelift surgery. Simply performing liposuction, suspending the lateral platysma border, and/or tightening skin over these problems (see Fig. 9.11.31) cannot correct them or produce the type of necklines associated with a fit, athletic, youthful, and healthy-appearing man (see Figs. 9.11.3, 9.11.4, 9.11.30, 9.11.37–9.11.40). Traditionally the submental incision is placed directly in and along the submental crease in a well-intended but counterproductive attempt to conceal the resulting scar (Fig. 9.11.22A). This incision plan should be avoided, however, as it will surgically reinforce the crease and accentuate a "double chin" deformity. Exposure of the submental region will also be compromised, and difficulty will be encountered when dissecting,

C

Figure 9.11.19  “Notching” of the occipital hairline due to poor incision planning and attempts to “hide” the scar in scalp hair. (A) Traditional occipital incision plan responsible for notching of the hairline. (B,C) Examples of "notching" of the occipital hairline seen in two patients whose surgeons used traditional occipital incision plans that resulted in neck skin being advanced into areas where hair bearing scalp should be present (procedures performed by unknown surgeons). (Illustration courtesy of Timothy Marten MD, FACS, used with permission.)

Preoperative planning in the male facelift patient

A

331

B

Figure 9.11.20  (A,B) Plan for incision along the occipital hairline. This incision plan allows skin to be excised along a proper posterior-superior vector, prevents hairline notching and displacement, and results in a well-concealed scar if carried out in a technically correct manner. Note that the incision is planned so that its inferior portion typically turns posteriorly into the occipital scalp at the junction of thick and thin hair but will vary in length in accordance with the amount of skin redundancy present in the anterior neck area (see Fig. 9.11.21). (A) Schematic of occipital hairline incision plan. (B) Occipital hairline incision plan marked on a patient. (Illustration courtesy of Timothy Marten MD, FACS, used with permission.)

A

B

C

Figure. 9.11.21  Plan for length of incision along the occipital hairline. The length of the occipital portion of the postauricular incision (red dotted line) will vary depending on the quality of the patient’s tissues and the amount of redundant skin present in the submental area (size of the “wattle”). (A) In patients with good tissue quality and minimal submental skin redundancy (“small wattle”). a “short” incision along the hairline will be indicated. (B) In patients with modest loss of skin quality and modest submental redundancy (“medium wattle”), a “ medium” incision is made along the occipital hairline. (C) In elderly patients with poor skin elasticity and a large submental skin excess (“large wattle”), a “long” incision along the occipital hairline will be needed. (Illustration courtesy of Timothy Marten MD, FACS, used with permission.)

performing “deep layer” neck maneuvers, and when suturing low in the neck. A more posterior placement of this incision will eliminate these problems, but still result in an inconspicuous and well-concealed scar (Fig. 9.11.22B & 9.11.23). The submental incision should be placed well within the mandibular shadow and well posterior but parallel to the submental crease at a point lying roughly one-half the distance between the mentum and hyoid. This usually corresponds to a site situated 1–2 cm posterior to the crease. The incision should be approximately 3–3.5 cm in length, but may be made longer as long as neither end will be advanced up upon a visible portion of the face when cheek skin flaps are shifted. Healing will be best, and the scar will be best concealed, if it is made as a straight, and not as a curved line, precisely parallel to beard follicles (Fig. 9.11.23).

Treating the forehead in the male facelift patient One of the most frequent errors made by plastic surgeons in treating the male patient is performing upper blepharoplasty when a foreheadplasty is needed. As the forehead ages, the brow descends and infra-brow skin moves into the upper orbit, producing an illusion of eyelid skin redundancy. This false excess of upper eyelid skin is known as "pseudoblepharochalasis", a term that emphasizes the deceptive origin of the problem and one that rightly draws attention to the need to consider forehead surgery in its treatment. Attempts to treat pseudoblepharochalasis with blepharoplasty alone will at best result in a sad, tired-appearing patient with poor eyebrow position and configuration, less

332

SECTION II

CHAPTER 9.11  • Male facelift

A

Figure 9.11.23  Healed submental incision in a male patient. Placement of the submental incision posterior to the submental crease will still result in an inconspicuous, well-concealed scar and allows the submental crease to be released and the “double chin” to be corrected. The submental incision should be made precisely parallel to beard follicles to minimize injury to them. Procedure performed by Timothy Marten, MD, FACS. (Illustration courtesy of Timothy Marten MD, FACS, used with permission.)

B

Figure 9.11.22  Planning the submental incision in the male facelift patient. (A) Traditional but incorrect plan for the submental incision and skin undermining. The incision (black line) should not be placed directly along the submental crease as this will accentuate it and reinforce the “double chin” appearance. Note that typical plan of skin undermining (orange shared area) also promotes a double chin because the crease is not undermined and retaining ligaments are not released. (B) Correct location for the submental incision. Placing the submental incision posterior to the submental crease (black line) prevents accentuation of the “double chin” and witch’s chin deformities and provides for easier dissection and suturing in the anterior neck (compare with [A]). Note that this incision plan allows the submental crease to be undermined (orange shaded area) and released, and the fat of the chin pad and neck to be subsequently blended.

eyelid skin, and a long scar extending off the eyelid and well onto the lateral periorbital/temporal skin. More likely, however, isolated blepharoplasty performed when significant eyebrow/forehead ptosis is present usually results in a loss of the stimulus for brow elevation, further descent of the eyebrow as the frontalis muscle relaxes, and the reappearance of a pseudo skin excess in the superior-lateral orbit and across the upper eyelid as infra-brow skin moves into the orbit. This, in turn, results in an exacerbation of the existing "pseudo-sad”, “pseudo-tired” or disinterested appearance, rather than improvement in it. This sequence of events explains why many male patients and their surgeons are often disappointed with the patient’s overall appearance after upper blepharoplasty, despite technical proficiency in the excision of upper eyelid tissue.

A key requirement in planning rejuvenation of the male forehead when it is indicated in understanding male brow aesthetics and optimal position and configuration of the male eyebrow. Proper position and configuration of the eyebrow is ultimately a subjective judgment in all patients influenced by racial, cultural and other factors that cannot be determined precisely by a fixed mathematical formula or arbitrary measurement, and marks, measurements and published parameters should be regarded as guidelines in planning surgery. They will not be appropriate in every situation or absolutely correct for every face. Ultimately, and as in the female face, the artistic imperative is to achieve proportion and balance with other facial features. Traditionally, surgeons have tried to define ideal eyebrow position in simple linear and absolute terms. While convenient, and useful to some extent, any such analysis is intrinsically flawed in that rigid linear measurements are ultimately inaccurate in that they assume each subject’s head and facial features to be the same size. A more accurate and appropriate guide to what is appropriate and attractive is the “golden proportion”. Simply stated, the “golden proportion” specifies that when the proportions of a facial feature, or relationship between two facial features, can be described by a ratio of 1:1.618, they will appear attractive and pleasing to the eye. A careful analysis of the attractive upper face will show that the aperture of the eye (the vertical distance between the upper and lower eyelids in forward gaze) and the distance between the margin of the upper lid and arch of the eyebrow are related to one another by the “golden proportion”. It is a commonly observed fact that male and female eyebrow positions are not the same and intuitively obvious that eyebrow position connotes sex differences. For most men, however, the attractive eyebrow will fall in inverse relation to that of the female but remain in golden proportion to the palpebral aperture (Fig. 9.11.24).

Preoperative planning in the male facelift patient

While more useful that any arbitrary fixed linear distance, the “golden proportion” should also be recognized as a guideline to eyebrow position and not an absolute ideal, and that under certain circumstances a higher or lower position may be regarded as appropriate and attractive. Perhaps the most useful clinical guideline is simply that the male brow will generally be regarded as attractive at a variety of heights if it is in a horizontal or near-horizontal configuration with its tail at the same

A

B

Figure 9.11.24  The “golden proportion” and eyebrow position. A careful analysis of the attractive upper face will show that the aperture of the eye (the vertical distance between the upper and lower eyelids in forward gaze) and the distance between the margin of the upper lid and arch of the eyebrow can be described by the “golden proportion”. It is a commonly observed fact that male and female eyebrow positions are not the same and intuitively obvious that eyebrow position connotes sex differences. (A) The “golden eyebrow” in a woman. (B) The “golden eyebrow” in a man. For most men the attractive eyebrow will fall in inverse relation to that of the female but remain in golden proportion to the palpebral aperture. (Illustration courtesy of Timothy Marten MD, FACS, used with permission.)

A

B

333

height as its medial aspect, or slightly superior to it (Fig. 9.11.25). Said differently, our goal is not so much to lift the eyebrow higher as it is to tilt it and shape it, and if one can achieve good eyebrow shape most patients and their surgeons will be happy. There are several useful forehead lift strategies applicable to the male patient and there is no one procedure that will be appropriate for all patients. Coronal and hairline incisions forehead lifts are only occasionally indicated in the male patient, and most male patient’s objectives can be met by simpler strategies including “small incision”, partial hairline, forehead crease, and superciliary lifts. Small incision lifts are possible in men with receding hairlines and in the bald or balding man if incisions are carefully sited (Fig. 9.11.26; see also Patient examples 1–3 in Figs. 9.11.37–9.11.39). Often, these lifts are much more technically difficult to carry out in men than in women, however, due to the thick heavy forehead tissues typically present in men, and the greater distance at which one is working due to retrodisplaced, receded hairlines. Partial hairline incisions are useful in some men as a means of reducing temporal hairline recession and actually reducing forehead redundancy and should result in an inconspicuous scar if the wounds are closed carefully and under no tension. Typically these procedures are performed in a dual plane – subcutaneously in the lateral forehead and in a sub-galeal place beneath the scalp – and the interface between them divided. In most men, hairline position and hair density will be mostly stable by the time they reach facelift age, and concerns that hair might recede from the scar are largely unwarranted. However, this plan (Fig. 9.11.27) may be off-putting to some men, such as those who wear shorter hairstyles, have had hair transplants, or who are otherwise concerned with the visibility of the scar. Bald or balding men, men who wear very short hairstyles, men who have previously had hair transplants and fear disruption of their hairline, and men with shaved heads can be effectively treated using an incision in a horizontal forehead crease (Fig. 9.11.28) or in a superciliary location along the superior margin of the eyebrow (Fig. 9.11.29). The superciliary “direct eyebrow lift” is particularly useful and well aligned for the older male with significant eyebrow ptosis who is resistant to a more complicated procedure employing incisions along the hairline or within the scalp. It is simple, straightforward, easy to perform, and if performed carefully, will result in a well-concealed scar.

Figure 9.11.25  Ideal eyebrow shape in women and men. (A) The female brow will appear attractive at a variety of heights if it is in an arched configuration with its tail higher than its medial aspect (white dots represent position of medial and lateral aspects of the eyebrow; white line shows horizontal). (B) The male brow will appear attractive at a variety of heights if it is in a near horizontal configuration with its tail at the same height as its medial aspect, or slightly superior to it. (Illustration courtesy of Timothy Marten MD, FACS, used with permission.)

334

SECTION II

CHAPTER 9.11  • Male facelift

Figure 9.11.26  “Small incision” temple and forehead lift. Most men need conservative treatment of their forehead and brow and are well served with a “sort scar” small incision plan as shown. The incision on the temporal scalp is used to make a subgaleal dissection and the incision on the parietal scalp is used to make a subperiosteal dissection. A lateral forehead flap can be mobilized and elevated by subsequently releasing the temporal line of adherence between the two planes and dividing the periosteum under the lateral aspect of the eyebrow. An endoscope is not required and the latter maneuvers can be accomplished under direct vision through the incision on the temporal scalp. (Illustration courtesy of Timothy Marten MD, FACS, used with permission.)

Figure 9.11.28  Forehead crease temple-forehead lift incision plan. Bald or balding men, men who wear very short hairstyles, men who have previously had hair transplants and fear disruption of their hairline, and men with shaved heads can be effectively treated using an incision in a horizontal forehead crease. Skin only is excised and minimum undermining only is usually required. The scar once healed is often less conspicuous than the forehead crease it was planned around if meticulously closed under no tension. Unlike a “superciliary” “direct” eyebrow lift (see Fig. 9.11.29) this plan allows lifting of the temporal face as well as the eyebrow, and reduction of temporal redundancy that is sometimes generated by a facelift procedure. (Illustration courtesy of Timothy Marten MD, FACS, used with permission.)

Treating the neck in the male facelift patient

Figure 9.11.29  Superciliary “direct” eyebrow lift incision plan. Bald or balding men, men who wear very short hairstyles, men who have previously had hair transplants and fear disruption of their hairline, and men with shaved heads can be effectively treated using and incision along the upper margin of the eyebrow. Skin only is excised and minimum undermining only is usually required. The scar once healed is typically inconspicuous, especially in men in the facelift age group. This plan does not allow lifting of the temporal face as and is not helpful in reducing temporal redundancy that is sometimes generated by a facelift procedure. (Illustration courtesy of Timothy Marten MD, FACS, used with permission.)

A well-contoured neck is an artistic imperative to an attractive and appealing masculine appearance, and a bold, well-defined neckline conveys a sense of youth, health, fitness, strength, vitality, and decisiveness (Fig. 9.11.30). Neck improvement is of high priority to almost every male patient seeking facial

rejuvenation, and the results of “facelift” procedure in men are often largely judged by the outcome achieved in the neck. If the neck is not sufficiently improved, most male patients will feel we have failed them.

Figure 9.11.27  Partial hairline forehead-temple lift incision plan. Partial hairline incisions are useful in some men as a means of reducing temporal hairline recession and reducing forehead redundancy. This plan should result in an inconspicuous scar if the incisions are meticulously closed under no tension. (Illustration courtesy of Timothy Marten MD, FACS, used with permission.)

Preoperative planning in the male facelift patient

A

B

Despite the fact that it is a common practice, it is not enough to perform submental liposuction and tighten the skin in most patients as such an approach ignores a number of anatomical problems present in most male patients seeking neck improvement including platysmal laxity, platysma bands, excess subplatysmal fat, large submandibular glands, digastric muscle hypertrophy and malposition, and developmental factors such as the size and shape of the bony jaw and chin. Removing subcutaneous fat and tightening skin over these problems does not correct them, and the presence or absence of each must be looked for in order to create and carry out an appropriate surgical plan (Fig. 9.11.31). Large anterior neck Z-plasties have been put forth as a means for direct treatment of the male neck by surgeons who have failed to meet their patients’ needs with submental liposuction and other conceptually flawed schemes. In some cases some surgeons combine anterior neck Z-plasties with subplatysmal fat reduction and “corset” tightening of the platysma muscles. In either case a large and objectionable-appearing tell-tale anterior neck scar is created that often heals in a hypertrophic fashion, and Z-plasty flap transposition results in abnormally directed beard growth. Both of these occurrences are often quite troublesome for male patients. It is far more productive to treat deep layer neck problems in the male patient through a much smaller and better concealed submental incision (see Figs. 9.11.22 & 9.11.23), and to remove excess skin against the occipital hairline where the scar is far better concealed. The results that can be obtained with short scar necklift (see Figs. 9.11.3 & 9.11.4), make clear the relative unimportance of skin excision and lateral platysmal tightening.

Treating the chin in the male facelift patient The difference between the presence of poor neck contour and microgenia is commonly misunderstood, and it is a common misconception that placement of a chin implant improves

335

Figure 9.11.30  The neck comprises a key element in rejuvenating the male face. Neck improvement is of high priority to almost every male patient seeking facial rejuvenation, and the results of male “facelift” procedures are often largely judged by the outcome achieved in the neck. (A) Preoperative view of male patient with poor neckline. (B) After view of same patient. A more fit, athletic, masculine and decisive appearance can be seen. All surgical procedures performed by Timothy Marten, MD, FACS. (Illustration courtesy of Timothy Marten MD, FACS, used with permission.)

Figure 9.11.31  “Deep layer” neck problems. The patient has undergone a previous facelift and necklift performed by an unknown surgeon in which submental liposuction and tightening of neck skin was performed. It can be seen that while the submental area has been stripped of subcutaneous fat this approach ignored a number of anatomical problems present in most males, including platysmal laxity, platysma bands, excess subplatysmal fat, large submandibular glands, and digastric muscle hypertrophy. Removing subcutaneous fat and tightening skin over these problems does not correct them. (Illustration courtesy of Timothy Marten MD, FACS, used with permission.)

neck contour. A chin implant is a treatment for microgenia – not a poor neckline – and the presence or absence of microgenia and the need for a chin implant is a cephalometric determination that is independent of the condition of the neck. Placement of a chin implant when microgenia is not present is a conceptual and artistic error that will create unnatural appearances. When true microgenia is present, however, placing a chin implant in combination with a necklift will produce a more harmonious and balanced profile, a more aesthetic and attractive cervicofacial relationship and a bolder more athletic masculine appearance (Fig. 9.11.32, see also Fig. 9.11.37). The male chin differs considerably from that of the female and the surgeon treating male patients must keep this in mind when planning and performing procedures. The male chin is

336

SECTION II

CHAPTER 9.11  • Male facelift

A

B

C

D

Figure 9.11.32  Treating the chin in the male patient. The difference between the presence of poor neck contour and microgenia is commonly misunderstood, and it is a common misconception that placement of a chin implant improves neck contour. Placement of a chin implant when microgenia is not present is a conceptual and artistic error that will create unnatural appearances. (A,C) Patient seen preoperatively has poor neck contour made worse by the presence of mild to moderate microgenia. (B,D) Same patient following “short scar” necklift and chin implant placement (note: a submental incision only was made and the patient has no scar around the ears). When true microgenia is present, placing a chin implant in combination with a necklift will produce a more aesthetic, more athletic, and attractive cervicofacial relationship. The patient has not only a better neck contour, but a more harmonious and balanced profile. All surgical procedures performed by Timothy Marten, MD, FACS. (Illustration courtesy of Timothy Marten MD, FACS, used with permission.)

broader, stronger, more square, and has more vertical height that that of the female, and a strong chin and balanced profile are arguably more important to male attractiveness than to female beauty. A man with a weak chin typically is regarded as appearing weak and indecisive – and in some cases, even unmasculine and effeminate. The male chin should also be smoothly confluent and well-integrated with the jawline, with a smooth and seamless transition across the geniomandibular confluence (see Figs. 9.11.34 & 9.11.37). Some strengthening of the male chin can be accomplished with fat grafting, which provides a means to readily increase vertical chin height. Often a chin implant can be used together with fat grafting to optimize lower facial contour in the male patient with the chin implant providing a reliable increase in

chin projection and the fat used to increase vertical height and to avoid an overly deep and unnatural labiomental sulcus.

Eyelid surgery in the male facelift patient The attractive male orbit and eyelid is distinctly full and, however well intended, traditional blepharoplasty procedures in which eyelid skin and fat are aggressively removed can degrade the appearance of the eye and result in an overly changed appearance in men. Brow ptosis is often marked in many men and simply looking at and then treating the upper eyelid can result in inappropriate over-excision of eyelid skin and functional and aesthetic problems. For many men, subtly repositioning

Preoperative planning in the male facelift patient

A

337

Often what appears to be a large lower eyelid “bag” is in reality merely a pseudo-herniation of orbital fat and in truth largely an atrophic midface and cheek. As such, replenishing lost midface and upper cheek volume is often more appropriate in those situations than removal of the lower eyelid “bag”. A good strategy that is commonly employed in treating the eyelids in men undergoing facelift surgery, especially if they are recognizable public figures or are worried about an overly changed appearance, is to not perform traditional blepharoplasties as part of the facelift procedure. Leaving the upper eyelid redundant, and a bag in the lower orbital area, preserves the patient’s appearance in important loci of identity, and can dissuade others from believing any surgery was performed – “he must not have had a facelift because the plastic surgeon would have surely fixed his baggy eyes ”.

Fat grafting in the male facelift patient

B

Figure 9.11.33  Fat grafting the upper orbit. Atrophy often plays a far greater role in the changes seen in the male orbital area with age than is appreciated, and replenishing lost orbital fat can be profoundly rejuvenating in male patients. Traditional blepharoplasty in these patients will actually degrade the appearance of the eye. (A) Patient seen preoperatively with hollow upper orbits. He has an aged and unmasculine appearance. (B) Same patient after periorbital fat grafting. The patient has a younger, more fit, healthy, attractive, and masculine appearance. (Note: patient has also undergone fat grafting to his temples, radix, cheeks and midface.) All surgical procedures performed by Timothy Marten, MD, FACS. (Illustration courtesy of Timothy Marten MD, FACS, used with permission.)

the lateral brow and fixing it in the position the patient holds it as a result of frontalis muscle contraction will lift the upper lid skin fold off the eyelashes and preclude the need for potentially functionally inappropriate upper eyelid surgery that aesthetically degrades the appearance of the eye. When upper eyelid surgery is performed in men, it should be done very conservatively. It is far better to perform a second-stage skin and fat excision at some future date than to remove too much tissue at the primary procedure and create an overly “changed”, hollow, unmasculine, or ill appearance. As is the case with many women, atrophy often plays a far greater role in the changes seen in the male orbital area with age, and replenishing lost orbital fat can be profoundly rejuvenating in male patients (Fig. 9.11.33). The typical male facelift patient will often express concern about his lower eyelids but lower blepharoplasty, if indicated, must be performed cautiously due to the predictable presence of lower lid laxity. If the lower lid distracts more than 5–6 mm, which is common, some form of canthopexy is likely indicated if lid retraction and a sad, melancholic, aged appearance (and potentially dry eye problems) are to be avoided.

A facelift procedure only addresses tissue ptosis and redundancy and often produces a “lifted” but tell-tale hollow, unhealthy, frail, and under-rejuvenated “geezer” appearance in men. Fat grafting allows loss of facial fat to be treated simultaneously with the facelift, and these sorts of appearances are to be avoided. All things being otherwise equal, simultaneous facelift and fat grafting will produce a better result than either technique performed alone, and when a facelift is performed in conjunction with fat grafting, both loss of facial contour and facial atrophy can be corrected, and optimal overall improvement can be obtained (see Figs. 9.11.39 & 9.11.40) Areas in need of treatment will vary from patient to patient, but any area that can be treated with non-autologous injectable fillers is potentially treatable with fat grafting, including, but not limited to, the temples, radix, upper orbit (“upper eyelid”), lower orbit (“lower eyelid”), cheeks, midface, buccal recess, lips/perioral, nasolabial crease, geniomandibular groove, chin, and jawline areas. Fat grafting is particularly useful in filling the hollow upper and lower orbits (see Fig. 9.11.33) in men as the youthful, attractive male eye is full, and traditional blepharoplasty procedures only exacerbate hollowness, and often actually degrade the appearance of the male eye. The young attractive, athletic and masculine face is also characterized by not only a full upper and lower orbit but also by a rectangular shape and a strong mandibular contour. Replenishing lost volume along the mandible, though initially counterintuitive, restores a more youthful male facial shape and a more bold and decisive appearance. In addition, a more masculine and eye-appealing transition from the face to the neck can be obtained (Fig. 9.11.34). It is commonly believed that fat grafting the lips in men will feminize the mouth, but the young, attractive, healthy male mouth is full, and replenishing lost perioral volume is an important part of creating a harmonious and natural-appearing rejuvenation of the male face. The key in most cases is filling of the lower lip and photographs of the patient when he was younger are often helpful in explaining the need for lip and orbital fat grafting as these will almost uniformly show a full appearance of those areas. Fat grafting the lips (predominantly the lower lip) combined with upper lip lift is an excellent approach for rejuvenation of the male mouth.

338

SECTION II

CHAPTER 9.11  • Male facelift

accommodating issues related to beard shift. A SMAS facelift, when performed in conjunction with necklift, forehead and eyelid surgery, fat grafting, and other procedures in a male patient, will often encompass up to 6–8 h or more, even when performed by a "fast" surgeon working with a well-organized and experienced operating room team.

Anesthesia in the male facelift patient A

B

Figure 9.11.34  Strengthening the male jawline using fat grafting. The young attractive, athletic and masculine face is characterized by a rectangular shape and a strong mandibular contour. Replenishing lost volume along the mandible restores a more youthful male facial shape and a more bold and decisive appearance. (A) Patient seen preoperatively. The posterior jawline is weak and an indistinct transition from the face to the neck is present. (B) The same patient after a facelift and necklift that included fat grafting. Fat grafting has been used to strengthen the cheek and jawline and create a more bold, athletic, youthful and masculine mandibular contour. A distinct transition from the cheek to the neck is now present. No facial implants were placed. All surgical procedures performed by Timothy Marten, MD, FACS. (Illustration courtesy of Timothy Marten MD, FACS, used with permission.)

Preoperative preparations in the male patient A general discussion of preoperative preparation of the facelift patient can be found in Chapter 9.8. Male patients are asked not to shave for 2 days prior to their procedure to allow assessment of beard follicle inclination when incisions are made and to facilitate destruction of beard follicles shifted onto the tragus if indicated. It is important that adequate operating room (OR) time be allotted for contemporary facelift procedures, especially in men, as they are deceptively time-consuming when compared with more limited traditional techniques. The male head is 20%–30% larger than that of a female, and will entail 20%–30% more dissection, suturing, tissue manipulation – and time. Most males will also present more difficultly in terms of bleeding and hemostasis, and the surgeon will typically need to spend extra time

The majority of our facelifts are now performed under deep IV sedation administered by an anesthesiologist using a laryngeal mask (“LMA”). A laryngeal mask allows the patient to be heavily sedated without compromise of their airway, but the patient need not receive muscle relaxants and can be allowed to breath spontaneously. In most cases the cuff need not be inflated and is used simply as and oral airway. A laryngeal mask is also less likely to become dislodged during the procedure than an endotracheal tube, and it is less likely to trigger coughing and bucking when the patient’s head is turned or when he emerges from the anesthetic. Despite some assertions to the contrary, a laryngeal mask is well-suited to long cases, and we have used laryngeal mask airways for 6–8-h long procedures for over a decade without any significant related problems. Hypertension is common in many male patients seeking facelifts and male patients are more prone to bleeding-related complications, including hematoma, than female patients. As such, hypertension must be carefully managed in the perioperative period in male patients. An important part of perioperative management of hypertension is the formulation of a proactive plan for preoperative, perioperative treatment and prevention, and most male facelift patients receive a beta-blocker (atenolol 12.5–25 mg PO) and clonidine 0.1–0.3 mg PO) preoperatively. Perioperative blood pressure is then closely monitored and aggressively treated intra-operatively if it becomes elevated (labetalol 5–10 mg IV q 10 min prn), with the goal of operating on a normotensive patient (mean arterial pressure within 10%–15% of preoperative value). Many male patients with pre-existing hypertension will be undermanaged preoperatively by their internist and in some cases it will be prudent for the surgeon (in conjunction with the anesthesiologist if possible) to tighten blood pressure control in the preoperative and postoperative periods. Employing hypotensive anesthesia, as advocated by some surgeons, carries an increased risk of postoperative bleeding-related complications, and increasing evidence is accumulating that such a practice may lead to cognitive dysfunction postoperatively. A proactive plan for the prevention of postoperative nausea and vomiting should also put in place and antiemetics are given routinely at the beginning of each procedure, and most patients are given several agents in an effort to block the emetic reflex at multiple levels (ondansetron 4–8 mg and dexamethasone 0.1 mg/kg). Limiting the use of IV narcotics and inhalation anesthetics is also helpful in reducing postoperative nausea and vomiting. In patients with a prior history of postoperative nausea and vomiting, additional agents should be considered (scopolamine patch and aprepitant (Emend) 40 mg PO 1–3 h preoperatively).

Ancillary procedures and alternative strategies in the male patient

339

Surgical technique A general discussion of surgical technique for the facelift patient can be found in Chapter 9.8 and highlights of points specific to the male patient are presented here.

SMAS suspension Management of the superior margin of the SMAS flap and the technique of flap suspension will vary depending on considerations particular to the patient including sex, race, and overall facial morphology (see Chapter 9.8). In most cases, however, the excess tissue on the superior margin of the flap in male patients is resected as overlapping of tissue segments that add volume to and restore lost projection over the zygomatic arch in women and would produce unwanted rounding and “ovalization” of the more ideally rectangular and angular male face. After excision of excess SMAS along the superior edge of the flap, the trimmed flap edge is anchored with multiple interrupted sutures of 3-0 polyglycolic acid (PGA; Vicryl) to the cut edge beneath it over the arch.

A

B

Drain placement Drains are routinely used and experience has shown that they reduce postoperative ecchymosis and induration, and allow patients to return to their work and social lives sooner. Two or three 10 F round “end-perforated”, “Jackson-Pratt” style closed-circuit suction drains are typically placed in male patients if necklift is concomitantly performed. One or two drains are placed subcutaneously across the anterior-inferior neck through a small stab incision on the occipital scalp 1–2 cm posterior to the apex of the occipitomastoid incision on both the right and left sides. A third drain is then placed in a similar fashion but pulled into the subplatysmal space. No drains are placed in cheeks or face.

Pre-auricular beard follicle epilation Before closure of the pre-auricular portion of the facelift incision an opportunity exists to reduce the beard follicles present on the part of the flap advanced onto the tragus in older men with larger flap shifts. Small skin hooks are used to invert the pre-auricular skin flap over the surgeon’s fingertip, pushing the beard follicles up out of the subcutaneous fat on the undersurface of the flap. This is facilitated greatly by not having the patient shave for 2 days prior to surgery. Using loupe magnification, individual follicles are then directly excised with a small, serrated scissors or epilated using a needle-tipped (“Colorado”) cautery set on low cautery current. Beard follicles can similarly be removed from a small cuff of skin in the pre-helical and perilobular parts of the check skin flap as well. Care must be taken to apply the cautery precisely and only to the individual follicles themselves. If current is applied carelessly or at too high a level, or otherwise allowed to flow to the skin, vascular compromise and slough could occur (Fig. 9.11.35). Following epilation, if required, the incision is then closed in one layer with multiple simple interrupted sutures of 6-0 nylon. No deep sutures are necessary or should be used.

C

Figure 9.11.35  Epilation of beard follicles from tragal skin flap. In the older male patient in whom large skin flap shifts occur, beard growth on the tragus can be reduced by intra-operative destruction of beard follicles from the underside of the skin flap. (A) The facelift flap has been trimmed but has not been sutured. Beard hair has been shifted into a normally non-hair-bearing area (area posterior to purple dotted line). Note: patient has not shaved for 2 days preoperatively. (B) The pre-auricular skin flap is inverted over the surgeon’s fingertip using small skin hook retractors. Because the patient has not shaved for several days preoperatively, beard stubble pushes the beard follicles out of the plane of the skin on the underside of the flap. Excising subcutaneous fat as shown further exposes the unwanted beard follicles and results in the direct removal of some follicles. (C) Using loupe magnification and a needle-tipped cautery set on a very low setting, remaining follicles and residual follicle elements are epilated. Care must be taken to only cauterize follicles and not apply cautery current to the skin itself. (Illustration courtesy of Timothy Marten MD, FACS, used with permission.)

Ancillary procedures and alternative strategies in the male patient Earlobe reduction Many men presenting for facelift surgery will be seen to have overly large earlobes that lend them a tell-tale old and aged “grandfatherly” appearance, and reducing them can

340

SECTION II

CHAPTER 9.11  • Male facelift

B

A

Figure 9.11.36  Earlobe reduction. (A) Preoperative close-up view of male ear. The large earlobe lends the patients a tell-tale old and aged “grandfatherly” appearance. (B) Same patient after a facelift that included earlobe reduction. The ear appears, smaller, younger, and more proportionate. All surgical procedures performed by Timothy Marten, MD, FACS. (Illustration courtesy of Timothy Marten MD, FACS, used with permission.)

A

B

E

C

D

F

Figure 9.11.37 Patient Example 1. (A) Front view; before surgery view of patient, age 42. The patient has full upper eyelids, ptotic, hollow upper cheeks, cheek ptosis, and a weak appearing jawline. (B) Front view; same patient, 2 years and 3 months after facelift, necklift, small incision forehead lift, upper and lower eye lifts, fat grafting, and chin implant. Note corrections of hooded eyelids, improved cheek contour, and creation of a youthful and masculine facial shape without a tight or pulled appearance. (C) Oblique view; before surgery view of patient, age 42. Note hooded upper eyelid, sagging cheek, hollow lower orbit, and loss of youthful neck and jawline contour. (D) Oblique view; same patient, 2 years and 3 months after facelift, necklift, closed forehead lift, upper and lower eye lifts, fat grafting, and chin implant. Note softer appearance to eyes, improved cheek contours, masculine jawline, and improved neck contour. The chin contour is also improved and the patient has a rested, fit, athletic, decisive, and masculine appearance. (E) Lateral view; before surgery view of patient, age 42. Note lower eyelid fullness, infra-orbital atrophy, poor transition from the lower eyelid to the cheek, poor jawline, weak chin, and full neck. (F) Lateral view; same patient, 2 years and 3 months after facelift, necklift, closed forehead lift, upper and lower eye lifts, fat grafting, and chin implant. The transition from the lower eyelid to the cheek is improved, the cheek position has been improved, chin contour is improved and a fit, athletic, masculine-appearing jawline and neckline can be seen. The face has a natural appearance and all scars are well concealed. All surgical procedures performed by Timothy Marten, MD, FACS. (Courtesy of Timothy Marten, MD, FACS, used with permission.)  

Ancillary procedures and alternative strategies in the male patient

significantly lighten male facial appearance and improve overall outcomes (Fig. 9.11.36; see also Fig. 9.11.39). Earlobe reduction can be performed simply and in a straightforward manner by marking the excess lobule, trimming off the excess, and closing the wound with a seam on the inferior margin of the lobule, and when this is done a well-concealed scar will almost always be obtained. Marks are made in marking ink and the lobule then generously infiltrated with dilute local anesthetic solution to stiffen in and facilitate excision of the redundant part. Skin is incised on the inferior margin of the marked line on the anterior surface of the lobule and on the superior margin of the marked line on its posterior surface and the redundant tissue excised. Incising the redundant portion of the lobule in this way subtly moves the resulting scar along the margin of

341

the lobule slightly onto its inner aspect. The wound is then closed with a simple running suture of 6-0 polypropylene (Prolene) suture and then inset into the cheek flap as previously described.

Upper lip lift Many men presenting for facelift surgery are often older than women undergoing the procedure and have a “long” upper lip (increased vertical distance from the base of the nose to the vermilion–cutaneous junction) and compromised upper dental show when smiling, and as such they are excellent candidates for upper lip lift procedures. The beard–skin interface at the base of the nose also provides an excellent location to place and hide the scar in most men.

A

B

C

D

E

F

G

H

Figure 9.11.38 Patient example 2. (A) Front view; before surgery view of patient, age 60. Hollowness can be seen in the under eye and upper cheek area. Loss of youthful facial contour can be seen in the cheek and jowl areas. (B) Front view; same patient, 1 year 2 months after facelift, necklift, small incision forehead lift, upper and lower eye lifts and partial facial fat grafting. Fat injections have provided filling of the under eye and cheek areas. Note restoration of youthful facial shape without a tight or pulled appearance. (C) Front smiling view; before surgery view of patient, age 60. (D) Front smiling view; same patient, 1 year 2 months after facelift, necklift, closed forehead lift, upper and lower eye lifts, and partial facial fat grafting. Note a natural appearance is present, even when smiling. (E) Oblique view; before surgery view of patient, age 60. Note lateral forehead wrinkling, sagging cheek and overall loss of youthful jawline contour. (F) Oblique view; same patient, 1 year 2 months after facelift, necklift, closed forehead lift, upper and lower eye lifts, and partial facial fat grafting. Note smoother forehead, restoration of cheek fullness, improved transition from lower lid to cheek, smooth, stronger jawline and improved neck contour. (G) Lateral view; before surgery view of patient, age 60. Note cheek flatness, infra-orbital hollowing, sagging jawline, perioral laxity, and loss of youthful neck contour. A protruding salivary gland can also be seen in the neck area. (H) Lateral view; same patient, 1 year 2 months after facelift, necklift, forehead lift, upper and lower eye lift, and partial facial fat grafting. The protruding portion of the salivary gland has also been removed. Note the restoration of cheek fullness, improved transition from lower eyelid to cheek, smooth jawline and improved neck contour. The face has a natural appearance and all scars are well concealed. All surgical procedures performed by Timothy Marten, MD, FACS. (Photos courtesy of Timothy Marten, MD, FACS, used with permission.)  

342

SECTION II

CHAPTER 9.11  • Male facelift

A

B

C

D

E

F

G

H

I

J

Figure 9.11.39 Patient example 3. (A) Front view; before surgery view of patient, age 68. The patient has eyebrow ptosis, full upper eyelids, sagging cheeks, deep cheek folds, and jowls. Loss of youthful facial contour can be seen in the cheek and jowl areas. (B) Front view; same patient, 1 year and 9 months after facelift, necklift, small incision forehead lift, upper and lower eye lifts, partial facial fat grafting and earlobe reduction. Note improved eyebrow position and configuration, corrections of hooded eyelids, diminished cheek folds, elimination of jowls, and restoration of youthful and masculine facial shape without a tight or pulled appearance. (C) Front smiling view; before surgery view of patient, age 68. Note suboptimal upper dental show and tired and disinterested appearance despite broad smile. (D) Front smiling view; same patient, 1 year and 9 months after facelift, necklift, small incision forehead lift, upper and lower eye lifts, partial facial fat grafting and earlobe reduction. Note alert and composed appearance and fit, masculine-appearing jawline. A more natural smile with improved dental show is also seen. (E) Oblique view; before surgery view of patient, age 68. Note drooping eyebrow, hooded upper eyelid, sagging cheek and overall loss of youthful facial contour. There is little if any transition from the lower cheek to the neck, and a poor jawline is present. (F) Oblique view; same patient, 1 year and 9 months after facelift, necklift, closed forehead lift, upper and lower eye lifts, partial facial fat grafting and earlobe reduction. Note eyebrow position and configuration, restoration of cheek fullness, diminished cheek (nasolabial) fold, bold masculine jawline, and improved neck contour. The patient has a rested, fit, decisive, virile and masculine appearance. An improved transition from the lower cheek to the neck is evident. (G) Lateral view; before surgery view of patient, age 68. Note lower eyelid fullness, sagging cheek, poor jawline, heavy jowl, and neck laxity. (H) Lateral view; same patient, 1 year and 9 months after facelift, necklift, closed forehead lift, upper and lower eye lifts, partial facial fat grafting, and earlobe reduction. An improved transition from the lower eyelid to the upper cheek can be seen, the cheek position has been improved, and a fit, masculine-appearing jawline and neckline is evident. The face has a natural appearance and all scars are well concealed. Note also that the earlobe has been subtly reduced, adding to an overall more youthful appearance. (I) Lateral view, looking down; before surgery view of patient, age 68. Note poor neckline when looking down. (J) Lateral view, looking down; same patient, 1 year and 9 months after facelift, necklift, closed forehead lift, upper and lower eye lifts, minor partial facial fat transfer, and earlobe reduction. Note improved neck contour in the flexed position. The face has a natural appearance and all scars are well concealed. All surgical procedures performed by Timothy Marten, MD, FACS. (Courtesy of Timothy Marten, MD, FACS, used with permission.)  

Ancillary procedures and alternative strategies in the male patient

A

B

E

F

I

C

G

343

D

H

J

Figure 9.11.40 Patient example 4. (A) Front view; before surgery view of patient, age 72. A previous facelift has been performed by an unknown surgeon. Note eyebrow ptosis, cheek ptosis, infra-orbital hollowing, perioral laxity, and long, older-appearing earlobes. Panfacial loss of volume can also be seen. (B) Front view; same patient, 11 months after facelift, necklift, temple lift, upper and lower eye lifts, panfacial fat grafting and earlobe reduction. Note improved eyebrow position and configuration, elimination of perioral laxity, replenishment of lost facial volume, and restoration of youthful and masculine facial shape without a tight or pulled appearance. The earlobes are smaller, lending the face a more youthful appearance (a portion of the patient’s hearing aids can be seen in the photo). (C) Front smiling view; before surgery view of patient, age 72. A previous facelift has been performed by an unknown surgeon. (D) Front smiling view; same patient, 11 months after facelift, necklift, temple lift, upper and lower eye lifts, panfacial fat grafting and earlobe reduction. Note natural appearance and fit, masculine-appearing jawline. Replenishment of lost facial volume and shortening of earlobes can also be seen (a portion of the patient’s hearing aids can be seen in the photo). (E) Oblique view; before surgery view of patient, age 72. A previous facelift has been performed by an unknown surgeon. Note ptotic eyebrow, sagging cheek, volume-depleted midface, large earlobe, and loss of youthful facial contour. Some retro-displacement of the sideburn and temporal hairline is evident. (F) Oblique view; same patient, 11 months after facelift, necklift, temple lift, upper and lower eye lifts, panfacial fat grafting and earlobe reduction. Note improved eyebrow position and configuration, restoration of facial fullness, strong masculine jawline, smaller earlobe, and improved neck contour. The patient has a rested, fit, decisive, virile and masculine appearance. An improved transition from the lower cheek to the neck is evident (a portion of the patient’s hearing aid can be seen in the photo). (G) Lateral view; before surgery view of patient, age 72. A previous facelift has been performed by an unknown surgeon. Note loss of perioral and midface volume, neck laxity, and large earlobe. A protruding salivary gland can also be seen in the submental area. Some retro-displacement of the sideburn and temporal hairline is also evident. (H) Lateral view; same patient, 11 months after facelift, necklift, closed forehead lift, upper and lower eye lifts, partial facial fat grafting, and earlobe reduction. An improved transition from the lower eyelid to the upper cheek can be seen. Fat grafting has provided a strong, fit, masculine-appearing jawline and more youthful-appearing perioral area. An improved neckline can be seen and the protruding portion of the salivary gland has also been removed. The face has a natural appearance and all scars are well concealed. Fat grafting the nasal radix has improved the nasal profile. Note also that the earlobe has been subtly reduced, adding to an overall more youthful appearance (a portion of the patient’s hearing aid can be seen in the photo). (I) Lateral view, looking down; before surgery view of patient, age 72. A previous facelift has been performed by an unknown surgeon. Note suboptimal neckline when looking down. (J) Lateral view, looking down; same patient, 11 months after facelift, necklift, temple lift, upper and lower eye lifts, panfacial fat grafting and earlobe reduction. Note improved neck contour in the flexed position. The face has a natural appearance and all scars are well concealed (a portion of the patient’s hearing aid can be seen in the photo). All surgical procedures performed by Timothy Marten, MD, FACS. (Courtesy of Timothy Marten, MD, FACS, used with permission.)  

344

SECTION II

CHAPTER 9.11  • Male facelift

Nasolabial fold excision Many mature men will be seen to have heavy facial skin and deep nasolabial folds with sharp nasolabial creases that are a concern to them and which will be minimally improved when even an aggressive facelift is performed. These patients are candidates for nasolabial fold excision. Nasolabial fold excision exploits the sharp creases and coarse skin present on many men’s faces, and a carefully closed wound will result in a scar that is not more conspicuous, or even less conspicuous, than the existing nasolabial crease. Nasolabial fold excision is an excellent procedure for men who have had a previous or recent facelift but have insufficient improvement in their nasolabial fold, men who have modest overall facial laxity but largely isolated nasolabial folds, men with bald or shaved heads, and men who are ambivalent about having a pre-auricular scar. The procedure is planned so that the resulting scar mimics the existing nasolabial crease. A mark is made along the existing crease and a second mark 10–15 mm (occasionally more) posterior-superior to it to define an elongated ellipse with its ends at the superior and inferior portions of the fold. The marked ellipse is cross-hatched to facilitate tissue realignment and wound closure after excision of outlined tissue. The marked areas are infiltrated with dilute local anesthetic solution and skin is incised along marked lines. The intervening ellipse of skin is excised, and when indicated and appropriate, along with some subcutaneous tissue. Wound edges are then undermined slightly to facilitate closure, more so on the posterior-superior wound margin, using a needle-tipped cautery. A two-layer closure is then meticulously made. The first layer consists of multiple deep dermal sutures of 5-0 PGA (Vicryl or Monocryl) followed by simple interrupted sutures of 6-0 nylon using hash marks to carefully realign re-approximate the tissue.

Postoperative care of the male facelift patient A general discussion of postoperative care of the facelift patient can be found in Chapter 9.8.

Access the reference list online at   Elsevier eBooks+

Summary Treatment strategies in men will be different from those in women and it is not appropriate to arbitrarily apply concepts and techniques that evolved largely for treating the female face to that of a male. The male face is arguably more nuanced than that of a female whom we have come to accept as having a more contrived and made-up appearance, and certain aspects of male facial aging are often regarded as signs of experience, wisdom, and power that many men wish not to lose. In these and other ways men often have different goals than women do when seeking rejuvenation of their faces, with the man arguably more concerned about a natural appearance, free of signs that a surgical procedure has been performed.

Case examples Several case examples of male facelift procedures are depicted in Figs. 9.11.37–9.11.40.

Declaration The concepts, methods, and technique described and contained in this chapter are the opinions of the authors and are not intended to be construed as, or used to define, a standard of care.

Acknowledgment and retention of rights All figures, photographs, illustrations, tables, text and descriptions of concepts, methods, and technique included in this chapter are courtesy of Timothy Marten and are used with permission. Opinions expressed in this writing are those of the authors and are not intended to be construed as, or used to define, a standard of care.

References

References 1. Marten TJ, Elyassnia DR. Facelift: male facelift vol. 4th edn. In: Rubin JP, editor. Plastic Surgery: Aesthetic. vol. 2 London: Elsevier; 2018. 2. Marten TJ, Elyassnia DR. Facial fat grafting: why, where, how, and how much. Aesthet Plast Surg. 2018;42:5. 3. Marten TJ, Elyassnia DR. The role of fat grafting in facial rejuvenation. Clin Plast Surg. 2015;42:219. 4. Marten T.J. Simultaneous facelift and fat grafting. In: Coleman S, ed. Fat Grafting. 2017. 5. Marten TJ, Elyassnia DR. Neck lift: defining anatomic problems and choosing appropriate treatment strategies. Clin Plast Surg. 2018;45(4):455–484. 6. Marten TJ, Elyassnia DR. Secondary necklift. In: Nahai F, Nahai F, eds. The Art of Aesthetic Surgery. 3rd edn. New York: Thieme; 2020. 7. Marten TJ, Elyassnia DR. Neck lift. In: Farhadieh R, Bulstrode N, Mehrara BJ, Cugno S, eds. Plastic Surgery: Principles and Practice. Elsevier; 2021. 8. Marten TJ, Elyassnia DR. Management of the platysma in neck lift. Clin Plast Surg. 2018;45(4):555–570. 9. Marten TJ, Elyassnia DR. Lamellar high SMAS face and mid-lift: improved design of the SMAS facelift for better results in the mid-face and infra-orbital region. In: Nahai F, Nahai F, eds. The Art of Aesthetic Surgery. 3rd edn. New York: Thieme; 2020. 10. Marten T.J. Lamellar high SMAS facelift: simultaneous lifting of the mid-face, cheek and jowl. In: Paul M. Clinics in Plastic Surgery; 2008.

344.e1

11. Marten TJ, Elyassnia DR. Secondary facelift in plastic surgery vol. 4th edn. In: Rubin JP, editor. Plastic Surgery: Aesthetic. vol. 2 London: Elsevier; 2018. 12. Marten TJ. Closed, non-endoscopic, small incision forehead lift. Clin Plast Surg. 2008;35(3):363–378. 13. Connell BF, Marten TJ. Foreheadplasty for men. Recognizing and treating aging in the upper face. Clin Plast Surg. 1991;18(4):653–687. 14. Marten TJ, Elyassnia DR. Forehead lift. In: Farhadieh R, ed. Plastic and Reconstructive Surgery. Wiley; 2015. 15. Marten TJ. Forehead aesthetics and pre-operative assessment of the foreheadplasty patient. In: David Knize D, ed. The Forehead and Temporal Fossa: Anatomy and Technique. Philadelphia: Lippincott Williams and Wilkins; 2001. 16. Marten TJ, Elyassnia DR. Short scar neck lift – neck lift using a submental incision only. Clin Plast Surg. 2018;45(4):585–600. 17. Connell BF, Marten TJ. Facelift for the Active Man. Instructional Courses in Plastic Surgery. St. Louis: CV Mosby; 1991. 18. Marten TJ. Open foreheadplasty. In: Knize D, ed. The Forehead and Temporal Fossa: Anatomy and Technique. Philadelphia: Lippincott Williams and Wilkins; 2001. 19. Marten T, Elyassnia D. Periorbital fat grafting: a new paradigm for rejuvenation of the eyelids. Facial Plastic Clinics North Am. 2021;29(2):243–273. 20. Marten T, Elyassnia D. High SMAS facelift: combined single flap lifting of the midface, cheek, and jawline. Facial Plast Surg. 2022;38(6):593–612.

 

SECTION II •  Aesthetic Surgery of the Face

9.12 Secondary facelift irregularities and the secondary facelift Timothy Marten and Dino Elyassnia

 

Access video lecture content for this chapter online at Elsevier eBooks+

SYNOPSIS

ƒ Although many aspects of planning and performing secondary facelift surgery are similar to those of the primary procedure, one must identify and treat not only new problems that are the product of age, but those that have resulted from any prior procedure as well. Often it is these secondary irregularities that present the biggest challenge in terms of creativity, planning, preparation, and technique. ƒ Recognizing the problems in the secondary facelift patient and appreciating their underlying anatomical abnormalities is fundamental to planning and performance of any repair. Although not all problems can always be completely corrected, any surgeon able to recognize their anatomic basis can, through the application of logic and careful planning, select techniques that are safe and effective. ƒ Secondary facelift irregularities are worth every surgeon’s consideration, even if they perform only the occasional secondary procedure, as they exist as compelling reminders of mistakes to avoid in the planning and performance of any primary procedure. ƒ Hairline displacement and disruption remain predictable outcomes of many currently used facelift plans and are a source of disappointment and frustration for patients and surgeons alike. These problems are the result of poor analysis and planning, and failure to use an incision along the hairline when indicated. ƒ Using the SMAS to lift sagging facial tissues and restore facial contour circumvents the problems associated with skin-only facelifts, as it is an inelastic structural layer capable of providing meaningful and sustained support. Although skin must be excised in SMAS procedures, only redundant skin is sacrificed and closure can be made under normal skin tension. ƒ It is not enough in most secondary facelift procedures to limit treatment of the neck to pre-platysmal lipectomy and post-auricular skin excision. For many patients, subplatysmal fat accumulation, submandibular salivary gland hypertrophy and digastric muscle malposition will contribute significantly to poor neck contour and necessitate additional treatment. ƒ The secondary facelift will generally require a comparatively small resection of skin, an increased focus on correcting deep-layer problems and secondary irregularities, and almost universally requires replenishing lost facial volume. In most cases, less focus and effort need be placed on the facelift procedure itself, and increased focus and effort

should be placed on restoring lost facial volume, the typically undertreated neck and forehead, and the incompletely rejuvenated perioral area, ƒ Many patients requesting secondary facelifts are chronologically elderly, but can be deceptively young in appearance. A careful medical history must be taken because they often have medical problems consistent for their chronological age group. ƒ The opportunity to perform a facelift is a unique artistic privilege granted to us by our patients that carries a sig nificant responsibility. It deserves nothing less than our best effort, and a few extra hours of our time in the operating room benefits our patients for the rest of their lives. ƒ Performing a secondary facelift is frequently a technically demanding undertaking when compared to primary procedures and its difficulty should not be underestimated. The procedure must be carefully planned, meticulously carried out, and the patient’s safety and wellbeing unfailingly insured. ƒ Performance of the procedure itself only fulfills part of our obligation to the patient and the care they receive perioperatively is arguably as important as the surgery itself. Diligent perioperative care will ensure the best result and reduce the likelihood that problems and complications will occur.

Introduction The increased number of patients seeking facelifts at a younger age, coupled with the continued good health of an older group of patients who have already undergone one or more procedures, has resulted in a significant increase in requests for secondary and tertiary procedures. Although many aspects of planning and performing secondary surgery are similar to those of the primary procedure, additional considerations must be taken into account in the evaluation and treatment of the patient presenting for secondary facelift, as one must identify and treat not only new problems that are the product of age, but those that have resulted from any prior procedures as well. Often, it is these secondary irregularities that present the

346

SECTION II

CHAPTER 9.12  • Secondary facelift irregularities and the secondary facelift

biggest challenge to the surgeon in terms of creativity, planning, preparation, and technique. Consideration must also be given to possible underlying anatomical compromise that may have resulted from previous procedures but is not evident as a visible problem. This includes possible damage to skin, fat, SMAS and deeper layer structures. Injury to these tissues at the time of the primary procedure can preclude certain maneuvers and limit the overall amount of improvement possible at the time secondary surgery is performed. “Red flag” procedures in this regard include radiofrequency and ultrasonic “skin tightening” treatments, prior “suture lifts”, and prolonged large-volume use of facial fillers (“filler fibrosis”). As in primary procedures, recognizing the problems in the secondary facelift patient and appreciating their underlying anatomical abnormalities is fundamental to planning and performance of any repair. Although not all problems can always be completely corrected, any surgeon able to recognize their anatomic basis can, through the application of logic and careful planning, select techniques that are safe and likely to produce a significant improvement (Video Lecture 9.12.1 ).

Strategy in treating the secondary facelift patient The strategy for treating the secondary and tertiary facelift patient will necessarily differ from that of patients undergoing primary procedures1–4,26 and the secondary or tertiary facelift procedure will generally require a comparatively smaller resection of skin, an increased focus on correcting deep-layer problems, and restoration of lost facial volume – depending upon the skill of the surgeon performing the primary procedure, the technique used, and whether the face was treated comprehensively or not. This is due to the fact that the focus of most primary procedures is usually predominantly on skin resection as this is more easily and quickly performed than more complicated and time-consuming, but superior, SMAS and deep-layer neck maneuvers. In addition, skin resection and skin tightening are the underlying cause of many secondary problems and thus very often the skin elevated and recruited by SMAS treatment at the secondary or tertiary procedure is needed to correct these problems and will not be excised, or only minimally so. It is also the case that the surgeon at the primary procedure often had a narrow focus mostly limited to the face (cheeks and jowls). Often they exhausted themselves performing the “facelift”, and did not have the time and energy to simultaneously properly address the neck,5–8,25 forehead9–14 and perioral area, or the time or energy to perform fat grafting.15–20,24 In these situations the need for an actual “facelift” at a secondary or tertiary procedure is actually subservient to the need for these other procedures on these other areas of the face. In many cases the facelift is performed in the secondary or tertiary procedure largely to recruit skin to correct earlobe and tragal irregularities, and to shift scars into more concealed locations. The lion’s share of improvement in many secondary and tertiary procedures comes from performing a proper necklift,21 correcting untreated or undertreated forehead ptosis, and carrying out comprehensive facial fat grafting to

replenish lost facial volume (see Case Studies 9.12.1–9.12.5). Often this translates to a less aggressive manipulation of the SMAS layer (especially if well treated in the primary procedure), and the SMAS layer can often be effectively and more simply managed by plication or SMAS stacking22 (see discussion later in this chapter), rather than by secondary elevation of a SMAS flap. An awareness of these facts provides the surgeon performing a secondary or tertiary surgery with a proper perspective on the approach to the procedure – that the secret of success typically lies in the surgeon’s ability to identify and correct irregularities from the primary procedure, properly treat the neck, and fill in the face.

Identification and analysis of secondary aging change Surgery does not halt the aging process and patients requesting secondary or tertiary facelifts usually present with many of the same problems seen when they presented for their primary procedures. This is particularly true if the primary facelift was limited and consisted of skin excision and skin tightening only. In such instances, a tight or pulled appearance will often be present, but problems of deep-layer origin will still be evident and will likely have worsened over time. These problems include residual forehead ptosis, periorbital atrophy, midface hollowing, malar flattening, jowl laxity, subplatysmal fat accumulation, submandibular gland hypertrophy, and cervical band formation (Fig. 9.12.1). Regrettably, many surgeons have been traditionally taught to perform a limited “tuck” or “touch-up” when performing secondary or tertiary procedures consisting of additional skin excision and skin tightening. This does not address the true underlying problems, however, and typically compounds the secondary irregularities present in many patients.

Identification and analysis of secondary surgical irregularities The number and degree of secondary irregularities present will determine the difficulty of any additional surgery and the overall potential for improvement possible. Typical problems seen in the patient presenting for secondary facelift include hairline displacement, hair loss, poorly situated scars, wide scars, scleral show, eyelid dysfunction, tragal distortion, earlobe distortion, over-excision of cervicofacial fat, distortion and abnormal appearances due to inappropriate tissue shifts, and abnormal appearances when emoting. Less commonly, problems related to nerve injury, skin slough, or other surgical complications may be present. These problems are worth every surgeon’s consideration, even if they perform only the occasional secondary procedure, as they exist as compelling reminders of mistakes to avoid in the planning and performance of any primary procedure.

Hairline displacement and disruption Hairline displacement and disruption remain predictable outcomes of many currently used facelift incision plans and are a source of disappointment and frustration for patients and surgeons alike. These problems are the result of poor analysis and planning at the time of the primary procedure, and failure

Strategy in treating the secondary facelift patient

A

347

B

Figure 9.12.1  Skin lift and SMAS lift compared. Surgery does not arrest the aging process, and patients requesting secondary facelifts usually present with many of the same problems seen when they presented for their primary procedures. This is particularly true if the primary facelift was limited and consisted of skin excision and skin tightening only. (A) Patient age 61 seen after “skin only” facelift performed by an unknown surgeon (note scar in pretragal location). Residual problems seen include forehead ptosis, midface ptosis, heavy nasolabial folds, prominent labio-mandibular creases, cheek ptosis, infraorbital hollowing, malar flattening, jowl laxity, submental fat accumulation, and platysma band formation. Note that although some wrinkling and atrophy are present, the patient’s predominant problem is deep-layer tissue ptosis. Additional skin excision and tightening under these circumstances will be of little benefit to the patient. (B) Same patient seen age 63 after secondary facelift that used a high SMAS facelift technique. A forehead lift and necklift have also been performed The patient has more youthful facial contour and a soft, natural, and non-surgical appearance. Note elevation of eyebrow, elevation of lid–cheek junction, improved transition from the lower eyelid to the cheek, improved malar projection, softening of nasolabial fold, improved posture of the mouth, improved jawline contour, correction of residual jowl, and improved neck. Secondary procedure performed by Timothy Marten, MD, FACS. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

to use an incision along the hairline when indicated. Although hairline displacement may be acceptable after some primary facelifts in which incisions were made in the traditional location within hair-bearing scalp, it will almost always be intolerable after a secondary facelift if such an incision plan is used again. For this reason, thoughtful planning of secondary and tertiary facelifts frequently requires the use of incisions placed along hairlines, rather than behind them within hair-bearing scalp. The placement of an incision and thus the resulting scar along a hairline at secondary surgery represents a choice between two imperfect alternatives but the best overall artistic and aesthetic compromise in most patients. Although incisions made within the hair-bearing scalp produce concealed scars within the hair when properly made and closed, they will result in tell-tale and objectionable hairline displacement in many patients that is usually readily apparent upon casual glance and at a distance. These irregularities are often not subtle and frequently result in an unnatural or even grotesque appearance (Fig. 9.12.2 & 9.12.3; see also Figs. 9.12.6 & 9.12.7). In addition, they are uniformly difficult for the patient to disguise and a challenge for the surgeon to correct. Placing the incision along a hairline, however, usually results in a fine scar only visible on close inspection when correctly planned and proper technique is used. And unlike displaced hair, a scar along the hairline can usually be easily concealed with make-up, if necessary, but generally goes

unnoticed in most social situations and casual encounters. Often, they are difficult to detect even on close inspection (see Figs. 9.12.5 & 9.12.9). Attempts to disguise displaced hair by combing adjacent hair over these areas is no more effective than the “comb-over” hairstyles worn by many balding men. Although this is perhaps preferable to the patient to having bald spots and missing hair showing, it is immediately evident that the problem is still present in most cases. The temporal portion of the facelift incision traditionally placed within the temporal scalp will frequently result in a tell-tale and unnatural-appearing superior elevation and posterior displacement of the temporal hairline. Secondary or tertiary facelifts using the same incision plan will compound this problem and often result in a bizarre-appearing and objectionable absence of temple hair (Fig. 9.12.3). This can best be minimized or avoided at secondary facelift by the use of an incision along the hairline (Fig. 9.12.4). If it is appropriately planned and carefully executed, an acceptable scar will result that is artistically and aesthetically superior to additional hairline displacement (Fig. 9.12.5). The occipital portion of the facelift incision is traditionally placed high up on the occipital scalp, in a well-intended, but almost always counter-productive effort to hide the resulting scar. Unfortunately, any such a plan embodies an inherent defect in design that will preclude optimal improvement in the neck and frequently result in a tell-tale and unnatural appearing displacement of the occipital hairline (Fig. 9.12.6).

348

SECTION II

A

CHAPTER 9.12  • Secondary facelift irregularities and the secondary facelift

B

C

Figure 9.12.2  (A,B) Displacement of sideburn and temple hairline due to poor incision planning in patients presenting for secondary facelifts (primary procedures performed by unknown surgeons). (C) Deconstruction of cause of temporal hairline displacement seen in A and B. The operating surgeon made an error in planning. The surgeon made a well-intended effort to hide the temporal portion of the facelift incision in the temporal scalp (red dotted line), but underestimated or did not appreciate the amount of skin redundancy over the upper lateral cheek. When the facelift skin flap was advanced (black arrow) skin was moved into an area where scalp and hair should be present. The black dotted line shows the incision plan that would have prevented this occurrence. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

Figure 9.12.3  Sideburn elevation and displacement of the temporal scalp after multiple facelifts. A secondary facelift using the same incision plan as at the primary procedure has resulted in the tell-tale displacement of temple hair and elevation of the sideburn. Procedure performed by an unknown surgeon. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

A high transverse post-auricular incision plan presumes that the resultant vector of skin redundancy is directed mostly superiorly and that the majority of skin redundancy is present over the lateral neck. Both careful consideration and direct observation will reveal the proper direction of postauricular flap shift to be in a mostly posterior, slightly superior direction that roughly parallels the mandibular border if an optimal result is to be achieved in the anterior neck and submental area. This is because it is along this vector that the majority of neck skin redundancy is present. As the flap is shifted along a more superiorly directed vector, as it must be with any high transverse occipital incision plan, a diminished effect will be seen over the anterior neck and submental regions. In addition, transverse cervical skin wrinkles, if present, will be unnaturally shifted superiorly up over the lower lateral face and the prelobular and postauricular areas. It must also be kept

in mind that neck contour should be achieved as the result of deep-layer neck maneuvers and repair, and not skin tightening. As such, neck skin should be shifted and excised along a vector that allows maximum elimination of skin redundancy, and not one that appears to produce the most neck tightness. Although occipital hairline displacement may sometimes be acceptable to patients after their primary procedure, secondary or tertiary facelifts using the same incision will compound this problem and usually result in an unnatural and intolerable absence of occipital hair and notching of the occipital hairline (Fig. 9.12.7). If an attempt is made to reconstitute the hairline by superior shifting of the post auricular flap, a wide transmastoid scar will usually result as the tissue discarded in any such maneuver is necessary for side-to-side head tilt and shoulder drop when the patient is in an upright position. These problems can best be minimized at the time of secondary facelift by the use of an incision along the occipital hairline to prevent further hairline displacement (Fig. 9.12.8). If the incision is appropriately planned and carefully executed, an acceptable scar will result that is artistically and aesthetically superior to additional hairline displacement (Fig. 9.12.9). In addition, this plan will sometimes allow scalp displaced at the primary procedure to be partially advanced back towards its proper position. When an incision is used along the occipital hairline, it should be planned in such a way that the inferior portion of the incision and thus the resulting scar is turned back into the scalp and at the junction of thick and fine hair on the nape of the neck see Fig. 9.12.8. It should not be carried more inferiorly because it will be incompletely concealed and is likely to be visible to others (Fig. 9.12.10). Fundamental to obtaining an inconspicuous, well-healed scar when incisions are placed along the temporal or occipital hairline is the diversion of tension to deeper tissue layers (SMAS and platysma) and precise skin flap trimming so that wound edges abut each another under no tension before sutures are placed. The incision is then closed using a combination of half-buried vertical mattress sutures of 4-0 nylon

Strategy in treating the secondary facelift patient

A

349

B

Figure 9.12.4  (A,B) Plan for incision along the temporal hairline. An incision along the temporal hairline should be considered whenever objectionable displacement of the sideburn and temple hair is predicted. Although a fine scar is present in these patients, it is not evident upon casual inspection (see Fig. 9.12.5). For a female patient the incision is planned as a soft curve approximately as shown in (A). For a man, the incision is planned in a more rectangular masculine shape to preserve a full, youthfulappearing sideburn23 (compare with Figs. 9.12.2 & 9.12.3). (Courtesy of Timothy Marten, MD, FACS, used with permission.)

A

B

C

Figure 9.12.5  Healed incisions along the temporal hairline. The use of an incision along the hairline, typically indicated in most secondary and tertiary facelift patients, can prevent posterior and superior hairline and sideburn displacement without compromising the end result. Although a fine scar is present along the hairline in each of these patients, it is not evident upon casual inspection. Note the preservation of abundant temple hair and a full, youthful, natural-appearing sideburn (compare with Figs. 9.12.2 & 9.12.3). All procedures performed by Timothy Marten, MD, FACS. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

with the knots tied on the scalp side and multiple simple interrupted sutures of 6-0 nylon. The 6-0 sutures provide precise wound alignment and are removed in 5 days. The half-buried vertical mattress sutures of 4-0 nylon provide wound support, while simultaneously avoiding cross-hatched marks. These sutures are removed 7–10 days after surgery. Although incisions placed along the frontal, temporal, and occipital hairlines will prevent additional hairline displacement at a secondary procedure, they do not provide for correction of large and severe problems sometime seen (see Figs 9.12.2, 9.12.3, 9.12.6, & 9.12.7). In these situations, consideration must be given to the use of hair flaps, hair transplantation,

and scalp expansion, with hair transplantation usually being the most effective treatment.

Hair loss Hair loss is an all too common and largely avoidable stigma of facelift surgery seen in many patients presenting for secondary procedures. Hair loss is generally the result of technical errors, including improperly made incisions that damage hair follicles, placement of overly tight sutures, or the closure of inadequately mobilized scalp flaps under too much tension. It may occur, however, in smokers, certain individuals with

350

SECTION II

CHAPTER 9.12  • Secondary facelift irregularities and the secondary facelift

A

B

Figure 9.12.6  Understanding the cause of occipital hairline displacement. (A) An example of avoidable notching and displacement of the occipital hairline seen in a patient whose surgeon inappropriately used a traditional occipital incision plan (procedure performed by an unknown surgeon) (see also Fig. 9.12.7). (B) Deconstruction of the occipital hairline displacement seen in (A). The surgeon made a well-intended, but conceptually flawed attempt to hide the scar in the occipital scalp (dotted red line) after underestimating the skin redundancy in the upper-lateral neck. Skin has been advanced (black arrow) into a position where scalp hair should be and the hairline is “notched”. The dotted black line shows the incision plan that would have prevented the problem. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

Figure 9.12.7  Elevation and displacement of the occipital scalp after multiple facelifts. A secondary facelift using the same incision plan as at the primary procedure has resulted in the objectionable displacement of the hairline. Procedure performed by an unknown surgeon (see Fig. 9.12.8). (Courtesy of Timothy Marten, MD, FACS, used with permission.)

scalp disease (alopecia areata), eating disorders, or patients with a variety of systemic illness in the absence of any errors or wrong-doing on the part of the surgeon. Consideration should be given to an origin of this sort before hair loss experienced by the patient at the primary procedure is attributed to technical error. Hair loss is also frequently the result of the ill-conceived shifting of scalp flaps along the wrong vector. This is commonly seen on the temporal scalp after erroneous attempts to smooth the forehead and glabella by applying lateral traction on the forehead flap (Fig. 9.12.11). The use of cautery near or within the plane of hair follicles can also result in hair loss, as can rough flap handling

Figure 9.12.8  Plan for incision along the occipital hairline. An incision along the occipital hairline should be considered whenever objectionable displacement of the occipital hairline is predicted in both primary and secondary procedures. This incision plan protects the hairline, prevents hairline displacement, and allows maximum excision of redundant neck skin along a proper vector. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

and pinching or prolonged folding of scalp flaps beneath retractors. Small areas of hair loss resulting from tight suture placement or attempts at spot suspension of the scalp can often be corrected at the time of secondary facelift by direct excision after adequate mobilization of surrounding tissue or by incorporation of the hairless area into a more comprehensive incision plan (Fig. 9.12.12). Larger areas of hair loss resulting from excessive flap tension, an overly tight closure or ill-conceived scalp flap shifting are usually much more difficult to correct, especially if scalp excision was aggressive at the primary procedure and little residual redundancy is present (Fig. 9.12.13). In such instances, the patient and surgeon must accept that complete correction may not be possible at the time of secondary facelift and that hair transplantation, scalp flaps, or scalp expansion

Strategy in treating the secondary facelift patient

A

Figure 9.12.9  Healed incision along the occipital hairline. The use of an incision along the occipital hairline will prevent hairline displacement without compromising the end result. Although a fine scar is present in these patients, it is not evident upon casual inspection and they are free to wear their hair up off their neck in any manner they choose. Procedures performed by Timothy Marten, MD, FACS. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

B

Figure 9.12.10  Improper design of an incision along the occipital hairline. The incision has been made too low and carried too far inferiorly in front of the fine hair on the nape of the neck. It would have been better concealed if it had been made more superiorly and turned posteriorly into scalp hair more superiorly. Procedure performed by an unknown surgeon. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

may be necessary at a later date. An important goal at any secondary procedure in these patients is to select a surgical plan that does not further compound the problem, and that might still provide some improvement.

351

Figure 9.12.11  Temporal hair loss. Hair loss is frequently the result of improper shifting of scalp flaps along the wrong vector. This is commonly seen on the temporal scalp after well-intended but misguided attempts to smooth the forehead and glabella by excising temporal scalp and applying lateral traction on the forehead flap. Procedure performed by an unknown surgeon. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

Poorly sited scars Poorly sited scars are a common problem after primary facelift and the result of artistic insensitivity, poor planning, and tension-based surgical techniques. In many patients, a secondary

352

SECTION II

CHAPTER 9.12  • Secondary facelift irregularities and the secondary facelift

because even a thin, well-healed scar will ultimately be visible and noticed by others, in most cases as a result of the gradient of skin color and texture typically present on each side of it. Although differences in skin color can sometimes be concealed with make-up, differences in texture usually cannot. Scars placed along natural anatomic interfaces tend to be overlooked by the eye, however, where a gradient of color and texture is expected to be seen and where the scar appears to be a natural crease on the face (Fig. 9.12.14B,C). Make-up becomes less necessary as the scar is lost in shadow, appears to be a natural part of the face, or is mistaken to be a reflected highlight (Fig. 9.12.14A).

Pre-helical portion of the preauricular incision

Figure 9.12.12  Hair loss resulting from tight suture placement or attempts at spot suspension of the scalp. These problems can often be corrected at the time of secondary facelift by direct excision after adequate mobilization of surrounding tissue or by incorporation of the hairless area into a more comprehensive incision plan. Procedure performed by an unknown surgeon. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

The preauricular region is a common point of reference for those seeking to identify the facelift patient, and, as such, it is of concern to patients and worthy of careful consideration by the surgeon. The pre-helical portion of the preauricular scar is often situated too far anteriorly in the patient presenting for secondary surgery and the illusion of the scar as an anatomical feature is lost (Fig. 9.12.15A). Moving this scar so that it rests in the helical–facial sulcus will result in a less conspicuous scar and a more natural appearance (Figs. 9.12.14 & 9.12.15C). This is generally possible in most secondary and tertiary cases if skin resection has not been overly excessive at prior procedures (see Fig. 9.12.18). The pre-helical portion of the preauricular incision should be planned as a soft curve paralleling the curve of the anterior border of the helix. This will result in a natural appearing "width" to the helix in keeping with the rest of the ear and the resulting scar, if visible, will appear to be a helical highlight and will be disguised as the natural transition between the smooth pinker skin of the helix and the coarser paler skin of the cheek (see Fig. 9.12.15C & Fig. 9.12.16).

Tragal portion of the preauricular incision

Figure 9.12.13  Large areas of hair loss. Large areas of hair loss are usually difficult to correct, especially if scalp excision was aggressive at the primary procedure and little residual redundancy is present. In such cases, complete correction may not be possible at the time of secondary facelift and hair transplantation, scalp flaps, and scalp expansion may be required. Procedure performed by an unknown surgeon. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

facelift will provide the opportunity to relocate these to a more appropriate, less conspicuous location, but in others it must be recognized and accepted that complete correction is not possible if additional problems are to be avoided. Poorly situated scars are typically seen in the preauricular, perilobular, and postauricular areas. They can also be found in the submental region in many patients. Proper placement of incisions is important, particularly in the preauricular area,

Although it is not possible to move a pretragal scar to a “retro-tragal” position along the posterior margin of the tragus in every patient presenting for secondary surgery, this is preferred when possible, for the reasons outlined above (see Fig. 9.12.18). The feasibility of relocating a pretragal scar to a retro-tragal position will depend on the amount of cheek skin redundancy that remains after the primary procedure. Because preoperative assessment of residual cheek skin redundancy can be difficult and exceedingly deceptive at the tragus, it is best in some cases to make the initial incision in a modified pretragal location (Fig. 9.12.17). The decision to sacrifice the remaining skin over the tragus and move the scar to the tragal margin can then be delayed until after cheek flaps have been mobilized, SMAS advanced and anchored, and the actual amount of cheek skin recruited through these maneuvers that is available, if any, is determined. Often, skin recruited is needed to recreate an absent pretragal sulcus and to correct a “buried tragus” irregularity (see Fig. 9.12.27B). In such instances, relocation of a pretragal scar to the margin of the tragus will not be possible and a pretragal location of the scar must be accepted. Although it is typically best to plan the preauricular incision in a retro-tragal location (see Figs. 9.12.14 & 9.12.18), if inadequate cheek skin is available to recruit for the repair, a defect will be created that will be difficult to properly close. In such cases the modified plan can be used (see Fig. 9.12.17). If adequate skin can be recruited, the island of skin on the tragus

Strategy in treating the secondary facelift patient

A

B

353

C

Figure 9.12.14  Retro-tragal scar. (A) The scar resulting from a properly situated retro-tragal incision will usually be inconspicuous, even if it is suboptimally healed, as the eye will mistake it for a reflected highlight. Note the well-concealed scar on this darkly complexioned patient. A scar of the same type would be more obvious if the incision had been placed in a pretragal position. (B) A healed retro-tragal facelift incision in another patient with fair skin. Transitions of color and texture are hidden along natural interfaces. (C) A healed retro-tragal facelift incision on another patient. If the incision is closed carefully, a natural appearance without anatomic distortion should result. Procedures performed by Timothy Marten, MD, FACS. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

A

B

C

Figure 9.12.15  Improper and proper placement of pre-helical scar. The pre-helical portion of the preauricular scar is often poorly situated (A,B) in patients presenting for secondary facelifts and the illusion of it as an anatomical feature is lost. (A) The pre-helical incision has been made too far anteriorly and the illusion of the scar as an anatomical feature is lost. Procedure performed by an unknown surgeon. (B) The pre-helical incision has been made too far posteriorly and the facelift skin flap advanced onto the helix, and has resulted in obliteration of the helical facial sulcus and part of the helix itself. The illusion of the scar as an anatomical feature is lost. Procedure performed by an unknown surgeon. (C) A patient with a properly placed pre-helical incision. The scar has been placed directly in the helical facial sulcus. In this location a transition of color and texture is expected and the scar appears to be a natural anatomical feature. Procedure performed by Timothy J. Marten, MD, FACS. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

can be excised and the scar sited in a retro-tragal location. If inadequate skin is recruited to move the scar to a retro-tragal location, this incision plan will typically result in a satisfactory, albeit suboptimally, situated scar. If the secondary facelift incision is initially made along the margin of the tragus when a pretragal scar is present but before intra-operative assessment of skin redundancy is

made, tragal skin may be erroneously excised. This will force an inappropriately tight closure and result in tragal distortion, tragal retraction, and obliteration of the pretragal sulcus.

Perilobular portion of the facelift incision The perilobular area is a common location in which one can find a poorly situated facelift scar in secondary and tertiary

354

SECTION II

CHAPTER 9.12  • Secondary facelift irregularities and the secondary facelift

facelift patients. Typically, it is low lying due to poor planning and the skin settling that occurs after “skin only”, non-SMAS facelift techniques (Figs. 9.12.19A & 9.12.20A). Unlike the pre-helical and postauricular portions of the facelift scar, however, which should be placed directly in their respective anatomic creases, the perilobular scar should not lie directly in the lobular-facial crease if the earlobe is anatomically naturally shaped because the crease itself constitutes a delicate, aesthetically significant anatomical subunit that cannot be easily reconstructed and should not be disrupted when possible. Other factors being equal, a superior result will be obtained if the scar is situated 1–2 mm inferior to this junction and an attempt is not made to join thin, soft earlobe skin directly with course, thick cheek skin. As is the situation with the relocation of other scars about the ear, relocation of the perilobular portion of the facelift scar at the time of secondary or tertiary facelift will depend on the amount of lower facial skin that remains after the primary procedure. If cheek skin excision has been excessive at the primary procedure, or if a “pixie” earlobe is present, relocation may not be possible. For these patients, it must be accepted that only partial correction can be accomplished. Figure 9.12.16  Optimal position of pre-helical part of the preauricular incision. The pre-helical portion of the preauricular incision (red dotted line) should be planned as a soft curve paralleling the curve of the anterior border of the helix. This will result in a natural-appearing "width" to the helix in keeping with the rest of the ear (black dotted lines) and the resultant scar, if visible, will appear to be a helical highlight and be disguised as the natural transition between the smooth pinker skin of the helix and the coarser, paler skin of the cheek. If the scar is situated too anteriorly (see Fig. 9.12.15A) or too far posteriorly where it encroaches on the helix (see Fig. 9.12.15B), the illusion of the scar as a helical highlight or the interface between the ear and the cheek is lost. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

Postauricular portion of the facelift incision A poorly located postauricular scar, although not as readily apparent and easier to disguise in most social situations than a poorly situated scar in the preauricular region, is nonetheless an objectionable irregularity that should be corrected when possible. Typically, the poorly located postauricular scar will be seen to lie outside the auriculomastoid sulcus, and too low over the mastoid to be concealed by the pinna. Such an irregularity is the result of poor planning and inferior–posterior migration of the post-auricular flap due to excessive tension placed upon it at the primary procedure (Figs. 9.12.20A & 9.12.25). Moving the postauricular scar so that it rests directly in the auriculomastoid sulcus is sometimes possible in secondary and tertiary patients, if tissue sacrifice has not been excessive or along an improper vector at the primary procedure. Moving the scar more superiorly, although seemingly straightforward, is often difficult because of the common practice of inappropriately excising tissue from the superior margin of the postauricular skin flap at the primary procedure. Attempts to do so will often result in a forced closure under excessive tension and eventual inferior migration and widening and hypertrophy of the scar due to inferior traction on the postauricular flap. Although an apparent redundancy will be present in the supine patient on the operating table due to a high-lying position of the shoulders, this will be seen to vanish in the upright position when the shoulders fall to a normal position. As a result, little if any redundant skin is typically available along the needed superior vector of shift.

Submental incision Figure 9.12.17  Modified pretragal incision plan if cheek skin deficiency is present. Although it is typically best to plan the pre-auricular incision in a retro-tragal location (see Figures 9.12.14 and 9.12.18) if inadequate cheek skin is available to recruit for the repair a defect with be created that will be difficult to properly close. In such cases the modified plan can be used. If adequate skin can be recruited the island of skin on the tragus can be excised and the scar sited in a retro-tragal location. If inadequate skin is recruited to move the scar to a retro-tragal location this incision plan will typically result in a satisfactory, albeit, sub-optimally situated scar. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

The submental incision will frequently be seen to have been erroneously placed directly along the submental crease in a well-intended effort to hide the resulting scar (Fig. 9.12.21A). Regrettably, this serves only to reinforce the submental retaining ligaments and accentuate a “double chin” or “witch’s chin” appearance. In such situations, consideration should be given to moving the submental incision 1–2 cm posterior to the crease so that the existing scar can be undermined and released (Fig. 9.12.21B). Although this results in a new scar, it

Strategy in treating the secondary facelift patient

A

B

355

C

Figure 9.12.18  Pretragal and retro-tragal incisions compared. (A) Pretragal incision in a patient presenting for secondary facelift. The scar has healed satisfactorily but attention is drawn to it due to differences in color and texture on each side of it. Procedure performed by an unknown surgeon. (B) Plan for relocating incision to retro-tragal position at secondary facelift. (C) Same patient as in (A) after secondary facelift in which incision was moved to a retro-tragal position. Color and texture differences, and the scar itself, are hidden along natural anatomic interfaces. Procedure performed by Timothy Marten, MD, FACS. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

A

B

will be inconspicuously hidden in the shadow of the mandible in all but the unusual case (Fig. 9.12.22). This is preferable and a worthwhile trade-off in many patients for correction of the more obvious and objectionable contour irregularity that would result if the incision were made again in the same place upon the existing scar. If limited work in the neck only is needed and minimal or no double chin irregularity is present, it may be possible and appropriate to use an existing scar in the submental crease as the site for secondary incision. If more extensive maneuvers are required and a marked double chin irregularity is present, however, a new more posteriorly situated submental incision is arguably indicated (Fig. 9.12.23).

Figure 9.12.19  Improper and proper placement of the perilobular incision. (A) The perilobular incision has been made too far inferiorly and is evident even on casual inspection. Although an extreme example is shown, if the scar is still visible less extreme inferior placement is almost equally objectionable. Procedure performed by an unknown surgeon. (B) A different patient seen after facelift. The perilobular scar has been placed more superiorly and in such a manner that it is tucked up and hidden by the lobule itself. In this location it cannot be seen. Procedure performed by Timothy Marten, MD, FACS. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

If skin excision has been aggressive and excessive at the primary procedure, relocation of poorly located scars may not be possible at the time of request for secondary facelift, regardless of how much the patient and surgeon would wish otherwise. These patients have typically undergone aggressive skin-only, non-SMAS procedures and have overly tight faces with wide and/or hypertrophic scars (Fig. 9.12.24). Often earlobes have been pulled or placed too far inferiorly into the cheek as well, compounding the problem. In such cases, it is usually best to defer surgery until scars are mature, skin has relaxed, and adequate tissue is available to make proper repair. In most cases, this will mean waiting until 2–3 cm or more of skin can be pinched up along each

356

SECTION II

A

CHAPTER 9.12  • Secondary facelift irregularities and the secondary facelift

Figure 9.12.20  Improper and proper placement of the postauricular incision. (A) The postauricular incision has been made too far posteriorly. The scar lies outside the auriculomastoid sulcus and is evident if hair is worn short or up off the neck. Procedure performed by an unknown surgeon. (B) A different patient seen after facelift. The postauricular scar has been placed in the auriculomastoid sulcus. In this location it mimics a natural anatomic feature and is overlooked on even close inspection. Procedure performed by Timothy Marten, MD, FACS. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

B

A

B

Figure 9.12.21  Incorrect and correct plan for the submental incision. (A) Incorrect position for the submental incision. The incision should not be placed directly along the submental crease because this will accentuate it and reinforce the double chin appearance. Note that the traditional plan of skin undermining (yellow shaded area) also promotes a double chin irregularity. (B) Correct position for the submental incision. Placement of the submental incision 1.5 cm posterior to the submental crease prevents accentuation of the double chin and witch’s chin irregularities and provides for easier dissection and suturing in the deep neck. Note that this incision plan allows the submental crease to be undermined (yellow shaded area) and released, and the fat of the chin pad and submental area to be sculpted and blended into a straight line. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

jawline along a line extending from the chin to the lobule. Re-operation in the absence of adequate skin to make proper repair will be a frustrating act of futility in which little if any benefit will be gained.

Wide scars Wide, thick, hypertrophic, and keloid scars, often attributed to be the result of the patient’s own poor healing, are more often due to the over-excision of skin along improper vectors in procedures in which the surgeon has erroneously employed skin tension as a vehicle to lift sagging deeper-layer tissue, rather

than the SMAS and platysma. In fact, it is noteworthy that scar widening and hypertrophic healing are rarely seen after a primary facelift in patients of all skin types, provided a SMAS technique that produces no skin tension is used. Because the factors underlying suboptimal healing leading to wide or hypertrophic scars are still present to some extent in the patient requesting secondary surgery, each must be approached with caution. Like the patient with a skin shortage and poorly located scars, the patient with wide or hypertrophic scars may be impossible to effectively treat if skin excision has been excessive at the primary procedure (Figs. 9.12.24 & 9.12.25). This is true, regardless of how much

Strategy in treating the secondary facelift patient

Figure 9.12.22  Placement of the submental incision. Close-up view of the submental region of a patient after secondary facelift. A previous incision had been made directly in the submental crease (small arrow). The incision used at the secondary procedure was made posterior to the prior incision (large arrow), and the scar and crease were released and intradermally fat grafted. Smooth submental contours are present, and both scars are inconspicuous. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

A

C

357

Figure 9.12.24  Poorly located, hypertrophic scars. If skin excision has been aggressive at the primary procedure, relocation of poorly situated incisions may not be possible at the time of request for secondary facelift. In these situations, it is usually best to defer surgery until scars have matured, skin has relaxed, and adequate tissue is available to make proper repair. This may mean waiting until 2 cm or more of skin can be pinched up along each jawline. Procedure performed by an unknown surgeon. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

B

D

Figure 9.12.23  Correction of the double chin and witch’s chin irregularities. If the submental incision is placed posterior to the submental crease, the submental retaining ligaments can be released and the fat of the chin and the neck blended. (A,C) Patients with double chin before secondary facelift. Procedures performed by unknown surgeons. (B,D) Same patients after secondary facelift. The submental incision was made 1.5 cm posterior to the submental crease, the submental restraining ligaments released, and the subcutaneous fat of the chin and the submental areas sculpted and blended to achieve optimal contour. Platysmaplasty, transverse platysma myotomy, and submandibular gland reduction were also performed. Procedures performed by Timothy Marten, MD, FACS. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

Figure 9.12.25  Wide, thick, hypertrophic and keloid scars, often attributed to be the result of the patient’s own poor healing, are usually due to the over-excision of skin along an improper superiorly directed vector in procedures in which the surgeon has employed skin tension as a vehicle to lift sagging deeper-layer tissue. As is the case in the patient with poorly situated scars, the patient with wide or hypertrophic scars may be impossible to effectively treat if skin excision has been excessive at the primary procedure. Procedure performed by an unknown surgeon. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

the patient and surgeon wish otherwise. Re-operation in the absence of adequate skin to make proper repair will be a frustrating act of futility in which little, if any, benefit will be gained.

Cross-hatched scars Cross-hatched scars are a completely avoidable irregularity commonly seen in patients presenting for secondary facelift.

358

SECTION II

CHAPTER 9.12  • Secondary facelift irregularities and the secondary facelift

Figure 9.12.26  Cross-hatched scars. The underlying cause of most cross-hatched scars can be traced directly to skin tension and tension-based facelift techniques. When incisions are closed under tension, necrosis occurs beneath sutures and these spots go on to heal as scars. As skin relaxation occurs, over time, the hatch marks and suture hole scars stretch and migrate away from the incision scar, giving the appearance that the wound was closed with large, widely placed sutures. Procedure performed by an unknown surgeon. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

Like most secondary facelift irregularities, they are the product of errors in both planning and technique. The underlying cause of most cross-hatched scars can be traced directly to skin tension and tension-based facelift techniques. When incisions are closed under tension, larger sutures must be used, and these must be tied tighter and left in longer. Inevitably, varying degrees of necrosis occur beneath each, and these spots go on to heal as scars or hypopigmented areas. As skin relaxation occurs, over time, the hatch marks and suture hole scars stretch and migrate away from the incision scar, giving the appearance that the wound was closed in a crude fashion with large, widely placed sutures. Almost always crosshatched scars are accompanied by other signs of over-reliance on skin tension, including hairline displacement, hypertrophy, and wide scars (Fig. 9.12.26). Cross-hatched scars can simply and easily be avoided by employing a facelift technique that does not rely on skin tension. Diverting tension to the SMAS allows skin incisions to be closed under little if any tension with loosely tied, fine sutures that can safely be removed in 4–5 days after surgery. Diverting tension to the SMAS and platysma will not, in and of itself, prevent cross-hatched scars. If skin is closed under tension, or shifted along an improper vector after SMAS and platysma fixation, the opportunity to avoid tension-based secondary irregularities will be lost and one of the major benefits of the utilization of the SMAS and other deep-layer tissue will be subverted. Accepting that skin need not be tight is difficult for most surgeons trained in classical facelift technique. For many, it seems not only counterintuitive but also at cross-purposes with traditional goals and objectives. Dismissing this idea, and failing to accept related concepts, however, are major stumbling blocks to achieving high-quality scars and a “non-surgical” and natural postoperative appearance. The correction of cross-hatched scars is often difficult because the factors leading to the problem are still present to

some extent in the patient requesting secondary surgery, and each must be approached with caution. As is the situation in the patient with hairline displacement and wide or poorly located scars, for the patient with cross-hatched scars, it may be impossible to effectively treat the cross-hatched scars if skin excision has been excessive at the primary procedure or if enough residual skin redundancy is not present to allow simultaneous excision of scars, skin flap advancement along an appropriate vector, and closure without tension. In many cases the goal will be to reduce and better conceal, but not eliminate them. It is a common error to think that scars can simply be excised and the skin needed for closure can be recruited by wide undermining of overly tight adjacent areas. Experience will show that re-operation in the absence of adequate skin to allow excision along a proper vector along with a tension-free closure will result in a recurrence of the problem and other associated tension-based irregularities. In most patients, it is best to accept partial correction of the problem, rather than create new or worse problems by attempting complete elimination. Make-up, tattooing or restyling of hair may be necessary to conceal the residual scars.

Distortion of tragal anatomy Distortion of tragal anatomy is a commonly seen problem in patients presenting for secondary facelifts. Like many other problems associated with secondary surgery, it is the result of artistic insensitivity, poor planning, and errors in technique. In many patients, the secondary facelift will provide an opportunity to improve or correct tragal distortion, but in others complete correction may not be possible if additional problems are to be avoided. Common types of tragal distortion seen after primary facelift include changes in tragal shape, changes in tragal contour, tragal retraction, and obliteration of the pretragal sulcus. Less commonly, more severe degrees of distortion can also be present. In rare cases, the tragal cartilage has been mistakenly or inadvertently excised and the tragus is absent. The most commonly observed forms of tragal distortion seen in patients presenting for secondary facelift are loss of tragal contour and obliteration of the pretragal sulcus. These are frequently seen concurrently, although they have somewhat different underlying causes. Loss of tragal contour is usually the result of improper incision planning, superior over-shifting of cheek skin, and imprecise trimming of the tragal skin flap. The tragus is seen to have no distinct beginning or end and no posterior projection. A tell-tale “chopped-off” appearance results (Fig. 9.12.27A). This is generally correctable if tension is diverted to the SMAS, skin recruited from secondary advancement of the cheek skin flap, and the skin flap is properly trimmed and fit over the tragal cartilage. Loss of the pretragal sulcus and a “buried tragus” results from failure to leave enough skin to fill the pretragal depression when the tragal flap is trimmed and is almost unavoidable in any technique in which tension is placed on the cheek skin flap. The over-trimmed skin flap bridges the pretragal sulcus which in turn is gradually filled with fibrotic tissue and scar over time. The tragus appears “buried” and indistinct from the cheek anterior to it. It can also be seen to have a flat, two-dimensional, rather than three-dimensional contour (see Fig. 9.12.27B).

Strategy in treating the secondary facelift patient

A

B

359

C

Figure 9.12.27  “Chopped-off”, “buried”, and “retracted” tragal irregularities. (A) In the “chopped-off” tragus irregularity the tragus is seen to have no distinct beginning or end and no posterior projection. It is usually the result of improper incision planning, superiorly over-shifting of the cheek skin and imprecise trimming of the tragal flap. (B) In the “buried” tragus irregularity the tragus appears indistinct from the cheek anterior to it and the normal pretragal depression is absent. This irregularity results from failure to leave enough skin to fill the pretragal sulcus and is commonly seen when tension is placed on the cheek skin flap. (C) The “retracted tragus” represents an extreme case of the “buried tragus” irregularity and is the result of an over-trimmed cheek skin flap. The retracted tragus irregularity differs from the buried tragus irregularity, however, in that not only is the pretragal sulcus obliterated, but the tragal cartilage itself is pulled anteriorly. This results in an open auditory canal and a tell-tale and unnatural appearance. All procedures performed by unknown surgeons. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

Correction of the buried tragus requires recruitment of sufficient skin from the cheek at the secondary procedure to fill the three-dimensional contours of the pretragal area. Pretragal subcutaneous scar filling the pretragal sulcus must also be excised, and the tragal skin flap must be redraped under no tension. Skin must then be trimmed to a precise fit while the flap is depressed and held in the pretragal sulcus. No deep suture is generally necessary to hold the skin flap in the pretragal hollow if the above steps are properly carried out but on occasion may be helpful. The “retracted tragus” represents an extreme case of the “buried tragus” irregularity. It too is the result of technical error and has its origin in an overly tight and excessively trimmed cheek skin flap. The retracted tragus irregularity differs from the buried tragus irregularity, however, in that not only is the pretragal sulcus obliterated by subcutaneous scar, but the tragal cartilage itself is pulled anteriorly by the overtrimmed skin flap. This results in an open auditory canal and a tell-tale and unnatural appearance (see Fig. 9.12.27C). Simple recruitment of skin from the cheek and excision of pretragal subcutaneous scar is not sufficient to correct a retracted tragus because the retracted tragal cartilage is usually stiff, fibrotic, and unable to return to its natural position and configuration on its own. Correction usually requires that the cartilage be scored on its anterior surface and then secured with a mattress suture once in its proper anatomic position (Fig. 9.12.28).

Distortion of earlobe anatomy There is perhaps nothing as tell-tale and objectionable in the patient who has undergone a prior facelift as distortion or

Figure 9.12.28  Correction of the “retracted tragus” irregularity. To correct the retracted tragus irregularity tragoplasty is performed. Cheek skin is undermined and subcutaneous scar in the pretragal sulcus is excised. The anterior surface of the tragal cartilage is then scored to allow it to bend posteriorly to its proper anatomical position in a manner analogous to performing an otoplasty. The cartilage is secured in this configuration with a mattress suture. Skin is then recruited by SMAS and facelift skin flap advancement and the tragal skin flap is carefully trimmed to ensure that adequate skin is preserved to fill the pretragal sulcus. In secondary cases, the skin flap is often anchored in the pretragal sulcus with a deep dermal suture. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

malposition of the earlobe. Like most other problems associated with secondary surgery, it is the result of artistic insensitivity, poor planning, and errors in technique. Common types of earlobe distortion seen after primary facelift include the “pixie earlobe” and the “loving cup ear”.

360

A

SECTION II

CHAPTER 9.12  • Secondary facelift irregularities and the secondary facelift

B

“Pixie ear” is a pejorative term used by some to describe the unnatural, impish, or elf-like appearance the ear assumes when the lobule is attached directly to the cheek and pulled anteriorly and inferiorly (Fig. 9.12.29A). It is often the result of inartistic, improper, or careless resetting of the earlobe into the cheek after the cheek flap has been suspended at the primary procedure. It can also result as a delayed effect after artistically appropriate resetting of the lobule at the time of surgery in a skin-only, non-SMAS facelift. The lack of deep-layer support in such cases will inevitably lead to some inferior migration and settling of the cheek skin flap and eventual traction on the lobule. “Loving cup ear” is used to describe the situation in which the ear resembles the handles commonly seen on vase-like trophy cups. In this irregularity, the earlobes are joined to the cheek in a less extreme fashion, but also have been inset too low or pulled too far inferiorly (see Fig. 9.12.29B). This problem is often made worse by inferior migration of the cheek skin flap over time when a skin-only, traction-based facelift technique is used. A full understanding of the origin of lobular irregularity requires that the surgeon understands and appreciates normal lobular anatomy. This sets the stage for appropriate and natural resetting of the lobule into the cheek at the time of the primary procedure and the avoidance of unnatural secondary irregularities. Young patients presenting for other procedures and young friends and family members who have not undergone plastic surgery serve as useful subjects for study in this regard. Photographs of actors, models, and celebrities are less valuable however, as many have secondary lobular deformities that may not be immediately recognized due to concealment of scars by photo-retouching, or make-up. A careful examination of the youthful aesthetically ideal lobule will show that it is distinct from the cheek and that its long axis lies approximately 15° posterior to the long axis of the ear itself (Fig. 9.12.30A). As the axis of the lobule is moved anteriorly to rest anterior to the long axis of the ear, a tell-tale “surgical” appearance is produced (see Fig. 9.12.30B). If the long axis of the lobule is shifted well anterior to the long axis

Figure 9.12.29  The “pixie ear” and “loving cup ear” irregularities. (A) “Pixie ear” describes the unnatural, impish or elf-like appearance the ear assumes when the lobule is attached directly to the cheek in a pointed or triangular configuration. It is the result of inartistic resetting of the earlobe into the cheek after the cheek flap has been suspended. It can also result as a delayed effect after artistically appropriate resetting of the lobule at the time of surgery in a “skin-only” facelift. (B) “Loving cup ear” describes the state in which the ear resembles the handles commonly seen on vase-like trophy cups. In this irregularity, the earlobes are not only attached to the cheek, but have been inset or pulled too far inferiorly. Procedures performed by unknown surgeons. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

of the pinna and/or is drawn inferiorly, an objectionable and sometimes grotesque appearance can result (see Fig. 9.12.30C). Not infrequently, a patient presenting for primary facelift will be encountered in whom the lobule sits naturally in an aesthetically suboptimal anterior–inferior position. In these patients, it is best to reset the lobule in an attractive, artistically appropriate, more posterior position and configuration, rather than where it was originally found. If the lobule is reset in its original position in these situations, a “surgical” appearance is likely to result. This will not only raise suspicion that the patient has had a facelift but also make appropriate positioning of the lobular difficult at a secondary procedure. Correction of the pixie earlobe and loving cup ear requires that sufficient skin can be recruited along the jawline at the secondary procedure to allow the lobule and cheek flap to be elevated to a natural position under no tension (see Fig. 9.12.31). As is the case in the patient with a skin shortage and poorly situated, cross-hatched, or wide scars, the patient with a pixie earlobe or loving cup ear may be impossible to effectively treat if skin excision has been aggressive and excessive at the primary procedure or if the earlobe has been erroneously inset too far inferiorly into the cheek. In addition, if deep-layer SMAS support is not provided, it is likely that skin elevated at a secondary procedure will migrate inferiorly over time and the problem will recur. This is true, regardless of how much the patient and surgeon wish otherwise, and re-operation in the absence of adequate skin to make proper repair will be a frustrating act of futility in which little, if any, benefit will be gained. Redundant skin available over the jawline and in the upper neck can be assessed by pinching it up and measuring it. In general, if less than 2–3 cm is present, it is best to advise the patient that complete correction will most likely not be possible. The extent to which correction can be made will also depend, of course, on the degree of irregularity present. Although commonly attempted, anchoring the lobule to auricular cartilage or adjacent deep tissue with buried sutures will not be effective if enough skin is not present to

Strategy in treating the secondary facelift patient

A

B

361

C

Figure 9.12.30  Earlobe aesthetics. (A) In the youthful-appearing aesthetically ideal attractive ear, the long axis of the lobule (dotted red line) will be seen to rest 15° posterior to the long axis of the pinna (solid red line). (B) As the long axis of the lobule is shifted anterior to the long axis of the pinna, a less natural “surgical” appearance is produced. (C) If the long axis of the lobule is shifted further anteriorly and/or inferiorly an objectionable “pixie” or “loving cup” irregularity will result (see Fig. 9.12.29). (Courtesy of Timothy Marten, MD, FACS, used with permission.)

A

B

C

Figure 9.12.31  Correction of “pixie earlobe”. (A) A patient who has undergone a previous facelift who has a tell-tale, misshapen ”pixie earlobe” and a poorly placed preauricular scar. The perilobular scar is also visible and poorly concealed. Procedure performed by an unknown surgeon. (B) Plan for correction in the patient seen in (A). Skin must be recruited from the cheek, jawline, and neck to make needed repair of the earlobe and to move the scar into a more concealed location. This cannot be achieved by skin undermining alone, and some sort of SMAS support is required to prevent the problems from reoccurring. (C) Same patient as in (A) and (B) seen after secondary facelift and pixie ear correction. The earlobe now has a more natural shape and transition into the cheek. The preauricular scar has been moved into a more concealed location (see Fig. 9.12.18) along natural anatomical interfaces and is only seen on close inspection. The perilobular scar sits in the lobular-facial cleft and cannot be seen (compare to appearance in (A)). A similar correction would be made for a patient whose earlobe sits naturally in a “pixie” configuration. Secondary procedure performed by Timothy Marten, MD. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

allow closure to be made under minimal skin tension. Over time, suspension will be lost and the lobule will migrate inferiorly. Not infrequently, there will not be enough skin present over the lower face in the secondary facelift patient to allow full correction of loving cup earlobes (see Fig. 9.12.29B) by simply undermining and elevating the cheek skin. It will also be an artistic error to simply place the lobule back in an inappropriate position. In such instances, it may be best to move the lobule into a normal position and carefully close the defect into which it was originally inset using meticulous technique. While not ideal management of the problem, the resulting

scar will often go unnoticed as the eye will not be drawn to the area as it once was by the abnormal-appearing earlobe. In addition, the scar itself will often heal well following this maneuver, especially in older patients, as the incision can be closed under minimal tension under these circumstances. A small amount of make-up or tinted sunscreen is usually sufficient to conceal it. If the healed scar is raised or irregular and is incompletely concealed with make-up, dermabrasion can be performed as a subsequent step. For many patients, a scar on the cheek will be less noticeable than a displaced and misshapen lobule, and an acceptable trade-off for obtaining proper earlobe position.

362

SECTION II

CHAPTER 9.12  • Secondary facelift irregularities and the secondary facelift

Over-excision of subcutaneous fat The introduction of liposuction, along with ill-conceived procedures in which subcutaneous fat of the face and neck is aggressively curetted, excised, subjected to internal laser, internal and external ultrasound, radiofrequency treatment, and cryo- and chemolipolysis, has resulted in a group of patients with an unaesthetic paucity of neck fat and accompanying irregularities (Fig. 9.12.32). These patients with “cadaver necks” have little fat between their cervical skin and the underlying platysma and present a difficult problem when they request secondary procedures. Often, they require platysma surgery, although they have little superficial fat to disguise any irregularities that may arise from these procedures. In addition, if isolated surgery on the

B

A

A

B

neck was performed as the primary procedure, pseudoptotic jowl fat and fat lying along the mandibular border has usually been erroneously excised. This can result in harsh or irregular contours when the SMAS is subsequently elevated and defatted areas are unavoidably advanced superiorly onto the face (Fig. 9.12.33). In these situations, care must be taken in any secondary procedure to preserve as much fat as possible and to carefully contour fat at the interface between face and neck. It should be the aim of every surgeon who endeavors to rejuvenate the face to create an attractive neck and not one simply devoid of fat. Excessive excision of subcutaneous fat does not produce attractive or youthful contours, and often exposes and accentuates other neck problems. These problems include platysma bands, prominent submandibular

Figure 9.12.32  Over-excision of subcutaneous fat. (A) The patient has undergone a “weekend” facelift in which aggressive liposuction was performed and too much fat was removed. The neck and submental region are irregular and unattractive. (B) A different patient who has had a previous facelift. Submental liposuction was performed as part of the procedure. Inappropriate over-resection of fat has resulted in harsh and unnatural submental contours. Note the contrast with the soft contours of the cheek and neck and the harsh appearance of the submental region. Procedures performed by unknown surgeons. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

Figure 9.12.33  Erroneous excision of submental and pseudoptotic jowl fat. (A) Aggressive liposuction is performed as a primary procedure over the neck and jowl (shaded area) in a misguided attempt to rejuvenate the face. (B) When the patient returns for a secondary facelift and ptotic deep-layer tissues are properly repositioned, denuded areas are advanced up onto visible areas of the face. This can result in harsh and irregular contours. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

Strategy in treating the secondary facelift patient

glands and large or malpositioned digastric muscles. Each of these neck problems generally requires that wide cervical skin undermining be performed if appropriate correction is to be made. This is often difficult when little fat is present. Any such dissection must be carried out with great care to avoid any injury to residual subdermal fat, the platysma, and regional motor nerves. Excessive fat excision can also result in troublesome dermomuscular adhesions. These frequently result in tethering and abnormal appearances in animation and generally require careful division if an open dissection of the neck is planned. If no modification of the platysma or other deep-layer structures is needed, dermomuscular adhesions can be treated transcutaneously with a “V”-tipped needle dissector and carefully placed fat injections. Although judicious excision of subcutaneous cervical fat is sometimes necessary as part of rejuvenation of the aging neck, the excision of facial fat will usually produce an aged and haggard look, inconsistent with the intended goal of producing an improved appearance. This haggard appearance is evident in many patients presenting for secondary surgery who have undergone “mini-lifts”, “weekend facelifts”, “micro-liposculpture”, and other procedures in which facial liposuction is often performed. In these cases, remaining fat must be carefully tailored to produce the best contours possible. These patients will also often benefit from facial fat injections.

Over-excision of subplatysmal fat Although not all surgeons routinely explore the subplatysmal space and excise subplatysmal fat, patients with an unappealing “dug out neck” or “cobra neck” irregularity are increasingly presenting for secondary procedures. The dug out neck and cobra neck are pejorative terms used by some to describe situations in which subplatysmal and/or deep cervical fat has been erroneously over-excised resulting in an objectionable depression in the submental region (Fig. 9.12.34). Typically,

A

B

363

this depression is more evident when the neck is flexed somewhat or when the patient swallows. Correction of the dug out and cobra neck is best made using fat injections if it is the only problem present. If large or malpositioned digastric muscles and/or proturding submandibular glands are present, reducing these as part of the procedure may be sufficient to correct the problem. If secondary surgery is planned and adequate platysma is present, an anterior invagination (rather than excision) of the redundant portion of the medial platysma borders can also produce some improvement. In such cases it is prudent to perform simultaneous platysma myotomy to avoid formation of an anterior neck band.

Over-excision of buccal fat Although the judicious excision of buccal fat will occasionally benefit certain patients seeking primary, and more often, secondary facelift, it will often result in an ill or haggard look inconsistent with the intended goal of producing an improved appearance (see Fig. 9.12.35A). This is evident in many patients presenting for secondary surgery who have undergone “mini-lifts”, “weekend facelifts”, and limited incision procedures in which buccal fat excision is often performed. In these patients, SMAS advancement or midfacelifts can exacerbate this situation by elevating the over-reduced buccal pad. These patients will often benefit from less aggressive SMAS surgery and avoidance of midfacelifting. Correction of the over-resection of buccal fat is most easily made using fat injections and these can generally be performed as part of the secondary facelift procedure (Fig. 9.12.35). Injections should be made meticulously in small amounts and in multiple passes with a small blunt infiltration cannula. In general, 1–3 cc of centrifuged fat is needed for each buccal recess but occasionally more or less will be indicated. Alternatively, free fat grafts, or dermis fat grafts can be used. Facial fat injections can also be performed as a separate procedure after secondary facelift is performed. This allows

Figure 9.12.34  (A,B) The “dug out neck” or “cobra neck” irregularity. The dug-out or cobra neck irregularity is a pejorative term used to describe situations in which subplatysmal and/ or deep cervical fat has been erroneously overexcised resulting in an objectionable depression in the submental region. Procedures performed by unknown surgeons. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

364

SECTION II

CHAPTER 9.12  • Secondary facelift irregularities and the secondary facelift

A

B

C

Figure 9.12.35  Inappropriate excision of buccal fat. (A) Excision of buccal fat as part of a “mini” facelift has resulted in an ill and haggard appearance. This problem is most easily corrected by fat grafting, and this can generally be performed as part of the secondary facelift procedure (procedure performed by an unknown surgeon). (B,C) Correction of the over-resected buccal fat pad. (B) Secondary facelift patient who had buccal fat removed as part of her primary procedure. An unattractive, ill appearance has resulted. Procedure performed by an unknown surgeon. (C) Same patient after secondary facelift that included fat grafting to the buccal recess. The lower face has been filled and lost buccal volume restored. A healthy, youthful, and attractive appearance results. Procedure performed by Timothy Marten, MD, FACS. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

C A

B

Fig. 9.12.36  Topography of deep-layer neck problems. Understanding the anatomic basis of neck problems is essential to planning and properly treating neck problems in both the primary and secondary surgery patient. (A) Patient presenting for secondary facelift with untreated deep-layer neck problems. Note the near absence of subcutaneous fat but residual submental fullness and cervico-submental obliquity. (B) Shaded area shows contribution from protruding anterior belly of the digastric muscle (compare to (A)). (C) Shaded area shows contribution from protruding submandibular gland (compare to (A)). (Courtesy of Timothy Marten, MD, FACS, used with permission.)

the patient and surgeon to examine what was accomplished during the secondary procedure, and adjust the fat injection procedure accordingly.

Under-rejuvenated neck The success or failure of a facelift (lift of the cheek and jawline) is often judged by patients by the improvement they obtain in the neck, and if the neck is not sufficiently rejuvenated our patients will feel we have failed them. It is frequently the case that at the primary procedure the surgeon performing the primary procedure has focused the majority of their energy on the facelift and neck treatment was limited to submental liposuction and postauricular skin excision – and in some cases “corset” platysma tightening. Such a strategy, however, ignores the anatomic basis of most patients’ neck problems and is usually destined to provide an initial improvement that is rapidly lost thereafter. In many secondary facelifts the most profound and appreciated improvement a surgeon can provide the patient rests in the performance of a comprehensive necklift that addresses untreated “deep-layer” neck problems. Indeed, in the typical secondary facelifts we perform, the “facelift” is performed largely to move scars to more

concealed positions and to correct pixie earlobes and similar irregularities, and the lion’s share of improvement is achieved by performing a comprehensive necklift that addresses deeplayer problems, restoration of depleted facial volume with fat grafting, and addressing often-ignored forehead aging. Key to achieving good outcomes in the neck are to address deeplayer neck problems that typically include subplatysmal fat accumulation, prominent submandibular glands, and hypertrophy or malposition of the anterior belly of the digastric muscles (Fig. 9.12.36).

Prominent submandibular glands As experience is gained in evaluation of patients presenting for secondary surgery, prominent submandibular glands will increasingly be recognized as a frequent part of the secondary neck problem and the underlying cause of objectionable residual bulges in the lateral triangle of the lateral submental region (Fig. 9.12.37). Often, these bulges go unnoticed at the time of the primary procedure due to the fact that they are obscured by neck fat and lax platysma muscle, or their contribution to neck obliquity is simply not properly understood by the surgeon performing the primary procedure. In most instances, the secondary facelift will provide an opportunity

Strategy in treating the secondary facelift patient

A

365

B

Figure 9.12.37  (A,B) Prominent submandibular glands. Prominent submandibular glands are commonly seen in patients presenting for secondary facelifts. They are typically evident as objectionable residual bulges in the lateral triangle of the lateral submental region. Prominent glands often go unnoticed at the primary procedure because they are obscured by neck fat and lax platysma muscle and skin. Procedures performed by unknown surgeons. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

for proper diagnosis and appropriate treatment, when present, and a corresponding marked improvement in cervicosubmental contour. If a prominent submandibular gland is present, it can usually be seen and/or palpated lateral to the ipsilateral anterior belly of the digastric muscle and medial to the ipsilateral mandibular border within its respective submandibular triangle. Large glands can be reduced through the submental incision after raising the ipsilateral platysma but before submental platysmaplasty is performed. Submandibular glands are usually firm and have a distinctive lobulated appearance. Reduction is begun by incising the glandular capsule inferomedially and grasping the inferior-most portion of the gland. The gland can then easily be separated from its capsule and adjacent tissue using a combination of gentle blunt and sharp scissors technique. Care should be taken when mobilizing the superior-lateral portion of the gland as both the retromandibular vein and the marginal mandibular branch of the facial nerve are in proximity in this area. An examination of the prominent submandibular gland will show it to be large, and not “ptotic”, and careful consideration of this fact will reveal that attempts to reposition it more superiorly with sutures or by tightening the platysma are misguided and will ultimately be fruitless. This observation forms the basis of the recommendation that partial resection be performed of the protruding part of the gland in patients where a prominent gland is present. No other treatment of the prominent submandibular gland has been shown to be effective. After the protruding portion of the gland has been exposed and mobilized inside its capsule and separated from adjacent tissue, the redundant portion of the gland is excised using a long paddle-tipped cautery and a long pair of atraumatic (DeBakey) forceps. Adequate exposure is necessary, as is good light, an attentive assistant, good source of suction, and a well-coordinated team effort. It is essential that the surgeon be scrubbed with two people during submandibular reduction. One scrubbed team member is necessary as a full-time assistant to provide proper exposure. A second is necessary to manage the instrument stand and pass needed instruments. It

is not possible for one assistant to do both these things, or for the surgeon to properly manage bleeding should it be encountered if scrubbed with only one assistant. It should be noted that all vital structures are situated lateral to the dissection and lie outside the glandular capsule. Excision is begun by grasping the inferior portion of the gland and gently pulling it inferiorly and medially out of its fossa and away from adjacent structures. The redundant portion is subsequently incised incrementally along the planned line of resection (Fig. 9.12.38). This corresponds to a plane tangent with the ipsilateral inferior mandibular border and ipsilateral anterior belly of the digastric muscle. Visualizing this plane in the surgeon’s minds-eye is essential to proper reduction of the gland, and is analogous to visualizing the line between the nasal tip and the radix when reducing the nasal dorsum in rhinoplasty. Intraglandular vessels will in most cases be encountered during gland reduction and these must be immediately cauterized in a controlled fashion. Any bleeding points on the raw surface of the gland are then further cauterized once the redundant portion has been excised. As experience is gained, one can isolate the vessel as the gland is divided before the vessel itself is divided, and directly cauterize it or, ideally, ligate it. Following excision of the protruding part of the gland it is not necessary or desirable to try to oversew the cut gland edge or close the capsule. These maneuvers have proven to be clinically unnecessary, and present a risk of injuring nearby neurovascular structures. Unnecessary cauterization of the cut edge of the gland should also be avoided and this increases postoperative swelling, salivary leakage, and pain. It is not necessary or appropriate to remove the entire part of the superficial portion of the gland situated inferior to the mylohyoid to create an attractive cervical contour. Complete excision of the superficial lobe of the submandibular gland risks injury to the marginal mandibular branch of the facial nerve, could produce sublingual dryness, and is likely result in a depression or other contour abnormality. Subtotal submandibular gland excision to date has resulted in no cases of nerve injury, hematoma, salivary fistula, permanent dry mouth, or gustatory sweating in our experience.

366

SECTION II

CHAPTER 9.12  • Secondary facelift irregularities and the secondary facelift

Figure 9.12.38  Overview of the technique for reduction of prominent submandibular gland. The patient’s chin on the right and the neck on the left. A submental incision has been made approximately 1.5 cm posterior to the submental crease and the neck subcutaneously undermined. The right platysma muscle has been elevated and is retracted with a double pronged skin hook and a malleable retractor. The gland will be seen as a distinct bulge just lateral to the ipsilateral anterior belly of the digastric muscle (scissors tips rest on the anterior belly of the digastric muscle). The capsule has been incised inferiorly and medially and the submandibular gland mobilized in its capsule using blunt dissection. The gland, once isolated, is gently pulled inferiorly (seen held by DeBakey forceps). The portion protruding inferior to the plane tangent to the mandibular border and the ipsilateral anterior belly of the digastric muscle is then excised incrementally with long, paddletipped, monopolar electrocautery, taking care to thoroughly cauterize or ligate the intraglandular vessel if encountered. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

Protruding digastric muscles As experience is gained in evaluation of patients presenting for secondary rejuvenation of their face, protruding, lowlying, “malpositioned” anterior bellies of the digastric muscles will increasingly be recognized as a frequent part of the secondary neck irregularity and the underlying cause of objectionable linear paramedian fullness in the submental region. These bulges often go unnoticed at the primary procedure because they are often obscured by neck fat and lax platysma muscle. In most cases, the secondary facelift will provide an opportunity for proper diagnosis and appropriate treatment (Fig. 9.12.39). Prominent anterior bellies of the digastric muscles can be treated by superficial subtotal myectomy. Superficial, subtotal anterior digastric myectomy is performed under direct vision, working through the submental incision after the subplatysmal space has been opened and the medial platysma muscle borders mobilized (Fig. 9.12.40). Partial digastric myectomy is usually best performed after subplatysmal fat excision and submandibular gland reduction have been performed, if indicated, as it is easiest to assess the muscles at that time. Two basic techniques can be used – incremental tangential shave excision and muscle-splitting myectomy. In the former (and the technique used most commonly by the authors) the protruding portion of the muscle is shaved tangentially in an incremental fashion using a DeBakey forceps and a long paddle-tipped electrocautery (or medium Metzenbaum scissors). The neck is re-examined and the maneuver repeated until an

Figure 9.12.39  Prominent anterior belly of the digastric muscle. The patient has had prior face and necklift. The anterior belly of the digastric muscle can be seen as objectionable linear paramedian fullness in the submental region that spoils an otherwise good result. Prominent digastric muscles often go unnoticed at the time of the primary procedure due to the fact that they are frequently hidden by cervical fat and lax platysma muscle (see also Fig. 9.12.36A,B). Procedure performed by an unknown surgeon. (Courtesy of Timothy Marten, MD, FACS.)

optimal contour is obtained. Usually this entails the excision of 25–50% of the superficial-most part of the anterior muscle belly near the hypoid, but occasionally more of the muscle must be removed. In the muscle-splitting partial myectomy technique the protruding portion of the muscle is gauged and isolated on a tonsil forceps or similar instrument, by pushing the instruments tips transversely through the muscle belly (Fig. 9.12.41A). The isolated segment is then excised with electrocautery in a manner in which the most muscle is removed near the hyoid (see Fig. 9.12.41B). Contours are checked and the maneuver repeated as indicated. It should be noted that typically the most muscle needs to be removed near the hypoid and the least near the chin (see Fig. 9.12.40). Platysmaplasty (suturing the medial borders of the right and left platysma muscles together in the midline) and platysma myotomy (transverse division of the platysma at the level of the thyroid or cricoid cartilage) are then performed as indicated. A 10 F closed suction drain is usually placed in the subplatysmal space when digastric myectomy is performed, and always if subplatysmal fat excision or submandibular gland reduction are carried out. Partial digastric myectomy has not resulted in dysphagia, dysphonia, or other functional problems but caution is advised and the procedure arguably should be performed conservatively in singers, voice professionals, and the like.

Residual platysma bands The introduction of liposuction has resulted in many surgeons adopting a closed plan of treatment for the neck at primary facelift procedures, consisting of suction excision of pre-platysmal fat with and without postauricular skin excision. Although this occasionally yields a good result in a younger patient with modest deep-layer problems, more often it accomplishes little more than exposing underlying platysma

Strategy in treating the secondary facelift patient

A

B

367

C

Figure 9.12.40  Partial digastric myectomy. Protruding anterior bellies of the digastric muscle can be treated by partial digastric myectomy. (A) Illustration shows part of the anterior belly of the digastric muscle to be reduced. Note that an asymmetrical resection is made with more muscle being removed near the hyoid and less near the chin. (B) Preoperative patient showing a prominent digastric anterior belly. Note that the protruding digastric muscle is a linear paramedial structure lying medial to the rounder and more laterally situated submandibular gland (SMG) protrusion (see also Fig. 9.12.36). (C) Same patient as seen in (B) after secondary facelift and necklift that included submandibular gland and digastric muscle reduction. Note that the result seen would not be possible if only the submandibular gland had been treated. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

A

B

Figure 9.12.41  Muscle-splitting partial digastric myectomy. (A) Isolation of the protruding portion of the anterior digastric muscle. The tips of curved hemostatic forceps are bluntly pushed through the midbody of the muscle belly. (View from patient’s right of right digastric muscle through submental incision. Patient’s chin is on the left and neck on right.) (B) Excision of protruding portion of anterior belly of the digastric muscle. The muscle has been isolated on a hemostat. The isolated muscle segment is then divided near the hyoid and the protruding part excised using electrocautery. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

bands, protruding submandibular glands and digastric muscles, resulting in an objectionable and elderly appearance. Primary and secondary platysma bands are best treated by transverse platysma myotomy (transverse division of the platysma at the level of the thyroid or cricoid cartilage), as the underlying problem is one of longitudinal platysma hyperfunction, not horizontal platysma laxity. Dividing the muscle defunctionalizes it similar to the way in which the gastrocnemius muscle is defunctionalized when the Achilles tendon is ruptured. Platysmaplasty alone (suturing the right and left platysma muscles together in the midline) and lateral platysmal suspension are both usually insufficient in most cases as they do not address the underlying cause of most platysma bands. Transverse platysma myotomy generally requires complete subcutaneous undermining of the neck because myotomy should ideally be performed at or near the level of the thyroid or cricoid cartilage where the platysma muscle is thin if visible irregularities are to be avoided. Bleeding will also be minimal when myotomy is performed at this location, and there is minimal chance that lower lip dysfunction will be produced. If platysma transection is performed higher where the muscle is thicker, bleeding from cut muscle edges is more

common, and contour irregularities are likely to be evident once swelling is gone and healing is complete. A high division of the platysma can also precipitate lower lip dysfunction. If wedge resection of the platysma is made near the hyoid as is often traditionally taught, contour irregularities and lower lip dysfunction can occur and an unattractive overly sharp transition for the submental area to the anterior neck can result. Anterior bands require transection of the platysma to a point lateral to the band to the approximate midpoint of the muscle (Fig. 9.12.42). If lateral bands are present, transection is extended further laterally to a more lateral point in the muscle to include them as well (Fig. 9.12.43). Platysma myotomy should be performed after anterior platysmaplasty and lateral platysmal suspension (lateral platysmapexy or postauricular transposition flap) has been completed as the platysma muscle will be uniformly distributed over the anterior neck and under slight tension. Myotomy should ideally be performed low in the neck at the level of the thyroid or cricoid cartilage and extended slightly superiorly as it is extended laterally. Myotomy is typically and is most easily performed under direct vision with a long paddle-tipped cautery. Myotomy is best begun working through the submental

368

A

A

SECTION II

CHAPTER 9.12  • Secondary facelift irregularities and the secondary facelift

Figure 9.12.42  Treatment of residual anterior platysma bands. (A) Schematic showing anterior band and plan for platysma myotomy. (B) After myotomy and SMAS flap advancement. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

B

B

incision just inferior to the inferior-most suture placed when platysmaplasty was performed. The medial platysma border is identified over the cricothyroid area and grasped and lifted away from the deep cervical fascia with a long DeBakey-type forceps. Myotomy is then made by nibbling through the muscle in small increments using electrocautery. As the muscle is divided it usually separates a centimeter or more, exposing the fascia beneath it. It is not necessary or desirable to divide the deep fascia. Myotomy is continued laterally and slightly superiorly according to the preoperative plan. If treatment of lateral platysma bands is planned, the lateral-most portion of the trans-section (lateral half of the muscle) is completed through the postauricular incisions by identifying the midlateral muscle border, incising it, and incrementally extending the incision until it is brought into continuity with the incision made in the muscle anteriorly through the submental incision using the technique previously described. In most patients this “full width” division of the platysma is made to insure

Figure 9.12.43  Treatment of residual anterior and lateral platysma bands. (A) Schematic showing anterior and lateral bands and plan for platysma myotomy. (B) After myotomy and SMAS flap advancement. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

comprehensive defunctionalization of the muscle and suppression of bands is achieved. Platysma bands are typically the result of platysma muscle hyperfunction and they are not logically or effectively treated in most cases by suspension sutures or direct (vertical) excision. Suspension sutures and straps, especially those extending from mastoid to mastoid, often result in an overly rigid noose that is disturbing and uncomfortable to patients, especially when they look down. Sutures of any type also do not directly address the actual anatomical basis of the problem. Direct (vertical) excision of platysma bands, although recommended by many surgeons and practiced for some time, can result in nerve injury and muscle dysfunction, and typically results in visible irregularity, and a recurrent problem. Direct excision of platysma bands, like suspension sutures, does not address the anatomic basis of the problem and often results in new bands on each side of the excised muscle.

Strategy in treating the secondary facelift patient

A

369

B

Figure 9.12.44  Plan for partial platysma myectomy for treatment of “noninvasive”, “radiofrequency”, and “ultrasound” neck irregularity. When marked fibrosis of the platysma muscle is present traditional platysma myotomy will typically be inadequate and effective treatment usually requires partial platysma myectomy and removal of a major section of the damaged muscle present on the anterior neck. (A) Preoperative patient with platysma muscle hyperfunction (“dynamic hard bands”) but uninjured muscle showing surface expression of hyoid, thyroid, and cricoid cartilages. This patient would likely be effectively treated with simply platysma myotomy and minor marginal myectomy performed at the level of the cricoid cartilage. (B) Schematic of the segment of platysma muscle removed in partial platysma myectomy (area shaded in red) when fibrotic, scarred platysma is present in cases of “radiofrequency” and “ultrasound” neck. Typically the procedure is begun by dividing the platysma transversely full width at the level of the mid thyroid cartilage, working through both the submental and postauricular incisions with electrocautery, taking care to avoid dividing the underlying fascia if possible. The superior and inferior cut edges of the muscle are then undermined using electrocautery on top of the underlying fascia for a distance of 5–10 mm. The undermined segments of muscle are then excised and beveled flat using Metzenbaum scissors or cautery. Note that a 1.5–2 cm cuff of platysma muscle is left in place and undisturbed below the cervicomental angle (below the level of the hyoid), especially laterally, to protect the cervical and marginal mandibular branches of the facial nerves. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

Treatment of “radiofrequency neck” and “ultrasound neck” Partial platysmamyectomy is useful in certain secondary cases in situations where there has been fibrosis and scarring of subcutaneous tissues and the platysma in anterior neck and submental area. These challenging problems frequently result from “noninvasive” treatment of the neck with radiofrequency, ultrasound, internal tissue heating, cryolipolysis, chemolipolysis, laser liposuction (see Fig. 9.12.32), or use of inflammatory fillers in the neck area. When these “noninvasive” neck irregularities are present, a “high” myotomy (division at the level of the thyroid cartilage rather than the cricoid), combined with marginal or partial myectomy (excising damaged platysma muscle from the anterior neck at the level of the thyroid cartilage), may be indicated (Fig. 9.12.44).

Undertreatment of the SMAS Uncorrected and undercorrected midface irregularities A careful examination of the typical patient presenting for secondary surgery is commonly remarkable for an uncorrected or undercorrected midface evident as infraorbital hollowing, malar flattening, and nasolabial fold formation. These changes often appear more obvious and more objectionable after the patient’s primary procedure as they typically stand in contrast to an overly tight jawline and against a background of aggressive rejuvenation of other adjacent areas. Treatment of midface problems has been controversial for many years but a consensus of opinion is forming that the

problem is more one of atrophy and deflation, than tissue ptosis, and the most effective treatment consists of fat grafting, and not midfacelifting. A major shortcoming of “skin lifts” and the typical “low” and “deep plane” SMAS flap elevated below the zygomatic arch is that they are not able by design to produce significant improvement in the midface area. Skin lifts fail because skin provides little in the way of support of the malar fat pad. “Low” and “deep plane” SMAS flaps are ineffective, as they are unable by design to exert a significant vector of pull over the midface and infraorbital region. Incising and elevating the SMAS flap “higher”, along the midbody of the zygomatic arch, and extending the dissection medially to release and mobilize midface tissue, however, enables problems in these areas to be addressed (see Chapter 9.8). This high SMAS plan, as such, provides a means for both elevating ptotic infraorbital and malar tissue and increasing lower lid support, and is a very useful maneuver in the secondary surgery patient whose SMAS layer is still in good condition. It is not uncommon at the time of secondary facelift surgery to find that the SMAS has been timidly or not formally dissected at the primary procedure and that the high, extended dissection described above can readily be performed in a mostly virgin plane. Fortunately, a secondary SMAS dissection is also still possible after a more extensive primary SMAS procedure, and the subSMAS plane usually offers little in terms of scar, adhesions, or other encumbrances if the SMAS procedure performed at the primary procedure was skillfully carried out.

370

SECTION II

CHAPTER 9.12  • Secondary facelift irregularities and the secondary facelift

Advancing the cheek SMAS flap superiorly and suspending it without excising its superior margin or folding its superior edge upon itself at the primary procedure, provides the ideal setting for secondary SMAS surgery. The overlapping tissue segments are easily dissected at some future date and minimal subSMAS cicatrix is produced. It should be recognized that the nasolabial fold and crease are a product of the patient’s individual anatomical make-up and in many cases a specific familial trait. In such cases, elevation of the midface as described should not be expected to eliminate or obliterate these features. Indeed, in such cases there is little artistic imperative to do so. Most midfacelifts are generally conceptually flawed and of limited utility in the secondary facelift patient in that they erroneously assume the problem seen in the anterior upper cheek to be solely one of tissue sagging. As such they have been steadily abandoned by many surgeons. Failure to acknowledge the fact that atrophy is present to a significant degree in most cases has led to general disappointment following many midfacelift procedures for both patients and surgeons alike, and has resulted in some surgeons adding dermis fat grafts, orbital fat transposition, and “septal resets” to “midfacelift” procedures. It is increasingly evident, however, that these procedures cannot produce a restoration of lost volume as simply, naturally, and effectively as can be obtained with fat grafting. The current practice of many experienced facelift surgeons seems to strongly favor a “filling” rather than a “lifting” approach.

Residual jowl Incomplete elevation of the jowl, or recurrent jowl ptosis, is a common problem seen in patients presenting for secondary facelifts that, in all but the unusual case, represents incomplete mobilization, improper shift, inadequate fixation or other improper or under-utilization of the cheek SMAS (Fig. 9.12.45).

Figure 9.12.45  Residual jowl and jawline laxity. Incomplete elevation of the jowl is commonly seen in patients presenting for secondary facelifts and represents incomplete or under-utilization of the cheek SMAS. Although liposuction and direct excision of jowl fat may straighten mandibular contours, most of this fat more appropriately belongs higher on the face and should not be arbitrarily sacrificed. Procedure performed by an unknown surgeon. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

In most patients, the secondary facelift will provide an opportunity to reposition sagging jowl tissues and to restore attractive mandibular contour. Although liposuction and direct excision of jowl fat can be used to improve mandibular contours in some instances, this fat more appropriately belongs higher on the face and should not be arbitrarily sacrificed (see Fig. 9.12.33). In addition, in most instances liposuction and/ or direct jowl fat excision was performed aggressively at the primary procedure, and little residual superficial fat is often present in secondary cases. Many patients with residual jowls presenting for secondary surgery will be better served by formal SMAS dissection and suspension, than by fat excision. In some cases, patients with very heavy jowls will require the combination of repositioning of jowl fat via SMAS elevation and conservative jowl fat removal via direct excision or micro-liposuction. In many instances, however, residual large jowls present after a primary facelift represent a combination of residual excess fat, jowl tissue ptosis, and atrophy at the geniomandibular groove, and a combination of SMAS elevation, judicious fat excision, and geniomandibular groove fat grafting may be indicated.

Distortion and abnormal appearances due to inappropriate skin shifts Many patients presenting for secondary facelift will have abnormal appearances due to inappropriate shifts of skin flaps. This problem is particularly common in the older patient with deep rhytides and poor skin elasticity and will typically be evident as superiorly over-shifted cervicofacial rhytides in the lower lateral cheek, perilobular area, and upper lateral neck sometimes referred to as a “wrinkle shift irregularity” (Fig. 9.12.46). Superior over-shifting of cervicofacial rhytides is commonly seen in skin-only facelifts, deep plane and “composite” type procedures, and in MACS (minimal access cranial suspension) lifts and other “short scar” procedures in which a short postauricular incision is used and skin is obligatorily shifted along a superiorly directed vector. This irregularity is commonly accompanied by temporal hairline displacement, unless an incision along the temporal hairline has been used. The fundamental problem with these procedures is that they fail to address the fact that skin and SMAS age at different rates and along different vectors. In general, skin needs to be advanced along a vector perpendicular to the nasolabial fold, whereas the SMAS and deep-layer tissue needs to be advanced along a more superiorly directed vector roughly parallel to the long axis of the zygomaticus major muscle. In skin-only lifts, skin is typically over-shifted along a superiorly directed vector in a misguided attempt to correct problems of deep-layer origin seen in the lower face and along the jowl. In deep plane and composite procedures, skin is obligatorily advanced as a composite monolayer with underlying SMAS and skin must be overshifted superiorly to obtain the best SMAS effect. The “wrinkle shift irregularity” is most problematic in MACS lifts and short scar procedures, and any similar procedure in which an attempt is made to shorten or eliminate the postauricular scar. These procedures, by design, require that cervicofacial skin flaps be shifted along a purely vertical vector, and do not provide a means for wrinkled cervical skin to be partially excised, shifted more posteriorly, and kept on the cervical area. Separating the skin and SMAS from one another into separate layers or lamella and advancing each along independent

Strategy in treating the secondary facelift patient

A

B

vectors allows each layer to be treated most appropriately and as indicated. When this is done, wrinkled cervical skin can be shifted posteriorly and partially excised, and kept off the face. This minimizes cervical wrinkle shift onto the face and other secondary irregularities resulting from improper overly vertical skin shifts. This treatment of the skin and SMAS as separate layers is referred to as a “lamellar” or “bidirectional” facelift. Neck-to-face wrinkle shift is difficult to correct, especially in the patient with little residual skin redundancy. Although skin flap elevation and re-advancement along a more posteriorly directed vector can produce some improvement, the degree to which the flap can be shifted back into a normal position will be limited by the severity of the previous skin over-shifting, the previous cut-out made for the lobule at the primary procedure, and the amount of recurrent redundant skin present at the time that secondary surgery is requested.

Compression of the temporal face Although advancement of the SMAS along a mostly superiorly directed vector will produce the most comprehensive improvement in the midface, cheek, jowl, and infraorbital areas, it will also inevitably produce compression of the temporal face and lateral orbital region if tissue shifts have been meaningful and temple lift or foreheadplasty is not performed. This compression and wrinkling not only contribute to a “young face–old forehead” irregularity, but also will be worse after a secondary facelift if temple and lateral upper facial tissue are not correspondingly repositioned. Patients are often aware that a problem exists in the temple area after their primary facelift but often mistakenly assume it to be a problem of skin wrinkling and residual “crow’s feet”. Many rightly observe that tissue compression is worse upon smiling. These patients will benefit from repositioning of temporal tissues or formal foreheadplasty if not performed as part of the primary procedure.

371

Figure 9.12.46  Abnormal appearance due to inappropriate skin shifts. (A) Wrinkles originally present on the neck have been moved up over the jawline and in front of the lobule at a previous facelift procedure. This “wrinkle shift” occurs in “skin lift”, “short scar”, and other procedures where the skin is advanced along an overly superiorly directed “vertical” vector in a mistaken and ill-conceived attempt to improve neck contour. It can also occur in “deep plane” and “composite” procedures in which skin and SMAS must obligatorily be advanced in the same direction (procedure performed by unknown surgeon). (B) After secondary facelift. Contour has been created using the SMAS and platysma and cheek skin has been shifted inferiorly to the extent possible to reduce the “wrinkle shift “ appearance. Secondary procedure performed by Timothy Marten, MD, FACS. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

Skin deficiencies and “tight look” Whenever prospective patients and the lay public discuss facelift surgery they inevitably express the most concern and dismay over the tight faces of various celebrities and their friends and acquaintances who have undergone the procedure. Many unhesitatingly demonstrate what they see to be the problem by pulling forcefully on their cheeks, eyes, and eyebrows, asking either not to look that way after their surgery, or stating they will never undergo surgery for fear of ending up with a similar appearance. This concern is reinforced by the numerous jokes and references in the popular press to “masks”, “wind tunnels”, and “faces so tight they will crack” if their wearer smiles. Despite these expressed concerns and the frequent popular ridicule of the typical outcome of multiple skin-only facelifts, procedures based predominantly on skin excision that produce a tight look continue to regrettably be widely performed. The fundamental problem with a “skin-only” facelift, especially if multiple such procedures are performed, is that skin is meant to serve a covering function and not a supporting one. Most of the changes seen in the aging face, however, are the result of an attenuation of support and subsequent descent of deep-layer facial tissues, and not sagging of skin. Any attempt to lift significant sagging of deep facial tissue with skin will be short-lived, destined to produce an overly tight appearance, and doomed to result in secondary irregularities. As the elastic limits of skin are exceeded in a skin-only facelift, a tight or pulled appearance develops and facial contour is flattened. Tightness and flattening will be most pronounced in the preauricular region where tension is highest and the threshold of elasticity exceeded the most. More inferiorly, in the jowl and perioral region, skin will be under less tension and below its threshold of inelasticity. Less tightness will thus be present in these areas, where it is needed most. Further tightening of the skin usually results in more preauricular flattening but little improvement in jowl and perioral

372

SECTION II

CHAPTER 9.12  • Secondary facelift irregularities and the secondary facelift

to contour the face by skin excision because the elastic limits of cheek skin are exceeded when the neck is flexed and its normal covering function is corrupted. This tell-tale irregularity is typically evident when the patient is looking down and the neck is flexed (e.g., when looking at a menu, book, or theater program). The patient presenting for secondary facelift who had skin excision only at their primary procedure is the prototypical patient in need of deep-layer support. Additional skin excision will result in an accentuation of their irregularities, and little improvement in facial contour.

Skin slough

Figure 9.12.47  “Tight lines”. Wrinkling and tightness extending from the lobule to the jowl and submental area when the patient looks down (“tight lines”) can be seen after well-intended attempts to contour the face by skin excision and occurs because the elastic limit of cheek skin is exceeded and its normal covering function is corrupted. (Note other tension artifacts including retracted lobule and wide, crosshatched perilobular scar.) Primary procedure performed by an unknown surgeon. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

Figure 9.12.48  “Drapery lines” and “lateral sweep”. “Drapery lines” and “lateral sweep” are common problems following “skin-only” facelifts. In these procedures skin tightness is most pronounced in the preauricular region, where it is least needed. More inferiorly, in the jowl and perioral region, skin will be under less tension where it is needed most. “Drapery lines” develop because skin is fixed and tethered in the preauricular and peristomal regions, but has little or no support in between where deep-layer tissue sagging is greatest. Primary procedure performed by an unknown surgeon. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

contour. Over time, “tight lines” (Fig. 9.12.47) will appear across the lower cheek and upper lateral neck upon neck flexion and “drapery lines” (Fig. 9.12.48), or “lateral sweep” will develop over the lower cheek and jowl. Drapery lines and lateral sweep develop because skin is fixed and tethered in the preauricular and peristomal regions, but has no support in between where deep-layer tissue sagging is greatest. Wrinkling and tightness extending from the lobule to the jowl and submental area when the patient looks down (“tight lines”) also occurs after well-intended attempts

The continued popularity of procedures in which the skin of the face and neck is extensively undermined and then suspended under abnormal tension in an attempt to create youthful contour has resulted in the continued occurrence of potentially avoidable secondary problems resulting from skin slough. Skin slough is also frequently the result of inappropriately aggressive surgery on smokers, or patients who have previously undergone radiofrequency or ultrasound “skin shrinking” treatments, and it can be the result of arguably risky procedures in which a facelift is performed concomitantly with aggressive laser resurfacing of undermined skin. While the number of patents who smoke has declined over the past few decades, the number of patients undergoing radiofrequency and ultrasonic “skin shrinking” treatments has skyrocketed. Patients undergoing these latter treatments have damage to their skin microcirculation and have grown to comprise a cohort of patients who present a similar risk of skin slough and healing-related problems as smokers, but has supplanted smokers in numbers. Fortunately, smokers and former smokers, and patients who have undergone radiofrequency and ultrasonic skin tightening treatments that present for secondary facelift have less risk of slough and related healing problems than patients undergoing primary procedures as their facial skin flaps have essentially been delayed at the primary procedure. Caution must still be exercised in these patients, however. Small areas of scarring resulting from skin slough in patients presenting for secondary surgery can sometimes be corrected at the time of the secondary procedure by direct excision after adequate mobilization of surrounding tissue or by incorporation of the scarred area into a more comprehensive incision plan. Larger areas of skin loss resulting from excessive flap undermining, excessive flap tension, rough tissue handling, or overly tight facial bandages are usually much more difficult to correct, especially if skin excision was aggressive at the primary procedure and little residual redundancy is present. Regrettably, this is all too frequently the case. In such situations, the patient and surgeon must accept that complete correction is not possible at the time of the secondary procedure no matter how much they wish it were so. It is a common error to assume that scarred areas can simply be excised and that the skin needed for closure can be recruited by wide undermining of adjacent cheek or neck tissue. Even the surgeon who knows better will often set good judgment aside when subjected to the persistent pleading of a patient desperate for some kind of improvement. Experience has shown, however, that simple scar excision and adjacent tissue undermining in these patients will result in inadequate skin for a tension-free repair and a forced, excessively tight

Strategy in treating the secondary facelift patient

373

closure. This tight closure, in turn, will inevitably result in wound dehiscence, scar widening, and associated tension-related irregularities including scar hypertrophy, cross-hatched suture marks, facial distortion, tragal irregularities, and lobular malposition. In these patients it is best to accept partial correction of the problem, rather than creating a new one, or injuring remaining normal tissue. Make-up, camouflage tattooing, or restyling of hair are better alternatives to conceal the residual scars in these circumstances. If make-up is ineffective in concealing scars due to ridges and step-offs where they abut normal tissue, dermabrasion may be helpful in reducing the discrepancy in tissue height and smoothing the transition between the two areas. Even if discrepancies in tissue height can be reduced in this manner, there is usually a marked difference in tissue texture that prevents the scar from being completely concealed. Patients wishing further improvement may benefit from scar excision and full-thickness skin grafting as this technique can provide cover with more natural-appearing skin texture. Several follow-up dermabrasion procedures may be necessary to smooth the interface between the skin and skin grafts and these patients are likely to benefit from the use of a silastic gel sheet and/or facial compression garments during the healing process. In some circumstances, it may be better to excise some normal skin along with scarred areas and graft a large anatomical subunit, rather than creating a patch quilt of smaller grafts. In extreme situations, consideration may have to be given to cheek or neck skin expansion. Skin slough can be minimized or avoided by exercising caution, using common sense, and adhering to basic plastic surgery principles. All patients who smoke or have a history of smoking should be identified and their surgery planned in a way that recognizes their increased risk for compromised healing skin necrosis. Consideration should be given to not performing a facelift on heavy smokers with a long history of tobacco use, or employing a facelift technique that does not involve wide skin flap undermining and skin flap tension. Many of these patients will be satisfied with a combination of limited lower-risk procedures, including closed foreheadplasty, eyelid surgery, conservative submental liposuction, fat injections, and laser resurfacing. Smokers should always be approached with caution, however, and every surgeon should recognize these patients have a higher risk of experiencing healing problems after surgery. Flap necrosis is dependent upon a variety of factors under the surgeon’s control and can be minimized by procedure design. These factors include tissue trauma, the extent of skin undermining, and skin tension. Because deep-layer techniques limit skin undermining, preserve important cheek perforators, and avoid excessive tension on cervicofacial skin flaps, a careful surgeon employing a gentle, atraumatic, technique in carefully selected patients should infrequently encounter skin slough. And when the procedure is performed in this manner, skin slough, should it occur, should be limited and easily managed.

maneuvers. SMAS injury during non-SMAS surgery can, however, result in distortion and irregularities of SMAS origin, even though no actual SMAS surgery was performed. The typical SMAS injury resulting in secondary irregularity occurs when the SMAS is knowingly or unknowingly “buttonholed”. This will result in asymmetries and contour irregularities, especially when the patient is in animation or clenches their teeth (Fig. 9.12.49). Identification and repair of these SMAS defects at secondary surgery will eliminate many of these types of problems. Larger rents or defects in the SMAS, resulting from larger areas of SMAS injury, SMAS excisions, and failed plications, present a bigger challenge and can be difficult to fully correct. Patients who have had prior SMAS lifts may have other secondary SMAS irregularities that must be recognized and addressed as well. These irregularities include ridges from SMAS plication or SMAS excision, irregularities from an uneven or overly tight SMAS suspension, and distortion and unnatural appearances from advancement of the SMAS along an improper vector. Ridges and irregularities from prior plication or SMAS excision may limit the potential for improvement in secondary procedures, and secondary correction techniques must be individualized according to the specific problems present. Some correction is usually possible if tissues are carefully examined and the origins of the problem can be ascertained. SMAS advancement along an improper vector can result in distortions in animation and at rest. These typically occur when the cheek SMAS flap has been erroneously advanced and suspended under tension along a predominantly posterior,

Distortion and abnormal appearances due to inappropriate SMAS shifts or SMAS injury

Figure 9.12.49  Contour irregularity due to prior SMAS injury. A common type of SMAS injury resulting in secondary irregularity occurs when the SMAS is knowingly or unknowingly “button-holed” at the primary procedure. This can result in bulges or contour irregularities when the patient animates or clenches their teeth. (Note the bulge (arrow) in the lower cheek in this patient when clenching her teeth.) Procedure performed by an unknown surgeon. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

Many patients presenting for secondary facelift will have had skin-only, non-SMAS procedures, and as such, will be potentially free from irregularities related to inappropriate SMAS

374

SECTION II

CHAPTER 9.12  • Secondary facelift irregularities and the secondary facelift

rather than mostly superior vector and are typically evident as a “clown mouth” or “pulled mouth” appearance and bizarre and unusual facial movements in animation. The proper vector of advancement of the SMAS is along a vector parallel to the long axis of the zygomaticus major muscle. If the SMAS is advanced along another vector, the zygomaticus major muscle will be bowed off its axis of normal function and its action corrupted. Posterior traction also exaggerates risorius action and results in an objectionable change in the resting posture of perioral tissues. Secondary irregularities related to an improper advancement of the SMAS flap are often markedly improved during secondary surgery when the SMAS is re-elevated and re-advanced along a proper vector.

“Smile block” Attempts to directly suspend the midface or malar fat pad with sutures, or low rigid suspension of the SMAS to the facial skeleton, will prevent natural gliding of cheek and midface tissue during animation. This will be clinically apparent postoperatively when the patient emotes as dimpling and contour irregularities, often referred to as “smile block” (Fig. 9.12.50). Smile block can usually be improved at a secondary procedure by a thorough release of the tethered area and re-suspension of ptotic tissues using a technique that allows unrestrained and natural gliding of malar pad and midface. This is usually best accomplished by high suspension of the cheek and midface using a high SMAS flap (see Chapter 9.8), or by employing a subperiosteal midfacelift technique. Techniques that require suture fixation of more superficially situated tissue, or “low” fixation on the face, should be avoided. Smile block can also often be improved percutaneously by release of tethered areas with a small “V”-tipped lipo-infiltration needle and concomitant fat injection.

Figure 9.12.50  “Smile block”. If the SMAS is suspended too low, too far medially over the zygoma, or too rigidly directly to the periosteum, tissue tethering can result in dimpling and other irregularities when the patient smiles (arrow). This problem can also be seen when attempts are made to directly suspend the malar pad or when the malar midface or other mobile area of the face is suspended to the infraorbital rim or other part of the bony skeleton. Procedure performed by an unknown surgeon. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

Unaesthetic facial implants It is not uncommon to find patients presenting for secondary facelift who have inappropriate or unaesthetic facial implants that detract from their appearance and limit the potential for improvement at any secondary procedure. Frequently, these implants were placed in an attempt to offset the deficiencies and shortcomings of a “mini-lift”, “laser facelift”, “infomercial lift”, “franchise facelift”, or “weekend” procedure, or placed in an isolated procedure in a patient who would have arguably been better served by formal facelift surgery. These can include under- and oversized malar implants, submalar implants, chin implants, and mandibular angle implants. Often even more troublesome are PTFE (Gore-Tex, W.L. Gore & Associates, Newark, DE) strips and similar implants placed in the lips and nasolabial folds. These can be seen to result in visible surface irregularities, buckling, and tethering upon facial animation. Although facial implants collectively comprise a significant advance in aesthetic surgery and have helped many patients, they were devised primarily to be used in individuals with skeletal deficiencies. Patients troubled by age-associated soft tissue ptosis are more logically, appropriately, and effectively treated by procedures that reposition and redistribute ptotic soft tissue, rather than those designed to augment the facial skeleton. Patients troubled predominantly by soft-tissue atrophy are likewise more appropriately treated by fat grafting than with facial implants. Many patients with unaesthetic facial implants are aware that all is not right with their appearance and are more than willing to consent to implant exchange or removal. These patients are typically seen to have small button-like chin or cheek implants, oversized malar implants, or submalar implants placed in a failed attempt to improve their nasolabial folds. A more difficult situation exists when the patient does not see the problem and is unwilling to consider implant exchange or removal. In these patients, one must decide whether it is possible to work around this, or if it is preferable to let the patient enlist the services of another surgeon. In general, the removal or exchange of facial implants at the time of secondary facelift is not difficult and results in a few untoward occurrences. If implants were originally placed subcutaneously, a more natural appearance can usually be obtained when they are moved to a subperiosteal position. Submalar implants often can be removed at secondary procedures, as cheek and midface repositioning will often result in abnormal appearances if these are left in place. Alternatively, they can be left in place and removed in a subsequent procedure, if necessary, if the patient desires. PTFE (“Gore-Tex”) implants placed in the lips and nasolabial folds present a particular problem in that they can be difficult to remove. In addition, removal can often result in troublesome and difficult to correct secondary irregularities. It is often best to encourage the patient to return to the surgeon who originally placed these implants before secondary surgery is performed if he or she wishes them to be removed. This allows problems associated with implant removal to be clearly defined prior to the secondary surgery, and an appropriate plan for correction to be made. If implant removal is made as part of the secondary facelift, problems may be erroneously attributed to that procedure or the technique used.

Strategy in treating the secondary facelift patient

A

B

The unrejuvenated forehead Rarely does isolated aging occur in the cheek and neck. Nonetheless, most attempts to rejuvenate the face are targeted at these areas and many patients presenting for secondary facelift will have a distinct and tell-tale “young face–old forehead” irregularity. This results from a failure to recognize and treat forehead aging at the primary procedure (Fig. 9.12.51). A careful consideration of the typical patient presenting for secondary facelift frequently reveals that isolated tightening of the neck and cheeks is often an artistically inappropriate undertaking. This is due, at least in part, to the fact that changes in the forehead are more likely to be mistakenly assigned emotional significance than those in the lower face and neck, and as such, play a greater role in how we interact with and are regarded by others. In addition, rejuvenating the lower face and neck only will typically result in facial disharmony and an unnatural, unbalanced, and “surgical” appearance. Recognizing the “young face–old forehead” irregularity is necessary for it to be corrected and a prerequisite to communicating the need for forehead surgery to the patient. To appreciate the “problem”, the surgeon must examine the patient’s face in its entirety and consider the way in which his or her appearance might make others feel. This is often best accomplished by viewing the patient’s face at a distance and momentarily deferring to one’s intuition. Because a patient’s hairstyle can conceal important signs of forehead aging, and compensatory frontalis spasm can give the false impression that the eyebrows are in an appropriate position, it is imperative that the face of the patient presenting for secondary facelift be examined with the patient’s hair pushed well back off their forehead. In addition, because patients who wear forehead-concealing hairstyles often do not see the full extent of these problems, it is helpful, as it is during the rest of their evaluation, for the patient to hold a hand mirror during

375

Figure 9.12.51  The “young face–old forehead” irregularity. (A) Patient seen after facelift, necklift, genioplasty, and eyelid surgery performed by an unknown surgeon. Her forehead appears older than the rest of her face, and her overall appearance is disharmonious and unnatural. (B) Same patient seen after hairline-lowering foreheadplasty. No eyelid surgery or other procedures have been performed. Her face appears more natural, harmonious, and balanced, and all areas appear to be the same age. Procedure performed by Timothy Marten, MD, FACS. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

this part of the examination. They can then be shown these important findings and counseled as to how they are actually the product of forehead ptosis. The erroneous assumption that forehead ptosis is not present because the eyebrow appears to be in a normal position is the single biggest stumbling block in evaluating the forehead for patients and surgeons alike. Patients are accustomed to optimizing the appearance of their face when looking at their reflection by unconsciously raising their eyebrows. This is often further compounded by the fact that many women aggressively pluck the inferior-lateral portion of their eyebrow to give the allusion that it is higher and more arched. In many cases, the entire outer third of the eyebrow will be seen to be missing and has been drawn on in a higher position with an eyebrow pencil. The all too commonly observed circumstance is one in which the patient with a marked frontalis spasm and marked transverse forehead wrinkling holds a hand mirror during his or her consultation and sees only that his or her eyebrows appear in a normal position. Because many patients presenting for secondary facelift will have unrejuvenated foreheads, foreheadplasty will usually be an important component of the planned facelift procedure.

Unrejuvenated perioral region Although advanced perioral aging is usually appreciated at the time of primary facelift, more subtle irregularities often go unnoticed, especially when viewed against a background of advanced aging elsewhere on the face. As a result, perioral aging often goes untreated at the primary procedure and usually appears more apparent after rejuvenation of adjacent areas is performed. This can result in a tell-tale “young face– old mouth” irregularity (Fig. 9.12.52). Recognizing the “young face–old mouth” irregularity is necessary if improvement is to be made and a prerequisite

376

SECTION II

CHAPTER 9.12  • Secondary facelift irregularities and the secondary facelift

A

B

Figure 9.12.52  The “young face–old mouth” irregularity. (A) Patient seen after facelift, and related procedures performed by an unknown surgeon with an unrejuvenated perioral area. Her mouth appears older than the rest of her face, and her overall appearance is disharmonious and unnatural. (Procedure performed by an unknown surgeon.) (B) Same patient seen 1 year and 4 months after facelift that included fat grafting and perioral resurfacing. Her mouth appears more youthful and healthy. Procedures performed by Timothy Marten, MD, FACS. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

A

B

Figure 9.12.53  Upper lip lift. (A) Patient seen after facelift and related procedures performed by an unknown surgeon with an unrejuvenated perioral area and “young face–old mouth” appearance. The distance from the base of her nose to the upper lip vermilion border is long and lends the mouth an elderly and incompletely rejuvenated appearance not in keeping with the rest of her face. Her overall appearance is disharmonious and unnatural. (Primary procedure performed by an unknown surgeon.) (B) Same patient seen after secondary facelift, necklift, upper lip lift, facial fat grafting, and perioral laser resurfacing. The distance from the base of her nose to the upper lip vermilion border has been shortened. Fat grafting has projected the upper lip vermilion border and filled the lower lip and other areas of the face, and the laser resurfacing has smoothed perioral wrinkles. The mouth has a more youthful, attractive and homogeneous appearance. Procedures performed by Timothy Marten, MD, FACS. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

to communicating the need for the procedure to the patient. Because many patients presenting for secondary facelift will have an unrejuvenated perioral area, perioral rejuvenation will often be an important component of the planned secondary “facelift” procedure. This will usually require some form of skin resurfacing to improve skin quality and reduce skin wrinkling, and fat or filler injections to counteract perioral atrophy. Other treatments such as upper lip lifts (Fig. 9.12.53) and corner lifts of the mouth are also very useful in secondary facelift patients.

Uncorrected facial atrophy Traditionally, the aging face has been thought of and defined in terms of tissue relaxation and surface wrinkling, but more recently surgeons have come to appreciate atrophy and lipodystrophy as integral parts of the aging process. A careful examination of patients presenting for secondary facelift will reinforce this assertion and reveal that simply smoothing wrinkles and lifting sagging tissues will fall short of truly rejuvenating the face in most cases. This is particularly true if the patient is

Strategy in treating the secondary facelift patient

A

B

C

D

E

F

377

Figure 9.12.54  Untreated facial atrophy. (A–C) Before surgery view of a woman, aged 75, who has had multiple prior facelifts and related procedures, including laser resurfacing, performed by unknown plastic surgeons. Note marked, uncorrected pan-facial atrophy. Despite her multiple traditional facelift lifts, a frail, ill, and elderly appearance is present. (D–F) Same patient, 1 year 4 months after secondary facelift, necklift, forehead lift, upper and lower blepharoplasties, canthopexy, and aggressive fat transfer to the forehead, temples, cheeks, upper and lower orbits, lips, perioral area, buccal recess, chin, and jawline. A total of 90 cc of fat was injected. No skin resurfacing, facial implants, or ancillary procedures were performed. Note that the patient has soft, natural facial contours and absence of a tight or pulled appearance. Atrophy in all treated areas has been markedly improved with fat injections to create a softer, more youthful, fit, healthy, and energetic appearance. Such an improvement cannot be obtained with traditional lifting and tightening. It can only be achieved by volume replacement. As was the case in this patient, for many secondary facelift patients, volume replacement is more important than the facelift itself. (Courtesy of Timothy Marten, MD, FACS, used with permission.)

thin, buccal fat was removed as part of the primary procedure, or facial liposuction was performed (Fig. 9.12.54). Atrophy is usually most profound and most easily observed around the orbits, upper midface, and infraorbital and perioral areas but can be seen on close inspection of many patients in the forehead, brow, temple, cheek, jawline, chin, and neck. Atrophy is not corrected by traditional “facelift” procedures,

and is usually incompletely or poorly corrected by traditionally used facial implants. These procedures may even exacerbate the problem, and result in an arguably more unnatural, hard, and objectionable appearance. Correction of facial atrophy requires the addition of volume to the face, not a subtraction, lifting, or tightening, and a rethinking of the traditionally taught approach to rejuvenation of the face. Unlike

378

SECTION II

CHAPTER 9.12  • Secondary facelift irregularities and the secondary facelift

problems corrected by a “lift” of the face, correction of atrophy requires the surgeon to employ techniques that “fill” and “sculpt” the face, and to think in three, instead of just two, dimensions (see Fig. 9.12.54). Currently, the most effective and natural correction of facial atrophy is best achieved through the use of fat grafting. Fat grafting, when properly performed, produces soft and natural contours and affords one the opportunity to correct problems traditional surgery cannot (see Fig. 9.12.54). As a practical matter, fat injections are most effectively performed in areas where tissue planes have not been opened. As a result, they are less applicable and less commonly performed concurrently with a facelift in some areas. These areas include the preauricular cheek and the neck. Other areas, however, including the temples, forehead, brows, glabella, radix, orbits, cheeks, midface, “tear troughs”, buccal recess, lips, nasolabial folds, nasal base, stomal angles, geniomandibular grooves, chin, and jawline, lend themselves to concurrent treatment, when indicated.

Eyelid skin deficiencies and eyelid malposition Many patients presenting for secondary facelift have undergone aggressive excision of eyelid skin at their primary procedure and are secondarily troubled functionally by nocturnal lagophthalmos, lid retraction, canthal laxity, scleral show, and dry eye problems, and aesthetically by orbital hollowing, change in eye shape, and unnatural ocular appearance. (These problems and irregularities and their treatment are discussed in Chapter 13.)

Over-reliance on laser resurfacing Motivated by largely unscientific claims made by laser manufacturers and seductive, but deceptive, early postoperative photographs of patients shown at meetings and included in commercial advertisements, many plastic surgeons and physicians in other specialties embraced laser resurfacing as a substitute for traditional surgical maneuvers in which ptotic deep-layer tissue was repositioned, redundant tissue excised, and lost facial volume was replaced. Indeed, laser resurfacing was often referred to as a “laser facelift” and numerous claims have been made regarding the laser’s ability to incite skin contraction and “tighten” the facial skin. Although laser resurfacing has proven to have clinical utility in smoothing the skin surface, experience has shown that it does not produce the skin tightening once hoped for. In addition, “wrinkle relapse” is common once patients are fully healed and all traces of swelling are gone. Many patients who have undergone laser resurfacing are now presenting for formal facelifts, disappointed in the lack of “lift” gained from their “laser facelift” and concerned over associated secondary irregularities including hypopigmentation, skin sensitivity, abnormal skin texture, lower lid malposition, and an unnatural “smooth face–wrinkled neck” appearance. Radiofrequency and ultrasound-based technologies suffer the additional drawback that they often result in loss of subcutaneous facial fat and damage to skin microcirculation and microlymphatics. Artistically, the fundamental problem with laser resurfacing (or resurfacing performed by other means) is that its primary effect is to smooth skin, and that it does little, if anything,

to reposition ptotic tissue, to reduce skin redundancy, or to correct facial atrophy. Its misapplication to the patient with ptotic deep-layer tissue and redundant skin typically produces an unnatural, incongruent and “smooth skin-sagging face” appearance. Because this combination appears rarely in nature, the patient is left with a tell-tale “surgical” appearance, often easily recognized by even the untrained eye at a considerable distance. In all but the unusual instance, optimizing facial shape and contour takes artistic precedent over smoothing skin. Indeed, a few surface wrinkles will be overlooked by the eye if youthful facial contour is successfully re-established. A more balanced, harmonious and natural appearance will result, and a less “surgical look” will be present. If the patient presenting for secondary facelift has had good repositioning of ptotic tissue at the primary procedure, and little recurrent ptosis is present, skin resurfacing may be worthwhile and appropriate if residual surface textural wrinkling is present. It must be kept in mind, however, that skin resurfacing will do little to permanently reduce wrinkles that are the product of muscle hyperfunction. These include glabellar frown lines, transverse forehead wrinkles, and lateral periorbital lines. Correction of these “expression lines” will require reduction or resection of hyperactive muscles, repositioning of ptotic tissue, or removal of excess tissue stimulating muscle contraction. Although skin resurfacing will temporarily disguise forehead wrinkles by inciting swelling, it is not a substitute for formal foreheadplasty when indicated. Patients who have undergone prior skin resurfacing can present a number of technical problems at the time of secondary facelift as well. The most vexing of these is the inevitable shift of the line of demarcation between resurfaced and unresurfaced areas below the jawline onto the lower face. This “demarcation line shift” usually requires that a second resurfacing procedure be performed to lower this line back into the shadow of the submental area. Although many surgeons now assert concomitant facelift and laser skin resurfacing to be safe (and cheek skin has arguably been “delayed” at the primary procedure), this combination of procedures still carries significant risk in any area in which skin has been undermined. For this reason, it is preferable to defer resurfacing until 4–6 months or more after the facelift procedure, at which time the face can be safely, comprehensively, and aggressively treated, if necessary. The patient who has had a previous combined facelift and skin resurfacing procedure is often an excellent candidate for secondary facelift. This is because the previous surgeon, fearing complications might result from aggressive surgical undermining or skin or relying heavily on resurfacing to make up for shortcomings of their chosen surgical procedure, has been conservative in their surgical approach and timid during dissection. Indeed, examination usually shows that these patients have residual uncorrected or undercorrected deep-layer ptosis and residual forehead irregularities. A new generation of “skin shrinking” technologies have now been introduced that have been widely embraced and said by some to eventually supplant the traditional facelift. In their current form this certainly is not the case, and for the time being at least, facelifts and secondary facelifts offer improvements unobtainable by these or other means.

Technical considerations in secondary facelift

Patient considerations Many patients requesting secondary or tertiary facelifts are chronologically elderly, but deceptively young in appearance. A careful medical history must be taken because they often have concomitant medical problems consistent for their age group that were not present at the time of their primary procedure. It is also wise to obtain independent medical clearance prior to surgery as this group of patients will commonly minimize existing problems and deny important symptoms of age-related illness. A careful documentation of all existing secondary problems and deformities must also be made in patients undergoing secondary facelift procedures, including, but not limited to, facial muscle weakness, dyskinesias, numbness, paresthesias, eye dryness, visual disturbances, and chronic pain. These problems do not show up in a photograph, and are not always recognized or volunteered by the patient. Photographs of the patient emoting (smiling, frowning, puckering their lips, tensing their platysma, etc.) must be taken before surgery. If these problems are not documented preoperatively, they will inevitably be attributed to be the result of the secondary procedure.

Technical considerations in secondary facelift The secondary or tertiary facelift will often present technical problems and certain risks not seen in primary procedures. In addition, the general approach to secondary procedures is somewhat different depending upon the type of secondary irregularities and residual problems present. It should also be recognized that secondary facelifts are often time-consuming and technically demanding when compared with primary procedures and are likely to test the patience and composure of most surgeons. It is highly recommended that additional operating room time be allotted for the procedure and that the services of an anesthesiologist or competent nurse anesthetist be enlisted. This is particularly true if the procedure is being performed on a patient who is overly apprehensive or has a history of anesthetic difficulties, hypertension, or other medical problems. Although less bleeding is often encountered in elevation of the skin flap in secondary surgery and the skin flap is arguably “delayed” and more durable, skin flap undermining is often more taxing because of subcutaneous scar and adhesions resulting from the previous dissection. Scissors-pushing techniques should not be used and it is wise that dissection be made carefully, under direct vision, in good light, with an experienced assistant. Most patients undergoing secondary facelift procedures have at least some areas of their face or neck that have been aggressively stripped of fat and these areas must be carefully dissected when skin flaps are elevated. Not uncommonly, dermomuscular adhesions are present in the upper lateral neck over the superficial-most portion of the great auricular nerve. It is also very common for the anterior neck and submental regions to have been aggressively defatted at the primary procedure by aggressive small cannula liposuction, ultrasonic lipectomy, excessive direct excision, or by other means.

379

In such patients, it is very easy to perforate (“button-hole”) the platysma or damage it while attempting to re-elevate the cervicosubmental skin. It is also easy to inadvertently enter a subplatysmal plane while attempting to elevate the cervicosubmental skin, and this can result in nerve injury and platysma dysfunction, and can render the SMAS or platysma useless in the planned repair. For these reasons, all skin flap dissection must be made with great care in secondary procedures and it is not advisable to use aggressively patterned “super-sharp” or serrated scissors for flap elevation. These scissors tend to pick up and cut delicate structures and are more likely to result in the inadvertent fenestration of the platysma, or unintended excision of subdermal fat. Subcutaneous fat is generally precious in the secondary facelift patient and as much of it as possible should be preserved until the surgeon is certain that its sacrifice is aesthetically appropriate and of benefit to the patient. Care must be taken, however, not to injure the SMAS and platysma, while elevating skin flaps as these will typically serve as the workhorse tissue layers in restoring more youthful facial contours. The margin for error can thus be small, and often critically so. The careful infiltration of dilute local anesthetic solutions is often helpful in these situations in pre-establishing the proper plane by hydrodissection. This beneficial effect will be lost if infiltration is made carelessly or in the wrong plane. A satisfactory and uncomplicated SMAS dissection can often be performed in secondary procedures particularly if the SMAS was dissected timidly or not at all at the primary procedure, or if it was elevated in a skilled manner by the previous surgeon. On other occasions however, the SMAS will be found to have been damaged or compromised by previous plication, filler injections, or suture lifts, making formal flap elevation difficult and putting facial nerve branches at risk. Raising the flap with cautery on a low setting as opposed to scissors can be helpful in such instances to differentiate retaining ligaments from nerve branches. Ultimately, however, no amount of aesthetic improvement is worth a facial nerve injury and dissection should not be continued if overly difficult and motor nerve branches are put at unacceptable risk. In such cases, a formal SMAS flap elevation may have to be abandoned and replaced by an arguably safer alternative SMAS treatment such as SMAS plication, or SMAS stacking. Unlike a primary facelift procedure where SMAS flap elevation plays a key role in the rejuvenation of the patient’s face, a less aggressive approach to the SMAS layer can often be taken in the secondary and tertiary surgery patients in whom SMAS surgery was skillfully performed at the primary procedure. In these patients it is often procedures on the neck and forehead that typically went untreated or were undertreated at the primary procedure – and the replenishment of lost facial volume by fat grafting – that are the most important and have the highest aesthetic payoff. In these situations it is arguably prudent for the surgeon to shift focus away from the “facelift” (cheeks and jowl) and aggressive management of the SMAS that one might typically perform in a primary procedure, and to consider less aggressive treatment such as SMAS plication, or SMAS stacking (Fig. 9.12.55). Indeed, this is a common strategy used by both authors in our treatment of secondary and tertiary facelift patients. SMASectomy, while a proven and useful technique in primary procedures in patients with full faces, is typically less appropriate in the secondary and tertiary facelift patients

380

SECTION II

CHAPTER 9.12  • Secondary facelift irregularities and the secondary facelift

SMAS undermined superior

tell-tale signs that a facelift has been performed. Some form of SMAS treatment is almost always required. Not all irregularities resulting from the primary procedure can necessarily be corrected and the patient needs to have their expectations realistically set in this regard. In addition, the secondary facelift patient will often need ancillary procedures on the neck, forehead, perioral area, and fat grafting in addition to secondary facelift surgery if maximum improvement and the best aesthetic outcome is to be obtained (see Case Studies 9.12.1–9.12.5).

Conclusion

SMAS left for fullness

SMAS stacked for lateral facial fullness

SMAS undermined inferior

Figure 9.12.55  SMAS stacking is a useful technique in secondary and tertiary facelift procedures where the SMAS layer may have been compromised during the prior procedure for use as a formal flap. Unlike lateral SMASectomy in which SMAS is excised obliquely over the lateral face and the cut edges approximated and facial volume is reduced and lateral facial flattening can occur, SMAS stacking provides SMAS support to the face without volume reduction or lateral facial flattening. Main illustration: The SMAS is incised in an oblique ellipse in a subzygomatic location as shown but the outlined segment of SMAS is not excised and left in situ. The superior and inferior wound edges are undermined in a subSMAS plane, and then the undermined edges advanced and sutured over the SMAS segment. Insets: Crosssection view showing SMAS segment left to preservation of facial fullness, and cut edges “stacked” over it to enhance lateral facial volume. (Redrawn from Rohrich RJ. The individualized component face lift: developing a systematic approach to facial rejuvenation. Plast Reconstr Surg. 2009;123:1050–1063.)

that are more often volume-depleted – especially in the lateral face. SMAS treatment that enhances volume in the lateral face, rather than removing it, is usually best in the secondary or tertiary facelift patient. While it is typically true that the secondary and tertiary facelift patient requires less focus on the face (cheeks and jowls) and less aggressive SMAS surgery as outlined above, the SMAS layer cannot be ignored in most cases and still plays a very important role in the overall procedure. SMAS treatment of some sort is almost always required to get tension off the skin, to recruit skin for correction of earlobe and tragal irregularities (or to prevent them from occurring), and to move existing scars to more concealed locations. It is unrealistic and will be a practical and artistic failure to proceed otherwise, and to simply undermine and lift a skin flap in these patients. The latter is a formula for compounding a tight, “face-lifted appearance”, and creating or compounding existing other

The increased number of patients seeking early facelifts at a younger age, coupled with the continued good health of an older group of patients who have already undergone one or more procedures, has resulted in an increase in requests for secondary facelift procedures. Although many aspects of planning and performing secondary surgery are similar to those of the primary procedure, additional considerations must be taken into account in the evaluation and treatment of the patient presenting for secondary facelift as one must identify and treat not only new problems that are the product of age, but those that have resulted from the prior procedure as well. Often, it is these secondary deformities that present the biggest challenge to the surgeon in terms of creativity, planning, preparation, and technique. The secondary facelift patient is also usually short on skin and will typically present with problems of deep-layer origin. Additional excision of large amounts of skin is likely to be counterproductive, result in unnatural appearances, and compound existing deformities. Many of the problems seen in the secondary facelift patient are worth careful consideration, even for the surgeon who performs only the occasional secondary procedure, as they exist as compelling reminders of mistakes to avoid in the planning and performance of any primary procedure.

Case studies Case study 9.12.1  Secondary cervicofacial rejuvenation A 62-year-old woman is seen before and 12 months after secondary facelift and related procedures (Fig. 9.12.56). The primary procedure was performed by an unknown surgeon. The secondary procedure consisted of a high SMAS facelift, necklift, small incision forehead lift, facial fat injections, TCA lower eyelid peel, scar revisions, perioral resurfacing, and earlobe repair. The neck procedures included excision of residual subplatysmal fat, submandibular gland reduction, superficial digastric myectomy, and anterior platysmaplasty with postauricular transposition flaps. No subcutaneous cervical fat was removed. Fat grafting was performed in the temples, upper and lower orbits, the radix and upper nasal dorsum, the cheeks, midface, nasolabial, stomal angle, perioral, lips, chin, GMG (geniomandibular groove), and jawline areas. A total of 70 cc of fat was placed. (A) Preoperative AP view. The patient can be seen to have had an ostensibly well performed primary facelift but she is

Case studies

A

B

C

D

E

F

G

H

I

J

381

Figure 9.12.56  (A–J) Multiple views of a 62-year-old woman seen before and 12 months after secondary facelift and related procedures.

noted to have residual cheek and jowl ptosis, and poor posture of the perioral tissues. The periocular appearance suggests aggressive upper and lower blepharorplasty had been previously performed. A mild ptosis is present on the right. Marked atrophy can be seen in the temples, orbits, cheeks, oral and perioral, and perimental areas. Facial asymmetry and mild perioral wrinkling are also present. Overall the face has a tired, and aged appearance, despite having undergone a previous facelift.

(B) Postoperative AP view. The patient has a soft, natural, non-surgical appearance. The lateral portion of each eyebrow has been raised and eyebrow position and configuration have been improved creating a more alert and engaged appearance (the uncorrected right ptosis still triggers right frontalis spasm that results in mild asymmetry). The cheek and jowls have been raised and the posture of tissues around the mouth improved. The temples and the upper and lower orbits and atrophy present in the oral, perioral, chin, geniomandibular

382

SECTION II

CHAPTER 9.12  • Secondary facelift irregularities and the secondary facelift

groove, and jawline areas has been nicely improved using fat grafting. The lips have been subtly filled with fat and the lip border enhanced. The combination of fat grafting and perioral resurfacing has produced natural-appearing correction of perioral wrinkling. Overall improved facial symmetry can also be seen. (C) Preoperative smiling view. Smiling reveals mandibular asymmetry and a poor transition from the lower eyelid to the cheek. (D) Postoperative smiling view. The patient appears natural when smiling. The temples and upper and lower orbital areas are distinctly fuller and more healthy and youthful appearing, and the transition from the lower eyelid to the cheek is improved. (E) Preoperative oblique view. The patient has a somewhat sad, forlorn appearance and the orbital area looks sunken and hollow. The lower face lacks strength and aesthetic appeal, and appears elderly. Suboptimal eyebrow position and configuration is evident and residual cheek and jowl ptosis can be seen. Atrophy can be seen in the temples, orbits, upper cheek, oral and perioral, and perimental areas. The chin is poorly integrated with the jawline. The posterior jawline is weak and the lips are thin and have an elderly, retruded appearance. The lower lip appears smaller than the upper lip. (F) Postoperative oblique view. The patient has a soft, natural, non-surgical look and a youthful, aesthetic and healthy appearance. The lateral eyebrow has been raised and the eyebrow position and configuration have been improved. The cheek mass and jowls have been repositioned and the temples and the upper and lower orbits have been filled. An improved transition from the lower eyelids to the cheeks is present. Atrophy present in the oral, perioral, and geniomandibular groove areas has been improved and the posterior jawline has been strengthened with fat grafting. This has resulted in a more aesthetic and youthful-appearing chin that is integrated with a stronger, more photogenic jawline. The lips have been subtly filled and the lip border enhanced, and the entire perioral area can be seen to have been filled and strengthened. A better overall aesthetic balance between facial features is present and the patient has a more attractive and feminine appearance.

groove (“pre-jowl sulcus”) has been filled integrating the chin and the jowl into a strong, aesthetically desirable, continuous line. The posterior jawline has also been strengthened with fat injections adding to the effect. The protruding portion of the enlarged submandibular gland has been reduced, the cervicomental angle improved, and platysma bands corrected. The improved cervicosubmental configuration provides a youthful, fit, decisive, and attractive appearance. (I) Preoperative lateral flexed view. The patient can be seen to have cheek and jowl ptosis, residual cervicosubmental fullness, an indistinct jawline, and a “double chin”. Residual poor neck contour results in an overweight appearance. The lips are flat and the perioral area is retruded resulting in an elderly appearance. An earlobe irregularity is present. (J) Postoperative lateral flexed view. The patient now has fit, athletic look and an attractive, photogenic appearance. A strong mandibular contour is present with the chin and the jowl integrated into a distinct, aesthetically desirable, continuous line. Residual subplatysmal fat and protruding portions of the submandibular glands have been removed, and plasysma laxity corrected. The posterior jawline has also been strengthened with fat grafting adding to the effect. The double chin irregularity has been eliminated. The lips and perioral area project to produce a more aesthetic and youthful appearance. The earlobe irregularity has been corrected.

Case study 9.12.2  Secondary cervicofacial rejuvenation A 58-year-old woman is seen before and 1 year and 8 months after secondary facelift and related procedures (Fig. 9.12.57). The primary procedure was performed by an unknown surgeon.

(G) Preoperative lateral view. The patient can be seen to have a poor transition from the lower eyelid to the cheek, cheek and jowl ptosis, residual cervicosubmental fullness and platysma bands, a large submandibular gland, suboptimal jawline contour, a retracted tragus, and a mild “loving cup” earlobe. Marked atrophy can also be seen in the upper and lower orbits, cheeks, oral and perioral, and perimental (geniomandibular) areas.

The secondary procedure consisted of a high SMAS facelift, necklift, small incision closed forehead lift, upper and lower blepharoplasties with reinsertion of the levator aponeurosis and canthopexy, facial fat grafting (52 cc), perioral resurfacing, scalp scar revisions, and nevus excision. The neck procedures included excision of residual subplatysmal fat, submandibular gland reduction, superficial digastric myectomy, anterior platysmaplasty with postauricular transposition flaps, and full-width platysma myotomy. No subcutaneous cervical fat was removed. Fat grafting was performed in the temples, upper and lower orbits, the upper nasal dorsum, the cheeks, midface, piriform, nasolabial, stomal angle, perioral, lips, chin, GMG (geniomandibular groove), and jawline areas. No resurfacing or other ancillary procedures were performed.

(H) Postoperative lateral view. Improved balance between facial features can be seen and the patient has an attractive, photogenic appearance. Scars are well concealed and the retracted tragus and loving cup earlobe have been corrected. The cheek mass and jowl have been raised resulting in improvement in labiomandibular and nasolabial folds. Atrophy present in the oral and perioral areas has been improved with fat grafting and the lips have been subtly filled and the lip border enhanced creating a more youthful and attractive mouth. The geniomandibular

(A) Preoperative AP view. The patient can be seen to have suboptimal eyebrow position and configuration with overelevation of the medial brow, residual cheek and jowl ptosis, and poor posture of the mouth and perioral tissues. The periocular appearance suggests aggressive upper and lower blepharoplasty had been previously performed. Marked atrophy can be seen in the temples, orbits, cheeks, oral and perioral, and perimental areas. Marked facial asymmetry, mild perioral wrinkling, and bilateral senile ptosis, are also present. Overall, the face has an ill, tired, and aged appearance.

Case studies

A

B

C

D

E

F

G

H

I

J

383

Figure 9.12.57  (A–J) Multiple views of a 58-year-old woman seen before, and 1 year and 8 months after secondary facelift and related procedures.

(B) Postoperative AP view. The patient has a soft, natural, non-surgical appearance. The lateral portion of each eyebrow has been raised and eyebrow position and configuration have been improved, creating a more alert and engaged appearance. The cheek mass and jowls have been raised and the posture of tissues around the mouth improved. The temples and the upper and lower orbits have been filled using fat grafting. A slight undercorrection of upper orbital atrophy

on the left can be seen. Atrophy present in the oral, perioral, chin, geniomandibular groove and upper nasal dorsum areas has been nicely improved using fat grafting as well. The lips have been subtly filled with fat and the lip border enhanced. The combination of fat grafting and perioral resurfacing has produced natural appearing correction of perioral wrinkling. Overall improved facial symmetry can also be seen. The patient’s ptosis has been improved.

384

SECTION II

CHAPTER 9.12  • Secondary facelift irregularities and the secondary facelift

(C) Preoperative smiling view. Smiling reveals mandibular asymmetry and a poor transition from the lower eyelid to the cheek. (D) Postoperative smiling view. The patient appears natural when smiling. The transition from the lower eyelid to the cheek is improved. The chin is integrated with the jawline and the two together form one continuous and desirable aesthetic line. The lips are fuller but the shape of the mouth is unchanged. (E) Preoperative oblique view. The patient has a sad, forlorn appearance and the orbital area appears sunken and hollow. The lower face lacks strength and aesthetic appeal, and appears elderly. Suboptimal eyebrow position and configuration is evident and residual cheek and jowl ptosis can be seen. Atrophy can be seen in the temples, orbits, upper cheek, oral and perioral, and perimental areas. The chin is frail and narrow appearing and is poorly integrated with the jawline. The posterior jawline is weak and the mandible has a diminutive appearance. The lips are thin and have an elderly retruded appearance. (F) Postoperative oblique view. Overall, the patient has a soft, natural, non-surgical look and a youthful, aesthetic, and healthy appearance. The lateral eyebrow has been raised and the eyebrow position and configuration have been improved. The cheek mass and jowls have been repositioned and the temples and the upper and lower orbits have been filled. An improved transition from the lower eyelids to the cheeks is present. Atrophy present in the oral, perioral, chin, and geniomandibular groove areas has been improved and the posterior jawline has been strengthened with fat grafting. This has resulted in a broader more aesthetic and youthful-appearing chin that is integrated with a stronger, more photogenic jawline. The lips have been subtly filled and the lip border enhanced, and the entire perioral area can be seen to have been filled and strengthened. Fat grafting to the upper nasal dorsum has also resulted in a more aesthetic and attractive nasal line. A better overall aesthetic balance between facial features is present and the patient has a more attractive and feminine appearance. (G) Preoperative lateral view. The patient can be seen to have a poor transition from the lower eyelid to the cheek, cheek and jowl ptosis, residual cervicosubmental fullness and platysma bands, a large submandibular gland, suboptimal jawline contour, and a retracted tragus. Marked atrophy can also be seen in the upper and lower orbits, cheeks, oral and perioral, and perimental (geniomandibular) areas. (H) Postoperative lateral view. Overall, the patient has a soft, natural, non-surgical look. Improved balance between facial features can be seen and an attractive, photogenic appearance is evident. Scars are well concealed and the retracted tragus has been corrected. The cheek mass and jowl have been raised resulting in improvement in labiomandibular creases and nasolabial folds. Atrophy present in the oral and perioral areas has been improved with fat grafting and the lips have been subtly filled and the lip border enhanced, creating a more youthful and attractive mouth. The geniomandibular groove (“pre-jowl sulcus”) has been filled integrating the chin and the jowl into a strong, aesthetically desirable, continuous line. The posterior jawline has also been strengthened with fat grafting adding to the effect. The protruding portion of

the enlarged submandibular gland has been reduced, the cervicomental angle improved, and platysma bands corrected. The improved cervicosubmental configuration provides a youthful, fit, decisive, and attractive appearance. (I) Preoperative lateral flexed view. The patient can be seen to have a poor transition from the lower eyelid to the cheek, cheek and jowl ptosis, residual cervicosubmental fullness, an indistinct jawline, and a “double chin”. Residual poor neck contour results in an overweight, indecisive, and unattractive appearance. The lips are flat and the perioral area is retruded resulting in an elderly appearance. (J) Postoperative lateral flexed view. The patient now has a fit, athletic look and an attractive, photogenic appearance. A strong mandibular contour is present with the chin and the jowl integrated into a distinct, aesthetically desirable, continuous line. Residual subplatysmal fat and protruding portions of the submandibular glands have been removed, and platysma laxity corrected. The posterior jawline has also been strengthened with fat injections adding to the effect. The double chin appearance has been eliminated by dissecting subcutaneously in a retrograde fashion onto the chin pad to release the submental retaining ligaments, and blending the fat of the chin and submental regions. The orbits have been filled using fat grafting, and the lips and perioral project to produce a more aesthetic and youthful appearance.

Case study 9.12.3  Secondary cervicofacial rejuvenation A 51-year-old woman is seen before and 1 year and 7 months after secondary facelift and related procedures (Fig. 9.12.58). The primary “short scar” facelift procedure was performed by an unknown surgeon. The secondary procedure consisted of a high SMAS facelift, necklift, small incision forehead lift, facial fat grafting, scar revisions, perioral laser resurfacing, and earlobe repair. The neck procedures included excision of residual subplatysmal fat, submandibular gland reduction, superficial digastric myectomy, and anterior platysmaplasty with postauricular transposition flaps. No subcutaneous cervical fat was removed. Fat grafting was performed in the temples, upper and lower orbits, the radix and upper nasal dorsum, the cheeks, midface, nasolabial, stomal angle, perioral, lips, chin, GMG (geniomandibular groove), and jawline areas. A total of 44 cc of fat was placed. (A) Preoperative AP view. The patient can be seen to have suboptimal eyebrow position, residual cheek and jowl ptosis, and perioral laxity. The upper eyelids appear heavy with little or no pretarsal show. Atrophy can be seen in the temples, tear trough, cheeks, lips, and perimental areas. The chin and jawline are poorly integrated, and a geniomandibular groove can be seen to be present. The face has a bottom-heavy appearance. (B) Postoperative AP view. The patient has a soft, natural, non-surgical appealing appearance. The lateral portion of each eyebrow has been raised and eyebrow position and configuration have been improved, creating a more alert and engaged appearance. The cheek mass and jowls have been raised and an improved, inverted oval shape to the

Case studies

A

B

C

D

E

F

G

H

I

J

385

Figure 9.12.58  (A–J) Multiple well-matched views of a 51-year-old woman seen before and 1 year and 7 months after secondary facelift and related procedures.

face is present. The posture of tissues around the mouth is improved. The temples, tear trough, midface, cheeks and lips have been filled using fat grafting. Atrophy present in the oral, perioral, chin, geniomandibular groove, and jawline areas has been improved as well. (C) Preoperative smiling view. The patient’s face has a heavy, full appearance. (D) Postoperative smiling view. The patient appears natural when smiling. (Note the patient is smiling more softly in the after view.)

(E) Preoperative oblique view. The patient has a tired and worn appearance. The lower face lacks strength and aesthetic appeal. A pixie earlobe is present. Atrophy can be seen in the temples, tear trough, midface, upper cheek, oral and perioral, and perimental areas. The chin is suboptimally integrated with the jawline. The lips are thin and the upper and lower lips appear approximately the same size. (F) Postoperative oblique view. The eyebrow has been raised and the eyebrow position and configuration have been improved. The cheek mass and jowls have been repositioned and a smooth, attractive and more photogenic jawline and

386

SECTION II

CHAPTER 9.12  • Secondary facelift irregularities and the secondary facelift

improved posture of the mouth is present. The “pixie” earlobe has been corrected. Atrophy present in the forehead, temples, cheeks, oral, perioral, and geniomandibular groove areas is improved. This has resulted in a more aesthetic and youthful-appearing chin that is well integrated with the jawline. The lips have been subtly filled and the lip border enhanced. Fat grafting of the forehead, radix, and piroform gives the appearance a rhinoplasty has been performed. (G) Preoperative lateral view. The patient can be seen to have residual cheek and jowl ptosis, cervicosubmental fullness, a large submandibular gland and prominent anterior digastric muscle belly, suboptimal jawline contour, and a mild “pixie” earlobe. (H) Postoperative lateral view. Improved balance between facial features can be seen and the patient has an attractive, photogenic appearance. Scars are well concealed and the “pixie” earlobe has been corrected. The cheek mass and jowl have been raised resulting in improvement in labiomandibular and nasolabial folds. The lips have been subtly filled and the lip border enhanced, creating a more youthful and attractive mouth. The protruding portion of the enlarged submanbicular gland and the anterior belly of the digastric muscle have been reduced and the cervicomental angle improved. Fat grafting of the forehead, radix and piroform gives the appearance a rhinoplasty has been performed. The chin has been subtly enhanced with fat grafts and a chin implant has not been placed. The improved cervicosubmental configuration provides a youthful, fit, decisive, and attractive appearance. (I) Preoperative lateral flexed view. The patient can be seen to have residual cervicosubmental fullness, poorly defined jawline, and a modest “double chin” when looking down. Residual poor neck contour results in an overweight and old appearance. Atrophy can be seen. The “pixie” earlobe irregularity is present. (J) Postoperative lateral flexed view. The patient has a fit, athletic look and an attractive, photogenic appearance. An improved mandibular contour is present, and the earlobe irregularity has been corrected. Protruding portions of the submandibular gland and the anterior belly of the digastric muscle have been reduced and plasysma laxity corrected. The double chin appearance has been eliminated. Fat grafting of the forehead, radix, and piroform gives the appearance a rhinoplasty has been performed. The chin has been subtly enhanced with fat grafts and a chin implant has not been placed. The improved cervicosubmental configuration provides a youthful, fit, decisive, and attractive appearance.

Case study 9.12.4  Secondary cervicofacial rejuvenation A 59-year-old woman is seen before and 12 months after secondary facelift and related procedures (Fig. 9.12.59). The primary procedure was performed by an unknown surgeon. The secondary procedure consisted of a high SMAS facelift, necklift along with secondary forehead lift, upper blepharoplasty, lower eyelid laser resurfacing, facial fat grafting, and earlobe reconfiguration. The neck procedures included

excision of residual subplatysmal fat, submandibular gland reduction, superficial digastric myectomy, and anterior platysmaplasty with postauricular transposition flaps. No subcutaneous cervical fat was removed. Fat grafting was performed in the temples, lower orbits, the cheeks, midface, nasolabial, stomal angle, perioral, lips, chin, GMG (geniomandibular groove), and jawline areas. A total of 48 cc of fat was placed. (A) Preoperative AP view. The patient can be seen to have residual cheek and jowl ptosis, and perioral laxity. Atrophy can be seen in the temples, tear trough, cheeks, lips, and perimental areas. The chin and jawline are poorly integrated, and a geniomandibular groove can be seen to be present. The face has a bottom-heavy appearance. (B) Postoperative AP view. The patient has a soft, natural non-surgical appealing appearance. The cheek mass and jowls have been raised and an improved, inverted oval shape to the face is present. The posture of tissues around the mouth is improved. The temples, tear trough, midface, cheeks and lips have been filled using fat grafting. Atrophy present in the oral, perioral, chin, geniomandibular groove, and jawline areas has been improved as well. (C) Preoperative smiling view. The patient’s face has a heavy, full appearance. (D) Postoperative smiling view. The patient’s face appears lighter and more feminine, and natural when smiling. (E) Preoperative oblique view. The patient has a tired and worn appearance. The lower face lacks strength and aesthetic appeal. Atrophy can be seen in the temples, tear trough, midface, upper cheek, oral and perioral, and perimental areas. The chin is suboptimally integrated with the jawline. The lips are thin. (F) Postoperative oblique view. The cheek mass and jowls have been repositioned and a smooth attractive and more photogenic jawline and improved posture of the mouth is present. Atrophy present in the forehead, temples, cheeks, oral, perioral, and geniomandibular groove areas is improved. This has resulted in a more aesthetic and youthful appearing chin that is well integrated with the jawline. The lips have been subtly filled and the lip border enhanced. (G) Preoperative lateral view. The patient can be seen to have residual cheek and jowl ptosis, cervicosubmental fullness, a large submandibular gland, suboptimal jawline contour, and an irregularity in the submental area. A poorly located prehelical scar, “chopped off” tragus, and irregular lobular-facial junction can be seen. (H) Postoperative lateral view. Improved balance between facial features can be seen and the patient has an attractive, photogenic appearance. Scars are better concealed and the tragal and earlobe irregularities have been improved. The cheek mass and jowl have been raised resulting in improvement in labiomandibular and nasolabial folds. The protruding portion of the enlarged submandibular gland has been reduced and the cervicomental angle improved. The chin has been subtly enhanced with fat grafts and a chin implant has not been placed. The improved cervico-submental configuration provides a youthful, fit, decisive, and attractive appearance. (I) Preoperative lateral flexed view. The patient can be seen to have residual cervico-submental fullness, poorly defined

Case studies

A

B

C

D

E

F

G

H

I

J

387

Figure 9.12.59  (A–J) Multiple well-matched views of a 59-year-old woman seen before and 12 months after secondary facelift and related procedures.

jawline, and a “double chin” when looking down. A poorly located pre-helical scar, “chopped off “ tragus, and irregular lobular-facial junction can be seen. Residual poor neck contour results in an old appearance. (J) Postoperative lateral flexed view. The patient has a fit, athletic look and an attractive, photogenic appearance. Scars are better concealed and the tragal and earlobe irregularities have been improved. An improved mandibular contour is

present. Protruding portions of the submandibular gland have been reduced and plasysma laxity corrected. The double chin appearance has been eliminated. The chin has been subtly enhanced with fat grafts and a chin implant has not been performed. The improved cervico-submental configuration provides a youthful, fit, decisive, and attractive appearance.

388

SECTION II

CHAPTER 9.12  • Secondary facelift irregularities and the secondary facelift

Case study 9.12.5  Secondary cervicofacial rejuvenation A 53-year-old woman is seen before and 11 months after secondary facelift and related procedures (Fig. 9.12.60). The primary procedure consisted of a short scar facelift and was performed by an unknown surgeon. The secondary procedure consisted of a high SMAS facelift, necklift, small incision forehead lift, facial fat grafting, scar

A

B

E

F

I

revisions, perioral laser resurfacing, and earlobe repair. The neck procedures included excision of residual subplatysmal fat, submandibular gland reduction, superficial digastric myectomy, and anterior platysmaplasty with postauricular transposition flaps. No subcutaneous cervical fat was removed. Fat grafting was performed in the temples, upper and lower orbits, the radix and upper nasal dorsum, the cheeks, midface, nasolabial, stomal angle, perioral, lips, chin, GMG (geniomandibular groove), and jawline areas. A total of 42 cc of fat was placed.

C

G

D

H

J

Figure 9.12.60 (A–J) Multiple well-matched views of a 53-year-old woman seen before and 11 months after secondary facelift and related procedures.  

Case studies

(A) Preoperative AP view. The patient can be seen to have suboptimal eyebrow position, residual cheek and jowl ptosis, and perioral laxity. Atrophy can be seen in the temples, tear trough, cheeks, lips, and perimental areas. The chin and jawline are suboptimally integrated, and a geniomandibular groove can be seen to be present. The face has a bottom-heavy appearance. (B) Postoperative AP view. The patient has a soft, natural, non-surgical appealing appearance. The lateral portion of each eyebrow has been raised and eyebrow position and configuration have been improved, creating a more alert and engaged appearance. The cheek mass and jowls have been raised and an improved, inverted oval shape to the face is present. The temples, tear trough, midface, cheeks, and lips have been filled using fat grafting. Atrophy present in the oral, perioral, chin, geniomandibular groove, and jawline areas has been improved as well. (C) Preoperative smiling view. The patient’s face has a heavy, full appearance. (D) Postoperative smiling view. The patient appears natural when smiling. (Note the patient is smiling more softly in the after view.) (E) Preoperative oblique view. The patient has a tired and worn appearance. The lower face lacks optimal contour and aesthetic appeal. A pixie earlobe is present. Atrophy can be seen in the temples, tear trough, midface, upper cheek, oral and perioral, and perimental areas. The chin is suboptimally integrated with the jawline. (F) Postoperative oblique view. The eyebrow has been raised and the eyebrow position and configuration have been improved. The cheek mass and jowls have been repositioned and a smooth attractive and more photogenic jawline and improved posture of the mouth is present. The “pixie” earlobe has been corrected. Atrophy present in the forehead, temples, cheeks, oral, perioral, and geniomandibular groove areas is improved. This has resulted in a more aesthetic and youthful-appearing chin that is well integrated with the jawline. The lips have been subtly filled and the lip border enhanced. Fat grafting of the forehead, radix, and piroform gives the appearance a rhinoplasty has been performed. (G) Preoperative lateral view. The patient can be seen to have residual cheek and jowl ptosis, cervico-submental fullness, a large submandibular gland and prominent anterior digastric muscle belly, suboptimal jawline contour, and a “pixie” earlobe. A wide, poorly located preauricular scar is noted. (H) Postoperative lateral view. Improved balance between facial features can be seen and the patient has an attractive,

Access the reference list online at   Elsevier eBooks+

389

photogenic appearance. Scars are now well concealed and the “pixie” earlobe has been corrected. The cheek mass and jowl have been raised resulting in improvement in labiomandibular and nasolabial folds. The lips have been subtly filled and the lip border enhanced, creating a more youthful and attractive mouth. The protruding portion of the enlarged submanbicular gland and the anterior belly of the digastric muscle has been reduced and the cervicomental angle improved. Fat grafting of the forehead, radix, and piroform gives the appearance a rhinoplasty has been performed. The chin has been subtly enhanced with fat grafts and a chin implant has not been placed. The improved cervico-submental configuration provides a youthful, fit, decisive, and attractive appearance. (I) Preoperative lateral flexed view. The patient can be seen to have residual cervico-submental fullness, poorly defined jawline, and a modest “double chin” when looking down. Residual poor neck contour results in an overweight and older appearance. Atrophy can be seen. The “pixie” earlobe irregularity is present. (J) Postoperative lateral flexed view. The patient has a fit, athletic look and an attractive, photogenic appearance. An improved mandibular contour is present, and the earlobe irregularity has been corrected. Protruding portions of the submandibular gland and the anterior belly of the digastric muscle have been reduced and plasysma laxity corrected. The double chin appearance has been eliminated. Fat grafting of the forehead, radix, and piroform gives the appearance a rhinoplasty has been performed. The chin has been subtly enhanced with fat grafts and a chin implant has not been placed. The improved cervico-submental configuration provides a youthful, fit, decisive, and attractive appearance.

Declaration The concepts, methods, and technique described and contained in this chapter are the opinions of the authors and are not intended to be construed as, or used to define, a standard of care.

Acknowledgment All figures, photographs, illustrations, text, and descriptions of concepts, methods, and technique included in this chapter are courtesy of Timothy Marten and are used with permission.

References

References 1. Marten TJ. High SMAS facelift: combined single flap lifting of the jaw line, cheek, and midface. Clin Plast Surg. 2008;35(4):569–603. 2. Marten TJ. Facelift: planning and technique. Clin Plast Surg. 1997;24:269. 3. Marten T, Elyassnia D. Lamellar high SMAS face and mid-lift: improved design of the SMAS facelift for better results in the mid-face and infra-orbital region. In: Nahai F, Nahai F, eds. The Art of Aesthetic Plastic Surgery. 3rd ed. New York: Thieme Medical; 2019. 4. Marten TJ. Maintenance facelift: early facelift for younger patients. Facelift: State of the Art. Semin Plast Surg. 2002;16(4):303–304. 5. Marten T, Elyassnia D. Necklift defining anatomic problems and choosing appropriate treatment strategies. Clin Plast Surg. 2018;45(4):455–484. 6. Marten T, Elyassnia D. Necklift. In: Farhadieh R, Bulstrode N, Mehrara BJ, Cugno S, eds. Plastic Surgery: Principles and Practice. Elsevier; 2021. 7. Marten T, Elyassnia D. Short scar necklift: necklift using a submental incision only. Clin Plast Surg. 2018;45(4):585–600. 8. Marten T, Elyassnia D. Management of the platysma in necklift. Clin Plast Surg. 2018;45(4):555–570. 9. Marten TJ. Forehead aesthetics and pre-operative assessment of the foreheadplasty patient. In: Knize DM, ed. The Forehead and Temporal Fossa: Anatomy and Technique. Philadelphia: Lippincott Williams and Wilkins; 2001. 10. Marten T, Elyassnia D. Forehead lift. In: Farhadieh R, ed. Plastic and Reconstructive Surgery. Hoboken, NJ: Wiley; 2015. 11. Marten TJ. Closed, non-endoscopic, small-incision forehead lift. Clin Plast Surg. 2008;35(3):363–378. 12. Marten TJ. Open foreheadplasty. In: Knize DM, ed. The Forehead and Temporal Fossa: Anatomy and Technique. Philadelphia: Lippincott Williams and Wilkins; 2001. 13. Marten TJ. Hairline lowering foreheadplasty. Plast Reconstr Surg. 1999;103:224–236. 14. Sullivan P, Salomon JA, Woo S, et al. The importance of the retaining ligamentous attachments of the fore-head for selective

15. 16.

17. 18. 19. 20. 21. 22. 23. 24. 25. 26.

389.e1

eyebrow reshaping and forehead rejuvenation. Plast Reconstr Surg. 2006;117:95–104. Marten T, Elyassnia D. Facial fat grafting: why, where, how, and how much. Aesthetic Plast Surg. 2018;42(5):1278–1297. Marten T, Elyassnia D. Simultaneous facelift and fat grafting: combined lifting and filling for rejuvenation of the aging face. In: Coleman S, Mazzola R, Pu L, eds. Fat Injection from Filling to Regeneration. 2nd ed. New York: Thieme; 2018. Marten T, Elyassnia D. Simultaneous facelift and fat grafting. In: Connell BF, Sundine MJ, eds. Aesthetic Rejuvenation of the Face and Neck. New York: Thieme; 2016:160–187. Marten T, Elyassnia D. Fat grafting in facial rejuvenation. Clin Plast Surg. 2015;42(2):219–252. Marten T, Elyassnia D. Peri-orbital fat grafting: a new paradigm for rejuvenation of the eyelids. Facial Plast Surg Clin North Am. 2021;29(2): 243–273. Marten T, Elyassnia D. Discussion of Shue et al. “Fat injection: a systemic review of injection volumes by facial subunit”. Aesthet Plast Surg. 2018;42(5):1271–1276. Marten T, Elyassnia D. Secondary necklift. In: Nahai F, ed. The Art of Aesthetic Plastic Surgery. 3rd ed. New York: Thieme Medical; 2019. Rohrich RJ. The individualized component face lift: developing a systematic approach to facial rejuvenation. Plast Reconstr Surg. 2009;123:1050–1063. Marten T, Elyassnia D. Male facelift. Clin Plast Surg. 2022;49:221–256. Marten T, Elyassnia D. Peri-orbital fat grafting: a new paradigm for rejuvenation of the eyelids. In: Massry, MD, eds. Facial Plastic Clinics Holds, 2021. Marten T, Elyassnia D. Secondary Necklift in Aesthetic Plastic Surgery Foad Nahai, MD ed 3rd ed. 2019. Marten T, Elyassnia D. High SMAS facelift: combined single flap lifting of the midface, cheek, and jawline. Facial Plast Surg. 2022;00:1–20.

 

 

SECTION II • Aesthetic Surgery of the Face

9.13 Perioral rejuvenation, including chin and genioplasty Ali Totonchi and Bahman Guyuron

 

Access video lecture content for this chapter online at Elsevier eBooks+

Despite the cardinal role played by perioral aesthetics in facial pulchritude or youthful appearance, minimal attention has been paid in the literature to correcting dysmorphologies of this region. There are two categories of patients who seek aesthetic improvement in the perioral area. In the younger patient, lip augmentation, lip shortening, or lip elongation can be applied singularly to enhance and harmonize the appearance of this area. In the older patient, skin changes (including dynamic and static lines), the tilt of the oral commissures, and lip ptosis all play a major role. Aging also may result in dyschromias. Volume loss and gravity can lead to an exaggerated depth of the nasolabial creases or marionette lines. The lips become thin, losing “crispness” in their white roll and philtral columns, and the surrounding skin loses its subcutaneous fat, allowing accentuation of the fine wrinkles resulting from repetitive orbicularis oris action. Ptosis of the malar fat pads lateral to the nasolabial creases combined with thinning of the skin over the creases draws attention to the aging perioral area, making depth over the nasolabial crease an issue to contend with during treatment.1 Because traditional rhytidectomy techniques often do not sufficiently address the perioral area, patients may be disappointed postoperatively about an imbalance of the face or insufficient improvement. Recognizing the changes that occur with aging in the perioral area and subsequently exercising the options available to rejuvenate the lower face are necessary to providing optimal facial harmony. Here we discuss the patient evaluation process and describe various techniques for aesthetic enhancement of the perioral region for patients of all ages. Chin projection and shape is closely related with face aesthetics in general and particularly with perioral aesthetics. In this chapter we therefore discuss perioral aesthetics along with chin and genioplasty.

Perioral anatomy and aesthetics An understanding of the perioral region’s structural anatomy allows the surgeon to choose the most appropriate and long-lasting treatment, whether that is surgery, soft-tissue fillers, fat grafting, skin resurfacing, or some combination of these techniques. The perioral region is bounded by the nasolabial creases superolaterally, the labiomental crease caudally, and the nasal base cephalically. Anatomical landmarks of this region include the philtrum, philtral columns, philtral dimple, Cupid’s bow, vermilion border, nasolabial crease, and labiomental crease (Fig. 9.13.1).2,3 The lower third of the face is divided again into thirds, with the upper one-third extending from the subnasale to the stomion and the lower two-thirds extending from the stomion to the menton. The oral commissure lies within a vertical plane drawn from the medial limbus of the iris. The lips should meet on repose. A key anatomic feature of the upper lips is the Cupid’s bow complex, formed by two high points of the vermilion joined by a V-shaped depression centrally. The upper lip usually has 75%–80% of the lower lip volume with raised philtral ridges.2 Ideally, in the youthful face, the upper lip projects minimally more anteriorly than the lower lip. The lower lip shows fullness in the central portion. The white roll refers to the raised line of skin that separates the cutaneous and red lip; it is prominent in youth. Aesthetically, 2–3 mm of the upper incisors may show in repose, but the full length of the incisors should show while smiling.4 The muscles of the perioral region are arranged in distinct patterns, and there are various classification systems. Nairn’s classification divides them into three groups based on attachments to the lip. Group I muscles enter the modiolus, which is the area of convergence for the tendinous fibers of muscles entering the lip. Group II muscles enter the upper lip, and Group III muscles enter the lower lip. The orbicularis

Perioral anatomy and aesthetics

Vermilion border

Cupid’s bow

White roll

Figure 9.13.1  This illustration demonstrates a key anatomic landmark, the Cupid’s bow complex, which is formed by two high points of the vermilion border, joined by a V-shaped depression centrally. The lower lip shows fullness in the central portion. The white roll is prominent in youth.

oris, levator anguli oris, depressor anguli oris, risorius, zygomaticus major, incisivus superioris, incisivus inferioris, and buccinator muscles comprise the Group I muscles. Group II muscles enter the upper lip as a flat sheet, and their fibers run at right-angles to the fibers of the orbicularis oris. These muscles include the levator labii superioris, levator labii superioris alaeque nasi, and zygomaticus minor. Group III muscles include the depressor labii inferioris, mentalis, and platysma muscles. As a group, these function opposite to the way the Group II muscles work for the upper lip.3 Sensory innervation of the upper lip comes from the superior labial and superior alveolar nerves, which are divisions of the infraorbital branches of the maxillary (V2) nerve. The mandibular (V3) divisions of the trigeminal nerve give rise to the inferior alveolar nerve, of which the mental nerve is the branch supplying the lower lip and chin. Blood supply is derived from the inferior and superior labial branches of the facial artery. The angular artery (off the distal facial artery) extends along the pyriform aperture and gives off branches.3

391

the oral commissure is lined up horizontally and the occlusal plane is horizontal as well, but the chin is shifted, this asymmetry is considered an isolated chin deformity. However, a tilt on oral commissure or occlusal plane or if the midline of maxilla does not correspond to the midline of mandible, would indicate a mandibular shift or maxillary–mandibular rotation. Again, it is critical to emphasize that while the underlying foundation is positioned abnormally, any surgery that corrects only the asymmetry of the chin will not result in an ideal aesthetic outcome. The life-size photographic facial analysis, coupled with clinical examination, can help to decide the number of millimeters advancement needed to achieve those aesthetic goals. Not only is hard-tissue analysis on cephalograms essential, but also soft-tissue analysis on life-size photographs assists in detailed planning and ensures increased predictability. Small fractions, such as 1.0–2.0 millimeters can make a significant difference in the harmony of the facial structures.5 The chin projection should be viewed on the profile picture for assessment. The most prominent portion of chin is called the pogonion. In an ideal chin projection, a line connecting the upper and lower lip will touch the pogonion, which is called Riedel’s line. An imaginary vertical line connecting the mid-glabella to the midline of the chin is the midline of the face, which divides the chin into two equal parts. To determine any chin deformities, one needs to assess the vertical and horizontal dimensions. The cardinal determinants of chin harmony are its projection symmetry and vertical length. The first step in full-face evaluation is to divide the face into three equal portions, with four horizontal lines on the life-size photograph in frontal view: one passing through the hairline, another passing through lower glabella, the next passing through the subnasale, and the last one passing through the most caudal portion of the chin, which is called the menton. To assess the vertical dimension, the lower third is subdivided using a line passing through the stomion (Fig. 9.13.2) The length between the

Chin aesthetics and analysis Although we are not going to discuss the facial analysis in detail within this chapter, the entire face needs to be analyzed before focusing on the chin. The chin is defined by a graceful transition of the mandibular angles toward the midline. It results in a double light reflection in males and single light reflection in females. Both the examination and photographic analysis are used to evaluate chin deformities. The patient’s entire face should be examined for any aesthetic imbalance. Either a simple chin asymmetry or the mandibular deformity can cause chin asymmetry. Upon examination of the lower face front view, the first part to note is the lips and commissural line-up. Except for facial paralysis, any distortion of commissural line usually indicates skeletal asymmetry. Therefore, genioplasty alone may not be an appropriate treatment. If

Figure 9.13.2  Four imaginary lines passing horizontally through the face. (Modified from Guyuron B. Genioplasty. Boston, MA: Little, Brown and Company; 1990.)

392

SECTION II

CHAPTER 9.13  • Perioral rejuvenation, including chin and genioplasty

menton and the stomion should be twice the distance from the stomion to the subnasale. A vertical line passing through the mid-glabella and the tip of a straight nose determines any chin asymmetry. Projection of the chin is assessed on the profile view. There are several methods to evaluate the chin projection. The most practical one is Riedel’s plane. This line connects the most prominent portion of the upper lip to the most prominent portion of the lower lip and continues caudally. The pogonion touches this line in an ideally balanced chin-to-lip relationship (Fig. 9.13.3). The labiomental groove is probably one of the most underrated features of the lower face. Generally, it is about 4 mm deep in a female and 6 mm deep in a male profile. The shape of the maxillary–mandibular arch is also important. A very wide mandibular arch is the result of a wide mandibular body and would thus necessitate adjustment in chin osteotomy. An overhead view and basilar view help evaluate the nasal and chin line-up and malar projection, especially in patients with minimal asymmetry. No patient should undergo a genioplasty without an intraoral examination. Any disharmony between the upper incisors and the lip indicates an underlying skeleton abnormality. In a relaxed position, 2.0 mm of upper incisor should be visible between the lips. This exposure reaches to the full length of the upper teeth on a full smile. Any excess visible gum above the crowns or inadequate tooth showing indicates abnormality of the underling maxilla or upper lip deficiency, and should be noticed. One of the most important parts of intraoral examination is dental occlusion, which has a role in the surgical planning. Any significant periodental disease should be eradicated completely in the patient undergoing genioplasty. Both the clinical examination and this type of chin analysis make the surgery plan more precise, which results in optimal outcome.

Perioral imperfections A careful examination of the perioral region may disclose one or several flaws. The area should be examined thoroughly to document these deformities. First, although most of the lip atrophy occurs with aging, hypoplastic lips can also be present in young patients. For these patients, the goal is to augment or increase volume. Second, patients could present with a descended stomion or elongated upper lip. Assessment of facial proportions is critical to identifying this imperfection. Third, it is important to make note of prominent radial wrinkling of both lips, which can be particularly noticeable on the upper lip. The physician should differentiate between dynamic lines (which appear only or mostly on animation) and static lines (which are present constantly). Fourth, patients may have a “downturned” or sad appearance to the creases and folds in the oral commissure area. Fifth, the depth of the nasolabial crease is important, and any asymmetry should be noted. With the patient smiling, the amount of maxillary incisor show should also be checked. Again, an optimal amount of incisor show is 2–3 mm. Less tooth show is suboptimal, and more than 3 mm of gingival show can be displeasing. The amount of tooth show changes with age, and an inadequate tooth show should be corrected to rejuvenate the face. Patients with excessive incisor show can be referred to as having a “gummy smile”. These patients expose a broad strip of maxillary gingiva above the teeth when smiling. This exposure could be due to excess maxillary length or may be the result of a short or hypoplastic upper lip. Correction of this exposure involves lip augmentation, maxillary osteotomy with height reduction, or lip lengthening with or without augmentation, depending on the dysmorphology. Another cause of a gummy smile is hyperfunction of the lip elevators, which can be surgically corrected through lip elongation with or without rhinoplasty to correct the anterior nasal spine and depressor septi nasi muscles. Also, delayed passive eruption is a developmental problem of the teeth, which can result in an excess amount of gum covering the dental crown. This is particularly evident in dynamic motion. Gingivectomy and vestibuloplasty can correct this, and these are usually performed by a cosmetic dentist or oral maxillofacial surgeon.6

Chin deformities and procedure selection

Figure 9.13.3  Riedel’s line (red). The dashed line shows the ideal position of the chin. (Modified from Guyuron B. Genioplasty. Boston, MA: Little, Brown and Company; 1990.)

Chin deformities can be classified to seven main categories (Table 9.13.1): (I) macrogenia, which can be horizontal, vertical, or a combination of the two (Figs. 9.13.4–9.13.6); (II) microgenia, which can be horizontal, vertical, or a combination of the two (Figs. 9.13.7–9.13.9); (III) a combination of macrogenia and microgenia in different directions (Figs. 9.13.10 & 9.13.11); (IV) asymmetric chin (Figs. 9.13.12–9.13.14); (V) pseudomacrogenia; (VI) pseudomicrogenia; (VII) witch’s chin deformity Asymmetric chin can be on a horizontal plane (side to side) or it can have a rotational element as well (clockwise or counterclockwise). It can be short or with increased anterior facial height. In pseudomacrogenia, the size of the chin is larger than normal and excess tissue is due to excess soft tissue with the size of the bone seeming to be normal. This condition

Chin deformities and procedure selection

393

Table 9.13.1  Classification of chin deformities I

Macrogenia Horizontal Vertical Combination

II

Microgenia Horizontal Vertical Combination

III

Combined micro- and macrogenia Vertical excess and horizontal deficiency Vertical deficiency and horizontal excess

IV

Asymmetric chin Normal anterior lower facial height Short anterior lower facial height Long anterior lower facial height

V

Pseudomacrogenia

VI

Pseudomicrogenia

VII

Witch’s chin deformity

Figure 9.13.6  Combination horizontal and vertical macrogenia. The dashed line represents the normal chin outline. (Modified from Guyuron B. Genioplasty. Boston, MA: Little, Brown and Company; 1990.)

Figure 9.13.7  Horizontal microgenia. The dashed line represents the normal chin outline. (Modified from Guyuron B. Genioplasty. Boston, MA: Little, Brown and Company; 1990.)

Figure 9.13.4  Horizontal microgenia. The dashed line represents the normal chin outline. (Modified from Guyuron B. Genioplasty. Boston, MA: Little, Brown and Company; 1990.)

Figure 9.13.8  Vertical microgenia. The dashed line represents the normal chin outline. (Modified from Guyuron B. Genioplasty. Boston, MA: Little, Brown and Company; 1990.)

Figure 9.13.5  Vertical macrogenia. The dashed line represents the normal chin outline. (Modified from Guyuron B. Genioplasty. Boston, MA: Little, Brown and Company; 1990.)

also is seen in the patient who has undergone removal of chin implants. In pseudomicrogenia, patients have long face deformity, causing clockwise rotation of the normal mandible. Witch’s chin deformity is referred to soft-tissue ptosis of the chin, which is usually seen in the patient with a long history of denture use after full dental extraction or purely due to age. In a study by Guyuron et al., in an evaluation of 2879 patients,

Figure 9.13.9  Combination of horizontal and vertical microgenia. The dashed line represents the normal chin outline. (Modified from Guyuron B. Genioplasty. Boston, MA: Little, Brown and Company; 1990.)

394

SECTION II

CHAPTER 9.13  • Perioral rejuvenation, including chin and genioplasty

Figure 9.13.10  Vertical excess and horizontal deficiency. The dashed line represents the normal chin outline. (Modified from Guyuron B. Genioplasty. Boston, MA: Little, Brown and Company; 1990.)

Figure 9.13.11  Horizontal excess and vertical deficiency. The dashed line represents the normal chin outline. (Modified from Guyuron B. Genioplasty. Boston, MA: Little, Brown and Company; 1990.)

Figure 9.13.12  Vertical excess and horizontal deficiency. The dashed line represents the normal chin outline. (Modified from Guyuron B. Genioplasty. Boston, MA: Little, Brown and Company; 1990.)

Figure 9.13.13  Isolated horizontal excess treatment. (Modified from Guyuron B. Genioplasty. Boston, MA: Little, Brown and Company; 1990.)

Figure 9.13.14  Isolated vertical excess treatment. (Modified from Guyuron B. Genioplasty. Boston, MA: Little, Brown and Company; 1990.)

684 patients were noted to have normal occlusion and some type of chin deformity. Among them 24.9% fell into group I, 63.6% group II, 7.9% group III, 0.6% group IV, 0.73 group V, 0.4% group VI, and 1.9% group VII. Usually, patients with macrogenia and asymmetry are not good candidates for alloplastic genioplasty, while osteotomy almost always provides predictable improvement or ideal outcome. Therefore, patients with simple microgenia are potential candidates for the alloplastic genioplasty and among this group the patients with mild to moderate microgenia who are older (above age 50) are better candidates for alloplastic genioplasty, while the rest of the chin deformities can be treated with osseous genioplasty with greater success. In patients with horizontal/vertical or oblique macrogenia (dependent on the deformity), osteotomy is performed by removing a segment of the bone and setting the chin back. Rarely, ostectomy by shaving of the bone using a wide burr can be accomplished (Fig. 9.13.15) for horizontal macrogenia. It should be noted that there is a major difference in soft-tissue response between patients undergoing osteotomy versus ostectomy (Table 9.13.2). The inclination of the osteotomies can be changed to deal with combination of horizontal and vertical excess (Fig. 9.13.16). In dealing with microgenia there are more surgical options available. However, since augmentation genioplasty will be discussed in a different chapter, here we will focus on osteotomy. Sliding horizontal osteotomy, which is performed 4–5 mm below the mental foramen, is shown in Fig. 9.13.26. For a combination of horizontal deficiency and vertical excess, the osteotomy travels posterior and caudal, and by advancing this segment, anterior height is usually decreased. A horizontal step osteotomy is also a possibility, this being more suitable for a wide-angle mandible with steep mandibular plane or a patient who requires significant chin advancement. Two osteotomies are done, and segments are advanced overlapping each other. For severe vertical deficiencies a bone graft can be added between the segments, or if the distances of the two segments is within the osteoplastic jumping distance of 4–5 mm, it can be left without bone grafting. If a patient has vertical deficiency and horizontal excess, rotation of the caudal segment caudally following a horizontal osteotomy can address the issue. As previously discussed, asymmetric chin is best addressed by an osteotomy, if the asymmetry is limited to the chin area. For isolated chin asymmetry with normal height, a segment from the long side can be removed and added to the short side after wedge osteotomy. If the facial height is small after wedge

Lip surgical corrections

395

Figure 9.13.15  Chin reduction with burr. (Modified from Guyuron B. Genioplasty. Boston, MA: Little, Brown and Company; 1990.) A

Table 9.13.2  Soft-tissue response to bone adjustment

Procedure

Response

Osteotomy Retraction Vertical reduction Advancement

0.9 for 1.0 0.8 for 1.0 0.9 for 1.0

Ostectomy Horizontal Vertical

0.25 for 1.0 0.5 for 1.0

Augmentation

0.8 for 1.0 B

Figure 9.13.17  (A) Preoperative markings are shown for a direct lip lift. (B) The immediate postoperative appearance is shown before sutures are placed.

Lip surgical corrections

Figure 9.13.16  Change of the inclination of resected bone. (Modified from Guyuron B. Genioplasty. Boston, MA: Little, Brown and Company; 1990.)

osteotomy, a bone graft can be added to the short side. If the overall facial height is excessive, a wedge can be removed from the long side. Occasionally, asymmetry is due to horizontal displacement, which can be treated by a horizontal osteotomy and repositioning of the segment in the horizontal plane sliding it side to side. Pseudomacrogenia, or soft-tissue excess, is treated by excision of the soft tissue through an elliptical incision in the submental area, including skin and subcutaneous layer without disruption of mentalis muscle. Pseeudomicrogenia patients require orthognathic surgery to correct the mandibular rotation. A witch’s chin deformity can be treated by a combination of tissue excision using an elliptical incision and application of fat graft to the submental mental crease.

After considering the patient’s aesthetic flaws, analyzing the patient’s face with a focus on the perioral area, and discussing the patient’s goals, the surgical options should be outlined according to Algorithm 9.13.1. The patient should be informed about what is surgically or procedurally possible.

Direct lip lift (DLL) In general, this technique is offered to the patient who is older than 50 years, has a long lip with inadequate incisor show, and has hypoplasia with ill-defined vermilion borders.6 Meticulous marking of the skin is critical for this surgery (Fig. 9.13.17). The caudal incision is placed approximately 0.25 mm cephalad to the existing vermilion border to maintain or restore a proper definition to this landmark. With this technique, the lip is infiltrated with lidocaine with 1:100,000 epinephrine. The lip skin is then excised and undermined 1–2 mm. The incision is repaired with 6-0 Monocryl (Ethicon, Inc., Somerville, NJ) and 6-0 fast-absorbing catgut. The repaired incision is then treated with one pass of a CO2 laser to minimize scar visibility. Complications of DLL include conspicuous scarring, asymmetry or limited lip motion as a result of scar contraction, and over- or undercorrection. The outcome of DLL is increased vertical height of the red lip, with

396

SECTION II

CHAPTER 9.13  • Perioral rejuvenation, including chin and genioplasty

Algorithm 9.13.1 LIP HYPOPLASIA or ATROPHY

LINES

STATIC

-without atrophy of lips → laser resurfacing +/- dermabrasion -with atrophy of lips → fat injection

(DYSCHROMIAS and KERATOTIC CHANGES only) - use laser resurfacing +/dermabrasion

Strategies OPTIMAL incisor show

DYNAMIC

-with dyschromias→ laser resurfacing +/- dermabrasion

INADEQUATE incisor show

Strategies -gingival shortening -dermis fat graft -fat injection

Strategies -conservative fat injection -conservative dermis fat graft

-without dyschromias→ fat injection or string graft

Long lip If young, narrow NLA, use ILL If older, optimal NLA, use DLL

EXCESSIVE incisor show

Normal lip length Lip augmentation

Short lip -maxillary lengthening -lip augmentation

ILL= indirect lip lift DLL=direct lip lift NLA= nasolabial angle

A

B

Algorithm for perioral enhancement addressing (A) lines and (B) lip hypoplasia or atrophy.

decreased length of the upper lip and increased incisor show (Fig. 9.13.18).6 One has to exercise caution when combining a lip lift with lip augmentation to avoid overcorrection.

Indirect lip lift (ILL) This technique is suitable for the patient who has a long lip, inadequate incisor show, and a well-defined vermilion border. Ideal patients are generally younger than 50. The ILL technique has the added benefit of allowing the maxillary teeth to re-emerge both at rest and during smiling.6–8 By elevating the central portion of the upper lip and restoring tightness at the base of the nose, in the properly selected patient, this procedure can enhance the lip “pout”. The technique relies on a variation of the double-curvilinear, “buffalo horn”-shaped incision at the nasal base, tapering to end at the nasoalar crease (Fig. 9.13.19A).8 The senior author prefers to stop the incision at the lateral limits of the alar base (Fig. 9.13.19B). For patients who lack a distinct nostril sill, the incision is extended into the nostril floor (Fig. 9.13.19C). About 3–5 mm of skin is excised, depending on the amount of correction desired. There is no undermining of tissue, and the incision is closed in two layers with 6-0 Monocryl and 6-0 fast-absorbing catgut. This procedure can be performed without an incision in the columellar base. The complications of ILL include visible scarring, asymmetry, and wound dehiscence. A patient demonstrating excessive incisor show is depicted in Fig. 9.13.20.

A

Resurfacing Some patients exhibit fine wrinkles, either static or dynamic. The dynamic lines (known as “smoker’s lines” or radial pucker lines) are most prominent on the upper lips and are caused by orbicularis oris action over time. The dynamic lines are difficult to correct and may require release of the fibrous bands with an 18 G needle, addition of a string dermis

B

Figure 9.13.18  (A) This 50-year-old woman presented for treatment of decreased philtral definition and elongation of the upper lip. (B) 14 months months after a direct lip lift, the patient demonstrated successful healing with a barely perceptible scar and shortening of her upper lip.

Lip surgical corrections

397

A

B

C

graft, fat injection, and laser or dermabrasion (Fig. 9.13.21). Fine static wrinkles are most effectively treated with ablative resurfacing techniques utilizing laser, dermabrasion, or deep chemical peels (Fig. 9.13.22).9,10 Coarser static wrinkles can be treated successfully with a combination of dermabrasion and laser.11 Dermabrasion removes the epidermis and upper dermis with a slow-to-medium-speed diamond fraise. Freezing the epidermis with ethylene chloride ensures uniformity in the level of dermabrasion.1,4,11,12 In our practice, the CO2 laser is applied at the following settings: Lumenis UltraPulse laser (Lumenis, Santa Clara, CA) 100 mJ, density of 5, and 60 W with two or three passes made in the perioral region from the nasolabial creases to the menton, with feathering at the mandibular margin; or Sciton Joule device (Sciton, Palo Alto, CA): 5–7 passes of erbium laser with setting of 100 μm of depth and size of 3 mm (Fig. 9.13.23). There is also usually a modest lip lift from laser resurfacing and dermabrasion. Complications of resurfacing procedures include hypopigmentation in patients with higher Fitzpatrick skin types. The hypopigmentation can respond to treatment with topical hydrocortisone and hydroquinone.13 This complication can also be minimized by proper patient selection. Persistent or prolonged erythema of the re-epithelialized skin can occur, but demarcation of laser-treated areas can be prevented or reduced by feathering and proper technique selection. Hypertrophic scarring and contracture are the most serious

Figure 9.13.19  The markings for an indirect lip lift with “buffalo horn”-shaped incisions are illustrated (A) and shown intraoperatively (B). In patients who lack a direct nostril sill, the excision is extended to the nostril floor (C).

complications of this operation. This complication can be treated by injecting a small amount of Kenalog 20–40 mg/mL (Bristol-Myers Squibb, New York, NY). The injections can be repeated every 4–6 weeks until the scar is flattened.1,13

Lip augmentation Patients who demonstrate excessive incisor show in repose, have excess gum show in animation, or have a hypoplastic lip are ideal candidates for lip augmentation.4 It is important to emphasize to the patient that complications can be more common with this procedure than with the average plastic surgery procedure, regardless of which technique is used. Although it is an extremely meticulous and unforgiving procedure, the results are often extremely gratifying (Fig. 9.13.24). An important aspect of lip augmentation is maintaining the “sensuous” feel of the lip. Soft lips have a significant role in intimate expression; therefore, the lips should feel as natural as possible once healing is complete. This is one of the major advantages of injecting autogenous materials.4 If autogenous material is used for augmentation, slight overcorrection for dermal fat grafts and significant overcorrection for fat injection are essential to achieving the intended aesthetic objectives (Fig. 9.13.25).1,10 There may be a protracted recovery time wherein patients’ lips would appear larger than desired. This

398

SECTION II

CHAPTER 9.13  • Perioral rejuvenation, including chin and genioplasty

A

C

B

D

Figure 9.13.20  (A,C) This 37-year-old man presented with excessive incisor show. (B,D) Five years after an indirect lip lift, the amount of incisor show was improved.

A

B

Figure 9.13.21  (A) This patient in her 50 s presented with upper lip shortening. (B) One year after full-face laser treatment with upper lip shortening.

is one of the drawbacks of autogenous injections but is not an issue with alloplastic materials. Furthermore, with autogenous techniques, the patient may require secondary procedures to correct minor imperfections.

Autogenous materials In our practice fat injection is commonly used and over time has replaced core fat graft and SMAS strip grafts.4,10 The fat is injected with a Coleman blunt cannula (Mentor Worldwide LLC, Santa Barbara, CA) into the areas that require enhanced volume.1,11 With fat injections, significant

overcorrection is needed to account for partial absorption (see Fig. 9.13.25). Approximately 1.2–1.5  mL should be injected into the upper lip and 1.5–2 mL into the lower lip. Postoperative complications of lip augmentation with fat graft include asymmetry, undercorrection, and occasionally overcorrection (Figs. 9.13.26–9.13.29).

Nonautogenous injectables Nonautogenous soft-tissue fillers come in many varieties. Hyaluronic acid (HA) fillers have gained significant

Lip surgical corrections

A

A

B

B

Figure 9.13.22  (A) This woman in her 60 s presented for treatment of her perioral region. (B) One year after laser treatment, the patient’s “smoker’s lines” have diminished, along with some of the dynamic creases noted preoperatively. The patient had also undergone a rhytidectomy and submental lipectomy at the time of this photograph.

399

Figure 9.13.24  (A) This 19-year-old woman presented with a hypoplastic upper lip, as well as an imbalance of upper and lower lip volume. (B) One year after lip augmentation with autologous fat grafts.

Figure 9.13.23  A female patient in her 70 s before and 6 months after perioral treatment with erbium laser in the office setting.

400

CHAPTER 9.13  • Perioral rejuvenation, including chin and genioplasty

SECTION II

popularity and replaced older fillers like collagen.9,10 HA is a highly hydrophilic, glycosaminoglycan polymer naturally found in the body. Its hydrophilic nature allows support of tissue volume. Because this material is not species- or tissue-­ specific, there is almost no antigenic response. The size of the molecules varies, which is important to its clinical application. Currently, Restylane (Galderma SA, Lausanne, Switzerland), with its 400-µm particle size, and Juvéderm or Juvéderm Plus (Allergan, Inc., Irvine, CA) are the preferred injectables for the vermilion border or white roll, the wet–dry junction, and the philtral columns of the upper lip. Perlane (Galderma SA,

A

B

Figure 9.13.25  (A) This woman in her 30 s presented with hypoplastic lips and desired augmentation. (B) Early results are shown following dermal grafting for volume enhancement.

A

C

A

C

B

D

Figure 9.13.27  Ostectomy. (Modified from Guyuron B, Erikson E, Persing JA, eds. Plastic Surgery: Indications and Practice. Philadelphia: Saunders/Elsevier; 2009.)

B

D

Figure 9.13.26  (A–C) Ostectomy; (D–J) Sliding osseous genioplasty. (Modified from Guyuron B, Erikson E, Persing JA, eds. Plastic Surgery: Indications and Practice. Philadelphia: Saunders/Elsevier; 2009.)

Conclusions CB

CD

ED

ED

EF

GF

GF

H G

HI

HI

JI

401

J

Figure 9.13.26, cont’d.

Lausanne, Switzerland) is also injected into the submucosa of the lips to restore volume. Complications of soft-tissue fillers can include granulomas, nodules, and cyst formation at the injection site, as well as asymmetry. These side effects can be minimized by massage, which helps to evenly distribute the filler material immediately postinjection. In addition, proper filler selection can eliminate the chances of patients developing nodules within the lips, which can be displeasing and sensitive. Any excess portion of J HA can be dissolved with small injections of hyaluronidase.

Conclusions Dysmorphologies of the perioral area have a variety of anatomical causes. Perioral rejuvenation, lip augmentation, lip rejuvenation, and lip shortening can all yield extremely gratifying results with proper technique and patient selection by restoring or enhancing the attractiveness of this area. Lip rejuvenation and shortening can also lend more uniformity to the rejuvenation achieved through facial rhytidectomy.

F

H

J

402

SECTION II

CHAPTER 9.13  • Perioral rejuvenation, including chin and genioplasty

Figure 9.13.28  Front view and profile of a patient before (left) and after reduction genioplasty with ostectomy (right). (Modified from Guyuron B, Erikson E, Persing JA, eds. Plastic Surgery: Indications and Practice. Philadelphia: Saunders/Elsevier; 2009.)

Conclusions

403

Figure 9.13.29  Front view and profile of a patient with combined horizontal and vertical micogenia before (left) and after osseous genioplasty and submental lipectomy (right). (Modified from Guyuron B, Erikson E, Persing JA, eds. Plastic Surgery: Indications and Practice. Philadelphia: Saunders/ Elsevier; 2009.)

Access the reference list online at   Elsevier eBooks+

References

References 1. Guyuron B. The armamentarium to battle the recalcitrant nasolabial crease. Clin Plast Surg. 1995;22(2):253–264. 2. Perkins SW, Sandel IV HD. Anatomic considerations, analysis, and the aging process of the perioral region. Facial Plast Surg Clin North Am. 2007;15(4):403–407. 3. Calhourn KH. Lip anatomy and function. In: Calhoun KH, Stiernberg CM, eds. Surgery of the Lip. New York: Thieme; 1992:1–10. 4. Guyuron B. Discussion of lip enhancement: surgical alternatives and histologic aspects. Plast Reconstr Surg. 2000;105(3):1184. 5. Guyuron B. Precision rhinolasty. Part 1: the role of the life size photographs and soft tissue cephalometric analysis. Plast Reconstr Surg. 1988;81(4):489–499. 6. Ezquerra F, Berrazueta M, Ruiz-Capillas A, Sainz A. New approach to the gummy smile. Plast Reconstr Surg. 1999;104(4):1143–1150. 7. Austin HW. The lip lift. Plast Reconstr Surg. 1986;77(6):990–994.

403.e1

8. Jeter TS, Nishioka GJ. The lip lift: an alternative corrective procedure for iatrogenic vertical maxillary deficiency: report of a case. J Oral Maxillofac Surg. 1988;46(4):323–325. 9. Perkins NW, Smith SP Jr, Williams III. EF. Perioral rejuvenation: complementary techniques and procedures. Facial Plast Surg Clin North Am. 2007;15(4):423–432. 10. Ali MJ, Ende K, Maas CS. Perioral rejuvenation and lip augmentation. Facial Plast Surg Clin North Am. 2007;15(4):491–500. 11. Guyuron B. Senescence, a multifactorial problem (abstracts: commentary). Arch Facial Plast Surg. 2006;8(5):346–347. 12. Guyuron B, Michelow BJ. Nasolabial crease: a challenge, a solution. Plast Reconstr Surg. 1994;93(3):522–529. 13. Schwartz RJ, Burns AJ, Rohrich RJ, Barton Jr FE, Byrd HS. Long-term assessment of CO2 facial laser resurfacing: aesthetic results and complications. Plast Reconstr Surg. 1999;103(2):592–601. 14. Guerrissi JO. Surgical treatment of the senile upper lip. Plast Reconstr Surg. 2000;106(4):938–940.

 

SECTION II •  Aesthetic Surgery of the Face

9.14 Facial feminization Patrick R. Keller, Matthew Louis, and Devin Coon

Access video and video lecture content for this chapter online at Elsevier eBooks+

Introduction Facial gender confirmation surgery (FGCS), also popularly known as facial feminization surgery (FFS) or facial gender surgery (FGS), is one of the fastest-growing areas in plastic surgery. It is the surgical art of transforming a transgender person’s facial appearance from masculine to feminine or vice versa. More than other gender-affirming surgeries, FGS has the potential to allow patients to “pass” as the opposite sex, making social acceptance in their identified gender easier. FGS is often life-changing for these patients. In contrast to genital and chest surgeries for gender dysphoria (a term now being subsumed by “gender incongruence”), Version 7 of Standards of Care, as described by the World Professional Association for Transgender Health (WPATH), considers FGS as ancillary procedures rather than a medical need.1 Evidence, however, supports the conclusion that FGS procedures can be of equal importance in treating gender dysphoria by improving patient-centered outcomes such as self-esteem, confidence, and ability to incorporate and adapt to their new role in the workplace, society, and family.1–5 In 2015, Sweden, which has been progressive on transgender rights issues, recognized the key role of FGS by declaring that it would be offered within their public healthcare system.6,7 Recently, consensus guidelines from the International Facial Gender Symposium were published in which FGS was deemed medically necessary; recommendations in keeping with this were also made for the upcoming Version 8 of WPATH Standards of Care.8 In the United States, all signs point toward continued coverage and growth of FGS procedures. A topic that deserves mention is facial masculinization surgery (FMS). At this time, FMS constitutes a limited number of FGS cases, likely less than 5%. This may be historically in part because many trans males grew beards on testosterone, which concealed some facial features. While there is currently very little published on FMS, the most commonly performed

surgical procedures include forehead augmentation, thyroid cartilage masculinization, chin and mandibular augmentation, rhinoplasty, and malar augmentation.9–14 Given the recent growth of FFS, it is expected that FMS will only increase over time. Because FFS is currently the predominant aspect of FGS, and little is published on FMS, most of this chapter focuses on considerations for facial feminization. FGS is most easily analyzed in anatomic thirds of the face. Upper third procedures include forehead contouring, orbital contouring, brow lift, hairline-lowering surgery, and hair transplantation. Middle third procedures include feminizing rhinoplasty, malar augmentation, zygomatic osteotomies, and lip lift. Lower third and ancillary procedures include genioplasty, mandibular reduction, and chondrolaryngoplasty. Many core FGS procedures are not wholly novel but have deep roots in aesthetic and reconstructive plastic surgery techniques. However, the unique goals of FGS (viz. transformation of gender appearance) require a different treatment of anatomy and specific alterations in surgical technique. In this chapter we aim to avoid duplicating a discussion of techniques described elsewhere in this textbook and, instead, highlight the important differences between FGS and their analogous predicate procedures.

Anatomy Facial properties that convey gender (i.e., sexually dimorphic features) are either primary (structural), or secondary (non-structural). Structural features are generally not amenable to change via hormonal therapy post-puberty and hence are usually modified surgically. While no one facial region is the most ‘gender-defining’ for all patients universally, limited data suggests that on average the forehead, brow and frontonasoorbital complex are key gender-defining areas.16,17 An overview of key differences between male and female soft tissue and bony craniofacial anatomy is seen in Table 9.14.1 and Fig. 9.14.1. The most important overall difference

Historical perspective

Historical perspective The historical roots of FGS can be traced to Douglas Ousterhout’s anatomic differentiation of female and male forehead skeletal anatomy in 1987. He published a treatment protocol for surgical feminization of the forehead based on analysis of several hundred skulls from the University of the Pacific School of Dentistry in San Francisco.15 Over the next

404.e1

20 years, relatively little focus was given to this area. As FGS is so new, past literature has struggled to systematically differentiate complications and outcomes between individual FGS procedures. Furthermore, current outcome measures are subjective and poorly defined. The lack of a systematic, objective approach to assessment of FGS outcomes makes critical appraisal of surgical techniques difficult. Thus as more providers begin to offer FGS procedures, it is critical that these gaps in FGS scholarly work are addressed.

Diagnosis, indications, pre- and postoperative management

405

Table 9.14.1  Key facial gender differences

Zone

Male feature

Female feature

Upper third of face and scalp

Supraorbital ridge hypertrophy, acute nasofrontal angle Increased frontal sinus prominence

Gradual curve of the frontal bone, obtuse nasofrontal angle

Lower-seated eyebrows, no significant arching

Higher eyebrows, arched toward the lateral brow

M-shaped hairline, male pattern baldness, temporal recession

Full hairline that is rounded or ovoid

Wider bizygomatic distance, greater malar bone volume Superior and lateral point of malar eminence

Increased malar fat, rounder cheeks with smooth subunit transition

Higher radix (at the upper lid crease)

Lower radix (just above the pupil)

Straight dorsal aesthetic lines

Curved dorsal aesthetic lines

Wider nasal width

Narrower nasal width

Increased nasal projection (34 mm)

Less projection (30 mm)

Less cephalic tip rotation

Greater cephalic tip rotation

Acute nasolabial angle (95–100°)

Wider nasolabial angle (100–110°)

Broader alar base

Narrower alar base

Longer upper lip

Shorter upper lip (by 4 mm)

Square jaw, greater bony volume

Trapezoidal jaw, less bony volume

Boxier, prominent, larger chin

Softer chin, narrow and tapering

More acute mandibular angle

Less acute mandibular angle

Prominent laryngeal prominence and superior thyroid horns

No laryngeal prominence

Middle third of face

Lower third of face and neck

is larger size of the male craniomaxillofacial skeletal and soft tissue envelope.18 Key features of the male upper third include frontal bossing, increased prominence of the supraorbital ridges, eyebrows that sit lower on the forehead and lack significant arching, and an M-shaped hairline with varying degrees of male pattern baldness and temporal recession. Key features of the female upper third include a more obtuse nasofrontal angle (145° in women, 129° in men), a more gradual curve of the frontal bone from supraorbital rim to the hairline, arched eyebrows, and a hairline that is round or ovoid in shape.15,19–22 Important male middle third features include a wider bizygomatic distance and greater zygomatic volume. Key female middle third traits include a greater concentration of malar fat which yields prominent, round feminine cheeks with a point of maximum projection inferomedial to that of the male. Female nasal characteristics include a slightly lower radix located just above the pupil (versus at the upper lid crease for men), narrower nasal width, curved dorsal aesthetic lines, less projection (30 mm female versus 34 mm male), greater cephalic tip rotation, wider nasolabial angle (100–110° female versus 95–100° male), narrower alar base (by 4 mm) and a shorter upper lip (again by 4 mm).1,19,20,23 Within the lower third, males generally have a squarer jaw and more acute gonial angle whereas females generally have a more trapezoidal jaw shape. The chin follows suit in that softer features and a narrow tapering are more feminine while a masculine chin is square and more prominent.24 Finally, the laryngeal prominence (Adam’s apple) is a

testosterone-sensitive cartilaginous structure that enlarges in size during puberty and does not respond to introduction of gender-affirming hormones.

Diagnosis, indications, pre- and postoperative management Patient selection criteria It is known that transgender people are an underserved population facing significant discrimination. They suffer from higher rates of socioeconomic problems compared with the general population, including homelessness, employment discrimination, underinsurance and are more likely to be the victims of violent crime.25 It is critical to evaluate patient psychosocial health before embarking on FGS, and to ensure they will be safe at home during recovery. The surgical team should ensure they have adequate mental health support and that they understand whether insurance will be covering the procedures or not.20 We typically prefer preoperative surgical readiness assessment of FGS candidates by a licensed mental health professional comparable to that done before chest surgery. This assessment also helps to elucidate any psychiatric or psychosocial issues that might interfere with the patient’s ability to make an informed decision so they can be optimized prior to surgery. It is additionally helpful in managing patient expectations and in ensuring they have a mental healthcare team for the possibility of postoperative mood changes.8

406

SECTION II

CHAPTER 9.14  • Facial feminization

Figure 9.14.1  Key differences in male versus female facial anatomy. Facial gender surgery alters masculine structures that cannot be changed by hormones.

Hormone therapy Hormonally-directed growth of osseocartilaginous structures during puberty is not medically reversible. For that reason, primary sex characteristics are typically treated with surgery. By contrast, secondary sex characteristics are more amenable to hormone therapy. Important secondary facial sex characteristics that are modified with exogenous female hormone therapy include hair density and hairline location, facial hair, skin texture, and the distribution and volume of facial fat.1 Ideally

hormones are started at least 12 months prior to performing FGS so that the final soft tissue envelope is stable.1,26,27 Hair removal is often performed during this period as well.

Timeline for FGS If the patient is pursuing chest and genital surgery, the relative timing of these respective operations is mainly dependent on patient preference. Regarding timing of FGS-specific

Outcomes, complications and future directions

407

procedures, each patient must be approached individually and with careful consideration of what facial regions are indicated for surgery. Skeletal contouring (forehead, mandible, zygoma, major rhinoplasty) is done before any soft tissue or skin tightening work that may be necessary (e.g., lip lift, face/neck lift, midface lift, blepharoplasty, fat grafting) to (1) allow for resolution of postsurgical inflammation and edema, and (2) allow readaptation of soft tissue to the new bone surface and associated scar contraction (which may lead to soft tissue tightening).1 We routinely obtain clinical photos and preoperative computed tomography (CT) scans if any bony work is being considered. A standard maxillofacial CT scan including the forehead is typically acquired unless natural head position is necessary in which case cone-beam CT is used. We also obtain 3D surface scans on all patients (VECTRA H1 3D Imaging System; Canfield Scientific, Parsippany-Troy Hills, NJ). With the exception of certain conditions (e.g., insurance issues), we routinely utilize virtual surgical planning (VSP) and CAD/CAM to plan bony work. This is discussed in further detail below.

Two studies in particular highlight the positive impact of FGS on quality of life. Ainsworth et al. created an FGS-specific PCO survey and demonstrated that FGS is directly correlated with improved physical and mental quality of life and social functioning.3 Their FGS PCO survey was a patient-reported Likert-scale type instrument (scored 0 to 100) that quantified self-image and social aspects of gender-related facial appearance (examples of questions include “My friends and loved ones perceive my face as feminine” and “In public I am confident my facial appearance is perceived as feminine”). The average score of patients who received FGS was 76, whereas patients who did not received FGS scored 44 (highly statistically significant). Morrison et al.30 conducted a prospective cohort study of 66 consecutive patients using the same instrument developed by Ainsworth et al. They too found that mean facial feminization outcome score (scored 0–100) improved significantly from preoperative (47 out of 100) to both shortterm (6 months, 81 out of 100) postoperative measurements.

General postoperative management

Medical necessity of FGS

Most patients experience significant facial edema after FGS, most notably in the periorbital region, nose, and lower jaw. Compression therapy is used for 2–3 weeks postoperatively after lower jaw surgery to aid in soft tissue re-adherence. The first week is spent without any exertion, followed by 2–4 weeks of minimal exertion. After this, the patient can resume their normal daily routine and proceed with very light physical exercise. Moderate physical exercise is resumed 3–6 months after surgery. Lastly, a mental health counselor should be available at all times to provide guidance and support in the postoperative period; mood changes are common.1

As discussed, FGS has a clear, well-defined positive impact on the lives of transgender patients. Nevertheless, FGS coverage is frequently denied by insurance companies. Currently, most insurance companies consider FGS as aesthetic surgery, in large part because of lack of clear guidelines in the WPATH SOC7. Current wording in SOC7 indicates that genital surgery and chest masculinization are medically necessary; by contrast, FGS is included under “various procedures” for which medical necessity is not clear. Over the last 5 years, consensus has formed in the medical community that most FGS procedures are in fact medically necessary.1,3,29–32 A recent paper from a multispecialty international group of experts delineates the rationale for medical necessity of FGS, with official recommendations for SOC8.8 They define medical necessity of FGS procedures as those which treat features that were affected by exposure to testosterone during puberty (viz., sexually dimorphic features of the face). One challenging area is distinguishing between aesthetic and reconstructive tightening procedures (e.g., necklift). It is proposed that medically necessary tightening FGS procedures are those which address iatrogenic sequelae of primary feminizing procedures (e.g., to elevate the mandibular soft tissue envelope after bony reduction of the mandible).

Outcomes, complications and future directions Outcomes and complications In experienced hands, FGS surgery has excellent surgical safety given the magnitude of the operations. According to a recent systematic review by Oles et al. of 21 FGS studies, facial numbness and/or paralysis were common but never permanent.16 For more serious complications, the revision operation rate was 4.1% (19 of 467 patients) for persistent infection, unmet expectations, nasal valve reconstruction, and bony non-union. Notably, however, the majority of these series came from a small number of highly specialized centers and complication rates are likely higher in inexperienced or low-volume centers. Complication data specific to individual procedures, where available, are discussed in each relevant section. Outcomes are also generally favorable: studies that examine both objective and patient-centered outcomes (PCOs) after FGS have demonstrated high rates of satisfaction and perceived femininity.3,16,17,28–30 In their systematic review, Oles et al. found that 80% (235 of 295) of patients were satisfied with (or noted an increase in) the femininity of their new face after FGS.16 In that same study, overall satisfaction was noted to be high after FGS, with 97% (534 of 550) being overall satisfied.

Future directions As more FGS is performed, it is worthwhile to note the limits of current knowledge regarding outcomes in FGS. Across most FGS studies, uniformity is lacking in the methods and instruments used to track both objective and patient-centered outcomes (PCOs). The Ainsworth questionnaire is an FGS PCO survey based on a previously validated facial plastic surgery questionnaire.3 While this instrument has been used in several FGS studies, it has not been validated in transgender patients and it is only 10 questions long; a more extensive, validated PCO is needed. Lastly, outcome data are rarely stratified by specific FGS procedure. FGS encompasses more than a dozen distinct surgical procedures, and so reporting non-stratified, general satisfaction after FGS ultimately hinders interpretation and evaluation of results of specific FGS procedures. A GENDER-Q

408

SECTION II

CHAPTER 9.14  • Facial feminization

patient-reported outcome measure survey is currently under development by the group that created BREAST-Q, with the goal to address many of these issues.33 Because surgical complications after FGS are already low, the driver for innovation and progress in FGS should be to produce more aesthetic results with greater predictability (Box 9.14.1). “Success” in FGS must be measured by more critical yet difficult to quantify factors, such as perceived femininity of facial appearance: judged by surgeons, lay people, and by the patient (self-perceived). These data should, when possible, move beyond collecting general data on the overall positive influence of FGS and move toward focusing on the benefits of specific FGS procedures, an obvious area of deficiency in the current literature. Another promising path toward improving outcomes of FGS is development of objective, standardized measurements of clinically important structures and landmarks. Two previous studies report improvement in nasofrontal angle after FGS.34,35 One other reported improvement in certain cephalometric values after FGS.30 Eventually, objective changes such as these can be correlated to PCOs within specific facial areas, procedures or even techniques, thus allowing for evidence-based growth and refinement in FGS surgical technique over time. As an example, cephalometrics can be recorded pre- and postoperatively, and the relationship between changes in these parameters and changes in self-reported patient-perceived femininity can be studied. When coupled with these yet-to-be created objective measures, computer-aided design and manufacturing (CAD, CAM) and VSP will become even more powerful tools in driving objective assessment and advancement of FGS technique and surgical results.36,37

Virtual surgical planning in FGS CAD/CAM and VSP have revolutionized the field of craniofacial surgery because they allow one to  perform possible maneuvers in a preoperative simulated setting, and they decrease operative time while maintaining or improving patient outcomes.38 Because complications rates in FGS are generally low, the value of VSP specifically in FGS originates from a patient-driven need for more aesthetic results with increased predictability. Studies have also shown that consistency in craniofacial surgical results is improved using these tools.39 VSP with 3D analysis enables the surgeon to communicate more clearly with the patient and set realistic expectations, to design cutting jigs and models that facilitate increased operative efficiency, and to obtain more consistent postoperative results with millimeter accuracy.36,37

BOX 9.14.1  Key factors for FFS outcomes • Femininity as judged by: • Surgeon • Lay people • Self • Anatomic landmarks • 3D cephalometrics • Artificial intelligence or machine-learning methods of scoring gender based on photos • Patient-reported gender dysphoria and quality of life

VSP may have benefits even for the skilled FGS surgeon. Cutting guides can yield millimeter precision, and thus liberate the surgeon to plan more extensive bony repositioning while maintaining an acceptably low risk of overtreating. Without precise patient-specific planning, a reductionist approach to FGS may lead to over-resected foreheads and mandibles due to overcorrection of the bony anatomy from a limited intraoperative view. VSP helps the FGS surgeon to avoid this unfortunate outcome. VSP also aids with improved evaluation and study of results. Important landmarks are registered and documented preoperatively, and when compared to postoperative measurements, the changes can be easily quantified. These changes can then be correlated to changes in perceived femininity (by surgeon, lay people, and the patient). This process can drive evidence-based evolution in FGS surgical techniques.

Upper third and hair Frontonasal-orbital contouring, hairline restoration and brow lift Introduction More papers have been published on forehead contouring than on any other individual FGS procedure, probably because supraorbital bossing is seen by many patients and surgeons to be the key masculine facial feature.2,40,41 Contouring of the supraorbital ridge was the first type of FGS to be documented.15 Ousterhout originally described three forehead types, and later expanded to four.12,42,43 Type III was the most common (90%), and described individuals with significant frontal bossing and presence of a frontal sinus. Treatment for group 3 was frontal sinus setback, which was then fixed in place. Types 1 (frontal sinus agenesis) and 2 (frontal bossing at normal level with poor superior projection) were much less common (3–5%), with treatment being bone burring sometimes with polymethylmethacrylate (PMMA) augmentation. Treatment for the rare group 4 (global small forehead and brow) was pan-forehead augmentation with PMMA. Since the 1980s, FGS of the upper third of the face has expanded to treat additional areas, including the upper and lower forehead, the nasofrontal angle, the orbits, the temporal ridges, the hairline, and the eyebrows. Refinements in surgical technique used to feminize the upper third have developed contemporaneously, with the majority of high-volume centers adopting frontal sinus setback techniques (except in cases of frontal sinus agenesis) and near-abandonment of PMMA/ forehead augmentation.42 Capitán et al., for example, cite three reasons for this approach: (1) to maintain anatomic integrity of the anterior frontal region because excessive burring could weaken the anterior table or cause it to resorb; (2) insufficient control with isolated burring over the inner cortex; and (3) the possibility of obtaining poor results at the level of the frontonasal transition.44 An area of innovation in upper third FGS is the development of approaches that integrate simultaneous hairline-redefining procedures.45 Commonly performed hairline-restoring procedures include hairline-lowering surgery (HLS) and simultaneous

Upper third and hair

or delayed hair transplant (SHT, DHT). Hair transplant can be done either with follicular unit transplantation (FUT) or follicular unit extraction (FUE).42

Anatomic considerations A key-defining feature of the male face is frontal bossing. This is accompanied by increased prominence of the supraorbital ridges, eyebrows that sit lower on the forehead and lack significant arching, and an M-shaped hairline with varying degrees of male pattern baldness and a temporal recession.19 In ciswomen, the nasofrontal angle is more obtuse (145° in women versus 129° in men) and is situated just above the pupil (at the upper lid crease for men), the curve of the frontal bone from supraorbital rim to the hairline is gradual, and the eyebrows carry more of an arch.15,20 Long forehead length is not well-tolerated in cis-women. Ideally, the vertical mid-glabella-to-trichion and mid-browto-trichion distances should be 7–9 cm and 5.5–5.8 cm, respectively.21 Hairline shape is undoubtedly the most critical: in cis-women the hairline is rounded or ovoid in shape, whereas in cis-men it assumes an M-shaped pattern.21,22 The hairline of a transwoman with stigmata of androgenic alopecia is unmistakably perceived as a male facial feature.

Preoperative considerations, diagnosis, indications Surgical planning for forehead recontouring includes assessment of the bony thickness and frontal sinus dimensions. Various historical approaches have been used to assess the frontal bones, including plain films, sinus

409

transillumination, and computed tomography scans. The use of CT scans in preoperative planning is routine for most surgeons.19 Most FGS surgeons today utilize frontal sinus osteotomy and setback combined with frontonasal-orbital complex burring. Isolated burring (without setback) carries a high risk of perforation of the anterior table, causing exposed frontal sinus. It also does not allow for proper modification of the nasoglabellar transition.2,42 For these reasons, we, along with most other surgeons at high-volume centers, avoid isolated burring of the forehead except in rare cases when there is no frontal sinus or when only scant reduction is needed. Burring and filling PMMA carries a high risk of creating a non-anatomic glabella and/or long-term infection from contamination by sinus flora and we do not use this technique. Simultaneous brow lift and hairline-redefining procedures such as hair grafting or HLS are common adjuncts, but are highly variable among surgeons and region of practice. The incision and approach to bony contouring of the upper third must consider the patient’s hairline. Examination should note hairline format, height, and density. Capitán et al. developed a hairline classification and treatment algorithm based on their experience (Fig. 9.14.2). The male-to-female transgender patient’s hairline format can be rounded (no recessions), M-shaped (with side temples), or undefined (frontotemporal recessions as a result of alopecia). The hairline height is the distance from the mid-glabella to the trichion and is either normal or high. Hair density is measured by the number of follicular units per square centimeter of scalp. The presence of miniaturization should also be noted. This analysis yields five different hairline types: Type I, normal height with rounded

Figure 9.14.2 Transgender hairline types. Type I, normal height, rounded (22%); Type II, normal height, temporal recessions (43%); Type III, naturally high hairline, rounded (4%); Type IV, high hairline, temporal recessions (21%); Type V, advanced alopecia, undefined hairline (10%). (From Capitán L. et al. Facial feminization surgery: simultaneous hair transplant during forehead reconstruction. Plast Reconstr Surg. 2017; 139: 573–584.)  

410

SECTION II

CHAPTER 9.14  • Facial feminization

format (22% of male-to-female transgender individuals); Type II, normal height with M-shaped temporal recessions (43%); Type III, naturally high hairline with rounded format (4%); Type IV, high hairline (naturally or from alopecia) with M-shaped temporal recessions (21%); and Type V, advanced alopecia with undefined hairline (10%).45 The frontal hairline in a transwoman patient should be stable by the time of FGS. Ideally, the patient will have been on hormone therapy for at least a year prior to surgery. If orchiectomy has not been performed, spironolactone is typically used as an anti-androgen. Finasteride or dutasteride may offer additional anti-androgenic alopecia benefit but this has not been well studied. Hair transplantation (HT) is timeconsuming, and SHT will add multiple hours to an already lengthy surgery. When we do HT, we opt for FUT, which involves the resection of a portion of the scalp about 10–15-mm wide, sectioning the strip, and extracting each follicular unit (see Chapter 24). This requires access to a dedicated team that prepares each mini-graft (3–4 hairs) or micrograft (1–2 hairs).42 In many countries, it is not financially realistic to do hair transplant as an inpatient under general anesthesia after a lengthy frontal sinus setback. We harvest the donor strip at the end of the forehead feminization, place the strip in a sterile container with HyperThermosol (100 cc; BioLife Solutions, Inc., Bothell, WA, US) and liquid ATP (1 cc) mix, put the container on ice, and have it transported to the hair transplant surgeon’s office. The container is kept on ice and can be stored overnight in a typical refrigerator. The next morning the patient is taken to the hair transplant surgeon’s procedure room to have grafting done under local anesthesia. Treatment of the male-to-female transgender patient’s hairline is anatomy dependent. Type I is ideal and hairlinerestoring procedures are not indicated, while Type V requires HT. Beyond that, centers diverge widely in their relative thresholds for use of a coronal approach with HT versus a pretrichial approach with hairline-lowering. Some suggest that male and female forehead lengths are actually identical and thus hairline lowering would be addressing the wrong issue. However, this fails to consider the otherwise clinically irrelevant distinction between Norwood 1 and 2 hairlines. A Norwood 1 patient will have a hairline comparable to a female, which should not be lowered. The vast majority of FFS patients, however, will present at Norwood 2 or greater where some degree of frontal recession has occurred, even without temporal recession, making hairline lowering reasonable. Patient preference is also essential: those who wear their hair back may prefer to avoid hairline incisions, while those who want the greatest possible hairline advancement will typically prefer hairline lowering during FGS followed by future HT. Initially our preference was predominantly for a coronal approach with immediate or delayed HT due to concerns about scarring and limited advancement potential in the presence of the mild–moderate temporal recession seen in most patients. Over subsequent years of experience, we found relatively few patients were able to afford HT so this was a theoretical ideal rarely being achieved. As a result, we developed a technique extending the pretrichial incision back into the temporal scalp, elevating temporal scalp flaps laterally and advancing them up with

cortical tunnel bone anchoring of the flap to close the “M” of temporal recession. This has allowed consistent frontal flap advancement of 1.5–2.5 cm even in the presence of recession with relatively little tension and thus producing favorable scars. We preoperatively counsel patients that a wide or unacceptable hairline scar could be corrected by HT at the hairline but no patients have felt this to be necessary. About one-quarter of patients present with no frontal recession or prefer to avoid the drawbacks of the pretrichial approach.

Surgical techniques, treatments Approach Two general approaches to the forehead exist: an anterior coronal incision (1–2 cm posterior to the central attachment of the upper pole of the ear) or a pretrichial hairline incision beveled to be trichophytic.19 Scalp advancement and forehead skin resection will decrease the length of the forehead, which is generally desirable in FGS. Capitán et al. describe a third option, the temporoparietooccipital (“posterior coronal”) approach, specifically for difficult type V hairlines. A benefit of coronal approaches (anterior or posterior) is that a donor strip can be excised for use in SHT, provided that the hair in that area is of adequate quality.45 Other techniques have been described, and there is ongoing debate in the literature over preferred incision placement (Fig. 9.14.3; Video 9.14.1 ).21,40,42,45–47 Some avoid creating the hairline with grafts because of a perceived “weeds before the forest” appearance. Once the hairline is established with grafting, then future HLS is relatively contraindicated; the hair density is often too thin to conceal a pretrichial incision. HLS, by contrast, can be serially re-advanced and even combined with hair grafting during a second or third stage (e.g., targeted grafting to the temples and surgical scars).12,21 We have evolved toward preferring a pretrichial hairline approach in about three-quarters of patients.

Figure 9.14.3  Markings for hairline-lowering surgery.

Upper third and hair

Frontal sinus setback and burring Our approach to the forehead has been previously described.42 The scalp is first infiltrated with standard tumescent fluid containing lidocaine and epinephrine. This improves hemostasis and facilitates hydrodissection. A strip of scalp or forehead skin can be excised as indicated for SHT or HLS. Trichophytic incisions should be used in hair-bearing areas, wherein the knife is beveled at the skin to an angle of 45°. The incision is carried through galea and the subgaleal plane is entered. Dissection is carried forward to the radix in the midline and to the superior and lateral orbital rims; this allows for burring and ostectomy of those regions. A rectangular pericranial flap centered over the frontal bone with its lateral borders extending to the frontozygomatic suture is marked out and elevated. It is critical to identify and protect the supraorbital bundles. If a true supraorbital foramen is encountered, then it must be osteotomized and the nerve liberated, such that it elevates with the scalp flap. In rare cases, the bundle exits the bone more than a few millimeters above the superior orbital rim. In these cases the extensive osteotomies required are likely more morbid than simply transecting and later repairing the nerve. Once exposure is obtained, planned osteotomies of the anterior table of the frontal sinus are marked. Osteotomies are often achieved with a piezoelectric saw (Synthes, Inc., Satelec, West Chester, PA, US), which is atraumatic to soft tissue and has a very narrow saw kerf. An osteotome can be used to complete osteotomies and free up any attachments of the bone flap to the sinus or septum. The anterior surface of the bone flap is slowly burred to reduce its thickness. The thinner the residual bone flap, the higher the likelihood of resorption or non-union. The trabeculae of the sinuses can be burred as well to facilitate adequate inferoposterior inset of the bone flap. We remove the mucosa off the bone flap to avoid mucosal seeding but do not disturb intact mucosa of the sinus. If a dural tear occurs during the setback, it should be repaired with Nurolon suture and fibrin glue or dural sealant. Various methods of designing the bone flap and repositioning it have been described. The most common is what we have termed the “set-in” technique where the anterior table is osteotomized and the residual frontal bone burred so that the bone flap can be set back into the sinus itself. This is conceptually simple and fast but produces step-offs at the edges of the osteotomy and the bone flap shape is problematic because it is often very asymmetric or the flap is larger than the area where convexity reduction is desired. We prefer the “hinge” technique where bone at the inferior part of the sinus is resected to allow the bone flap to rotate down. While it requires more intraoperative adjustment to obtain an ideal fit, it largely eliminates contour discrepancies and allows the bone flap to be designed for the desired aesthetic contour regardless of the underlying frontal sinus position. Additionally, while mucoceles have been reported after set-in because the bone flap obstructed the nasofrontal duct, we are unaware of reports of any after the hinge technique, presumably because it does not involve positioning anything inside the actual cavity of the sinus itself. The adjacent frontal bone is then burred to obtain an appropriate contour without prominent step-offs. For this step, one is more likely to end up with variable depths of burring if a systematic approach is not used. Our approach is to draw a

411

grid on the frontal bone to help guide the amount of burring. One should keep in mind that over-reduction of the forehead superior to the sinus simply causes the bone at the glabellar region to appear relatively more prominent and the sinus setback less effective. The radix is also reduced or repositioned inferiorly with burring, if indicated. The lateral supraorbital rim is treated next. Whereas cismen have a larger orbital volume on average, cis-women have a proportionally larger orbital opening in relation to the rest of the face. Either ostectomy or burring of the superior lateral orbital rim is often performed (Video 9.14.2 ). Common areas of bone burring can be seen in Fig. 9.14.4. When burring is finished, the anterior wall of the frontal sinus is rigidly fixated in its new position. Our technique is to use two- or four-hole ultra-low-profile microplates (0.3 mm thickness; Synthes MatrixNeuro). We also use low-profile but non-flexible mesh (0.3-mm mesh; KLS Martin Group, Jacksonville, FL, US) rather than flexible screen mesh in areas with a bone gap or concern for thin bone at risk of future resorption. Some surgeons prefer wire fixation, which is a reasonable alternative, though the rigidity of the construct after wire stress relaxation is uncertain and the facial trauma literature supports rigid fixation as pioneered by Paul Manson. We recommend against suture fixation because it is non-rigid and confers too great a risk of bone flap resorption. For hairline-lowering procedures, transverse galeotomies for frontal scalp advancement are performed just through the galea, with care taken to avoid transecting superficial vessels and the temporal flaps are then advanced medially and temporal skin excised. The pericranial flap is draped and secured over the area of bony work. The scalp is re-draped and fixated to set the brow position and arch. If a coronal incision was used, we use resorbable Endotines (MicroAire Surgical Instruments, Charlottesville, VA, US) placed under hairbearing scalp. For pretrichial incisions, two 3-0 PDS browpexy sutures per side are anchored to cortical tunnels and tied on the desired tension. The incisions are then closed in layers over

Figure 9.14.4  Common areas of bone burring in the upper third. Red, forehead; blue, temporal ridges; yellow, supraorbital ridge and frontonasal junction; green, lateral supraorbital orbital rim.

412

SECTION II

CHAPTER 9.14  • Facial feminization

A

C

B

D

Figure 9.14.5  Example of frontal sinus setback using hinge technique and virtual planning. (A) Segmented craniofacial skeleton demonstrating unilateral frontal sinus. (B) Planned bony movement (pre- is blue and post is red). (C) Planned hinge-type setback with osteotomies in green. (D) Postoperative surgical outcome, demonstrating reduction of the supraorbital ridge and a smooth nasofrontal junction without step-off.

a single closed suction drain. Fig. 9.14.5 demonstrates typical results of frontal sinus setback to achieve facial feminization.

Postoperative care If multiple procedures are performed, the patient is usually kept for observation overnight and the drain is removed on postoperative day 1. Head of bed elevation greater than 30° is important to decrease swelling. The patient receives perioperative antibiotics. Pretrichial sutures are removed at 5–7 days and staples at 10–14 days.

Outcomes, prognosis, and complications Feminization of the forehead is a safe and effective procedure but can be associated with infrequent complications (aggregate rate 1.3%).16,48 Most patients who undergo an anterior coronal approach will experience temporary scalp anesthesia that resolves about 3 months after surgery.16 Alopecia, malunion or non-union of bones, infection (especially if using alloplastic materials), and cerebrospinal fluid (CSF) rhinorrhea may require reoperation, including the use of bone harvesting or scalp advancement.19,48,49 Non-union and mobility of the anterior table bone flap generally requires reoperation.17

Altman et al. reported a 5% rate of cerebrospinal fluid rhinorrhea after forehead contouring.49 Reoperation is required if the CSF rhinorrhea does not abate with conservative measures. Additional potential complications include sinus dysfunction, mucocele and sinusitis, visible scarring (if HLS was performed), and frontal branch nerve injury. Both objective (e.g., anthropometrics) and PCOs are important in forehead feminization. Bellinga et al. reported decreased acuity of the nasofrontal angle (from 133° preoperative to 149° postoperative) in patients who received feminizing rhinoplasty and, in 87% of cases, with simultaneous forehead reconstruction.34 A different study noted similar postoperative increase in nasofrontal angle (141° to 150°).35 While previous studies have examined PCOs after FGS as a whole, there are currently no validated patient-centered outcomes that specifically assess forehead feminization. In these studies, satisfaction is generally high.16,19 Because forehead feminization is often the most frequently performed procedure in those studies, it is tempting to conclude that patient satisfaction with forehead feminization is also high. While anecdotal experience and expert opinion supports this claim, it is not directly deducible based on available data. Future work should strive to report validated PCO measures that are specific to individual areas of the face and specific procedures, including forehead feminization.

Middle third

Middle third Malar augmentation and zygomatic osteotomies Introduction The midface is an essential area for FGS. Common procedures include fat grafting, malar onlay implants, and several types of zygomatic osteotomies. It is essential to avoid creating unnatural facial proportions in an attempt to ‘camouflage’ overly large (i.e., masculine) features. Evaluation of the midface is challenged due to limited data on normal malar structure in humans. This limits use of absolute measurements within the craniofacial skeleton to guide surgical management.50 Generally speaking, men have a wider bizygomatic distance and greater zygomatic bone volume, resulting in well-defined masculine cheeks.23 Women have greater estrogen-driven concentration of malar fat, which manifests as prominent, round feminine cheeks. The overarching goal of malar alteration in FGS is to achieve a round and wellprojected cheek with subtle lateral prominence. Most importantly, the cheeks should look normal when compared with forehead projection, and bitemporal and bigonial widths.

Preoperative considerations, diagnosis, indications The malar regions should be assessed for three key features: malar projection (both location and magnitude), amount of bone versus soft tissue, and bizygomatic width. The creation of the appropriate surgical plan is dependent on these variables.1 Malar anatomy has been described as consisting of five anatomic zones (Fig. 9.14.6).51–53 Augmentation of each different type of zonal deficiency yields predictable changes in midface appearance. For instance, augmentation of the major portion of the malar bone (zone 1) leads to increase projection of the malar eminence, whereas augmentation of zygomatic arch (zones 2 and 4) yields broader bizygomatic width and a high-arched appearance.

413

Assessment of malar hypoplasia is clinical, but is aided by the Jelks categorization of globe–orbital rim relationships54: malar (maxillary) hypoplasia is likely if the malar eminence is located posterior to a tangent line drawn from the most anterior portion of the globe (termed negative vector relationship). This can be achieved with either soft tissue replacement (we prefer fat grafting) or skeletal augmentation with either an implant or zygomatic osteotomies. If the patient has an unacceptably large bizygomatic width then the optimal treatment is to narrow this width with zygomatic osteotomies. See Algorithm 9.14.1 for an algorithmic approach to the malar region.

Surgical techniques, treatments Approach For malar implant augmentation, the approach is via an intraoral upper buccal sulcus incision (see Chapter 9.13). For zygomatic osteotomies, a 1.5 cm preauricular or mid-sideburn incision is added to provide access for arch osteotomies.

Malar implants If the patient has isolated malar hypoplasia, implants or fat grafting are used to increase malar projection, depending on the severity and etiology of the hypoplasia. Regarding alloplastic material, we have used polyether ether ketone (PEEK), porous polyethylene (Medpor), and titanium implants. Porous polyethylene is favorable in that it can be easily adjusted in the operating room and has been shown to have ideal tissue ingrowth and adaptability. Titanium implants (Fig. 9.14.7) offer better resistance to infection and fewer constraints on implant design (e.g., minimum thickness allowance), but intraoperative modification is not feasible. PEEK implants do not integrate into surrounding tissue and may be more likely to lead to abnormal tissue movements during facial animation.

Zygomatic osteotomies Zygomatic osteotomies are indicated to narrow a large bizygomatic width. They are a powerful tool that can change the 3D point of maximal malar projection via rotation, translation and

Figure 9.14.6 The five anatomic zones of the midface as described by Terino. (From Terino EO. 3D facial volumization with anatomic alloplastic implants. In: Scuderi N, Toth BA, eds. International Textbook of Aesthetic Surgery; 2016: 985–1030. Berlin, Heidelberg: Springer. doi:10.1007/978-3-662-46599-8.)  

414

SECTION II

CHAPTER 9.14  • Facial feminization

Algorithm 9.14.1

Y

N

Sharp visual zygoma-maxilla transitions due to bony concavities N

N

Zygomatic body deficient or negative orbital vector

Y

Y

Zygomatic osteotomies with virtual planning

Fat grafting to blend midface transitions

Malar implant designed for projection and fat grafting

Isolated malar hypoplasia

Bizygomatic distance unacceptably wide (vs bigonial, bitemporal)

Malar implant designed for smoothing and fat grafting

Y

Zygomatic osteotomies with sagittal advancement and medial translation

N

Zygomatic osteotomies with medial translation and rotation

Concomitant malar hypoplasia?

Malar treatment algorithm.

the widest point of the arch through a 1.5-cm preauricular or sideburn incision. We find the use of patient-specific cutting and drill guides created with CAD/CAM and VSP invaluable for this because the osteotomized zygoma is essentially completely mobile. VSP allows for much greater precision and control in determining the outcome of zygomatic osteotomies, with pre-drilled pilot holes allowing the use of the custom fixation plate to ensure accurate reduction and fixation of the zygoma (Fig. 9.14.8).

Autologous fat grafting

Figure 9.14.7  Intraoperative view of custom titanium malar implant placement.

even reduction of the mobilized zygomatic segment. Sagittal advancement can be incorporated to address malar deficiency. The technique used depends on the goals of surgery and how much of the zygoma is included in the mobilized segment. We typically employ an L-shaped osteotomy extending from the medial edge of the zygoma up to the inferior orbital rim then out diagonally to emerge at the junction of lateral orbital rim and zygoma. Another osteotomy is performed at

We use fat grafting in virtually all FFS cases to soften masculine regions. There are many techniques for performing fat grafting to the cheeks. Fat can be harvested from any available site using a multihole 2-mm cannula, and decanted. The supernatant fluid is discarded after allowing to sit upright in 10 cc syringes for 10 min. One to two malar puncture sites are created with an 18 G needle, passing just through the dermis, and are hidden in rhytids. Fat is injected via withdrawal technique through a 1-mm blunt tip cannula using a Coleman technique.55 Fat grafting survival rates are around 50–60%. Complications of fat grafting include poor survival, contour irregularities and fat necrosis.7

Postoperative care A supportive dressing is placed at the completion of surgery and is removed the next morning. We do not routinely use drains. Oral antibiotics are prescribed for 1 week. The patient is instructed to elevate the head of bed and eat a soft diet for

Middle third

A

B

C

D

415

Figure 9.14.8  Zygomatic osteotomies, demonstrating feminization of the midface and narrowing of bizygomatic distance. Other procedures performed include forehead setback and burring, rhinoplasty, genioplasty, mandibular reduction, and fat grafting. (A) Preoperative (B) Planned ostectomy. (C) Planned final position with custom plate. (D) Final postoperative position.

the first 3 days. Depending on the number and extent of malar procedures performed, we may keep the patient overnight for observation.

Feminizing rhinoplasty and lip augmentation

Outcomes, prognosis, and complications

The nose occupies a central and prominent position on the face, and its size and shape are distinctly different between genders. Like forehead reconstruction, feminizing rhinoplasty has the ability to dramatically feminize the face. The first case series to document rhinoplasty as a part of gender-affirming surgery was in 1997 by Hage (12 patients).56 While the techniques currently used to create a feminine nose are not fundamentally new, it is the manner and degree to which these techniques are applied to the FGS-seeking patient that distinguish feminization rhinoplasty from traditional techniques. A review of traditional rhinoplasty is out of the scope of this chapter (see Chapter 19). Instead, we aim to highlight what is different about feminization rhinoplasty (see Fig. 9.14.1). Distinguishing features of the female nose include a wider nasofrontal angle (145° female vs. 129° male), a lower radix located just above the pupil (at the upper lid crease for men), narrower nasal width, curved dorsal aesthetic lines, less projection (30 mm female vs. 34 mm male), greater cephalic tip rotation, wider nasolabial angle (100–110° female vs. 95–100° male),

It is critical that the surgeon obtains the correct diagnosis of the midface. For example, in a patient with wide bizygomatic width, if malar augmentation is performed in this patient in an attempt to camouflage a wide face, this may achieve equilibrium in the isolated midface. This results, however, in a top-heavy appearance to the face as a whole that is highly unnatural. Jaw feminization and reduction of lower third width actually exacerbates the problem even further. Complications of zygomatic osteotomies include asymmetry, non-union or malunion, and facial nerve injury. Complications of malar implants include asymmetry, contour abnormalities, injury to facial nerve and musculature, malposition, migration, infection, underlying bony resorption, extrusion of the implants and poor cosmetic result. There is no high-quality data regarding complications associated with malar implants specifically in FGS, but a broader discussion of complications associated with facial implants and skeletal augmentation can be found in Chapter 9.13.

Introduction

416

SECTION II

CHAPTER 9.14  • Facial feminization

E

F

G

Figure 9.14.8, cont’d (E) Intraoperative view. (F) Overlap of preoperative (green outline) and postoperative 3D soft tissue scans showing reduction in bizygomatic width. (G) Pre- versus postoperative soft tissue scan.  

narrower alar base (by 4 mm) and a shorter upper lip (again, by 4 mm).20

Preoperative considerations, diagnosis, indications There are three goals to accomplish when performing rhinoplasty in the context of FGS: (1) create a nose that appears feminine; (2) maintain harmony between the nose, forehead and maxillomandibular complex; and (3) obtain an aesthetically pleasing result that accounts for differences beyond gender (i.e., ethnicity and age).34,57,58 The nasofrontal and nasolabial junctions are important gender-defining zones; alterations to any one of these structures will affect the others. For this reason, it is common to perform simultaneous forehead reconstruction at the same time as feminizing rhinoplasty. The most commonly indicated procedures include dorsal reduction, nasal bone osteotomies for reduction of nasal width, decrease in tip projection and width, and cephalic tip rotation. 19,34 Other common adjuncts include lip lift (especially if >40 years old), alar reduction, septoplasty, spreader grafts, and fat grafting (Table 9.14.2; Algorithm 9.14.2).

Table 9.14.2  Key technique nuances in feminizing rhinoplasty

Male feature(s)

Technique(s)

Female result(s)

Highly projected tip, non-rotated tip, acute nasolabial angle

Cephalic trim, domal sutures, grafts (columellar strut or caudal extension), angled caudal septal reduction

Tip deprojection, increased tip rotation, tip refinement

Dorsal hump, high radix

Dorsal hump reduction, spreader grafts/flaps

Straight or slightly concave dorsum; smooth, mild frontonasal transition

Straight dorsal aesthetic lines, wide nasal width

Osteotomies of nasal bones or frontal process of maxilla

Reduced nasal width, concave dorsal aesthetic lines

Wide alar base

Weir alar base reduction and/or sill reduction

Narrower alar base

Middle third

417

Algorithm 9.14.2 Nasal width

Narrowing desirable? N

Open roof?

Y

Y

Nasal bone osteotomies

Offset dorsal reduction, close open roof

Low-High

Moderate bony narrowing

Low-Low

Major bony narrowing

Low-Low + paramedian

Maximum bony narrowing

Open piezo

Pre-op Cottle maneuver positive, or evidence of INV collapse?

Spreader grafts or flaps

N

No osteotomies

Algorithm for treatment of a wide nasal base. INV, Internal nasal valve.

Detailed preoperative patient evaluation is critical for success in femininizing rhinoplasty, particularly because the nose displays high anatomic variability between individuals. Specific features of the nose to note are in Table 9.14.3. During the initial consultation, patients are asked what features of their face they feel are and are not congruent with and affirming of their gender identity. Other things discussed include recent initiation of estrogen therapy (skin changes may take 12 months or more) and ethnic and cultural aspects of their desired nasal appearance.20 The female upper lip is on average 4 mm shorter than the male upper lip, with slightly greater anterior projection of the vermiliocutaneous junction and about 3 mm of incisal show in repose (vs. 1 mm in men), when the mouth is open and in resting position.19 While there are multiple cosmetic indications for lip lift or augmentation, the indication for a lip lift in FGS is to create a more feminine upper lip. This entails shortening the upper lip with a goal of approximately 3 mm of incisal show or show of four to six upper teeth.1

Table 9.14.3  Salient nasal features and surgical implications

Nasal feature

Clinical implication

Skin thickness and quality

Limits the degree of refinement achievable

Nasal width

Informs if and how nasal bone osteotomies are performed

Septal deviation

Possible need for septoplasty

Nasofrontal angle

Impacts surgical plan to address glabella and forehead

High/low radix

Can be directly altered from coronal approach during forehead

Nasolabial angle

Possible need for lip lift

Cottle maneuver

May indicate need to support internal nasal valve

418

SECTION II

CHAPTER 9.14  • Facial feminization

Surgical techniques Approach The approach used is either open or closed (endonasal). Most surgeons use an open approach because of the need to make significant size reductions and structural alterations of the nose. In certain patients, such as with a smaller or more feminine-appearing nose, an endonasal approach may be sufficient. If performed with a lip lift, then the open rhinoplasty dissection may be done either through a separate more distal transcolumellar incision59 or through the existing superior lip lift incision.4,34 The latter avoids the theoretical risk of skin necrosis of the intervening columellar skin bridge, although Insalaco et al. noted no complications in 105 patients treated with a separate transcolumellar incision and, frequently, simultaneous alar base reduction.59 If the superior lip lift incision is to be used alone, it is connected to the nasal mucosal incisions at the most basal (posterior) aspect of the nostril sill.

Dorsal hump reduction The goal of the dorsal hump reduction is to create a straight or slightly concave dorsum that undergoes a smooth, mild frontonasal transition.20 Component or composite dorsal hump reductions are preferred. See Chapter 19 for an in-depth review of these techniques. Care must be taken to not over-resect, especially in the radix, or excess skin can produce epicanthal folds along the medial canthi of the eyes.60 Open-roof deformities are common due to the need for sizable dorsal reductions, and can occur in both component and composite techniques. In the case of a wide midvault, the open roof facilitates free movement of the midvault that is achieved after nasal osteotomies are performed and can greatly aid in narrowing the bony dorsum. It is critical to ensure that the open roof is corrected, otherwise an inverted-V deformity or internal nasal valve (INV) collapse may occur. If the cartilaginous midvault is not too narrow, an excellent alternative is the upper lateral cartilage tension spanning suture.61 Spreader grafts and auto-spreader flaps are indicated to reconstruct the dorsal roof, restore dorsal aesthetic lines, and maintain patency of the INV. Our preference is to use auto-spreader flaps when there is any question about INV patency (e.g., positive preoperative Cottle maneuver). Spreader grafts should be used thoughtfully; they widen the midvault and thus have the potential to work against feminization of the nose.

Nasal bone osteotomies The purpose of nasal osteotomies in feminizing rhinoplasty is both aesthetic (to reduce nasal width and straighten deviated nasal bones) and functional (close an open-roof deformity). The dorsal aesthetic lines on front view should be slightly concave. Because cis-men have much thicker nasal bones and maxillary frontal processes, aggressive osteotomies are often required to achieve a feminine nose. A review of osteotomy techniques is available in Chapter 19. For FGS, we prefer a graded approach whereby more aggressive techniques are used for larger, wider noses (Table 9.14.4). For patients with excess width at the nasal base, specifically in the middle and upper thirds of the nose, use of paramedian osteotomies in addition to low-to-low

Table 9.14.4  Graded approach to nasal bone osteotomies in feminizing rhinoplasty

Osteotomy ladder

Indication

Low-to-high

Offset dorsal reduction and/or close open-roof deformity

Low-to-low

Mild to moderate narrowing of the bony bridge

Low-to-low + paramedian

Significant narrowing of the bony bridge

Open piezoelectric osteotomy

Maximum narrowing of the bony bridge, including the frontal process

osteotomies creates a hinge that allows increased reduction of base width. In cases where the greatest possible narrowing is desired, open osteotomies are performed at the nasofacial junction with a piezoelectric saw (Fig. 9.14.9), and can follow the point of inflection where the frontal process of the maxilla takes off anteriorly from the maxillary bone. The bone in this area is generally too thick for reliable full-thickness osteotomy using standard osteotomes. Another benefit of using piezoelectric saws is that they are less likely to cause damage to adjacent soft tissues. The release of the pyriform ligament and greater exposure for open osteotomies does sometimes lead to longer edema.

Tip reduction, rotation and deprojection Tip modification in feminizing rhinoplasty should aim to create a defined, narrow and cephalically rotated tip. Most patients will require cephalic trim, domal sutures, and alar modification with grafts. See Chapter 19 for procedural details. Cephalic trim: a thin strip of cartilage is sharply removed from the cephalic edge of both lower lateral cartilages, with care taken to preserve at least 6 mm of caudal cartilage. Alar modification: alar grafts are frequently required to provide long-term stability when reshaping the tip. Those commonly used in feminizing rhinoplasty include lateral crural strut, alar batten, and tip grafts.34 Domal sutures: transdomal and intradomal sutures are frequently used to improve tip projection and refinement. As nasal tip rotation is increased, the tip projection must be controlled to prevent an abnormal supratip break. Columellar strut: columellar strut or caudal extension grafts are typically used to add support to the tip and may help provide a columellar (infratip) break. Lateral crural resection: tip deprojection is almost invariably required, ranging from mild (1–2 mm) to significant (5+ mm). Resection of a segment of the lateral crura followed by repair is a safe and reliable way to deproject the tip. Lateral crural strut grafts can be added afterwards to address crural convexity. The female nose generally has more cephalic rotation than the male nose, and thus angled caudal septal reduction is often indicated. Shortening of the nose via resection of a portion of the anterior septal angle and some mucosa will reduce nose length in the inferosuperior direction; it is, however, much less frequently indicated than angled caudal septal reduction.34,35 Angled septal trim coupled with a tip rotation

Middle third

A

419

B

C

Figure 9.14.9  Open piezoelectric osteotomies. Clinical photos before (A) and after (B) demonstrating significant reduction in nasal width. (C) 3D computed tomography imaging demonstrating path taken with open piezo-electric osteotomies.

stitch to Pitanguy’s ligament provides reliable and consistent cephalic tip rotation and a supratip break.

Lip lift Various non-filling procedures exist to reduce the vertical dimension of the lip, including direct and indirect lip lift, corner of the mouth lift, and the V-Y lip advancement.62 The most frequently used technique in FGS is an indirect lip lift via a subnasal bullhorn incision, which is our preference.34 The superior incision starts at the lateral base of the alar-facial groove, follows the contour of the nose–lip junction inferior to the nostril sill, crosses the base of the columella, and continues similarly on the contralateral side. The inferior incision follows the contour of the superior one at a predetermined margin. Common resection sizes range from 3 mm to 8 mm. Autologous fat grafting provides a reasonable method of permanently augmenting lip volume. Patient expectations should be tempered that edema can be prolonged and graft survival is fairly low due to lip motion. If grafting to the lip is to be performed we prefer to avoid doing it concomitantly with lip lift.

Postoperative care Dressing of the nose consists of placement of several SteriStrips and a thermoplast splint. Doyle splits are placed and kept for 7–10 days if a septoplasty was performed. Nonabsorbable sutures and Steri-Strips are removed between 7 and 10 days.

Outcomes, prognosis, and complications As with forehead feminization, anthropometric and PCOs are important in feminizing rhinoplasty. One group reported decreased acuity of the nasofrontal angle (133° preoperative to 149° postoperative) in patients who received feminizing rhinoplasty (87% with simultaneous forehead reconstruction).34 A different group noted comparable postoperative increases in nasofrontal angle (141° to 150°), as well as increases in nasolabial (107° to 115°) and supratip (2° to 13°) angles.35 PCOs were obtained by Bellinga et al. via a novel but unvalidated 5-point Nose Feminization Scale, and showed that the degree of satisfaction with the rhinoplasty result was “much better”

420

SECTION II

CHAPTER 9.14  • Facial feminization

for the majority of patients (46%), followed by “exceptional” (26%) and “a little better” (22%). Their PCO results were purely descriptive and were not tested for significance. Most patients report mild to moderate paresthesia of the nasal tip that begins to resolve 3 months postoperatively. Mild to moderate nasal edema and periorbital ecchymosis after surgery are expected. Bruising resolves after 2–4 weeks. Mild edema may persist for several months or longer, and patients should be forewarned of this. In the absence of significant data on complication rates specifically after feminizing rhinoplasty, the complications associated with traditional rhinoplasty (see Chapter 19) guide perioperative planning. In addition to standard surgical risks, patients should be forewarned about nasal valve insufficiency, tip collapse, failure to feminize the nose, and dissatisfaction with the result. In the largest case series of feminizing rhinoplasties (200 patients), no major complications were observed. The rate of revision rhinoplasty in their patients was 4% (8 of 200), largely due to chronic tip infection, dorsal irregularity, or patient dissatisfaction with the level of tip refinement.34 Results from smaller case series support these results. The novice rhinoplasty surgeon is reminded that the surgeons reporting these results in these case series have considerable experience in achieving predictable results in feminizing rhinoplasty. While there are more similarities than differences between traditional and feminizing rhinoplasty, future studies should report outcomes and complication rates specific to feminizing rhinoplasty. Complications of lip lift include over-excision or underexcision, visible scars, wound breakdown, and lip swelling for several days postoperatively. Complications of lip augmentation with alloplastic materials include infection and rejection.19

Lower third and neck Mandibular reduction and genioplasty Introduction The goal of lower jaw recontouring in FGS is to create harmony between the lower third of the face and the upper two-thirds. This often includes gonial angle reduction via ostectomy or burring, reduction of mandibular body projection, and genioplasty. Facial height is a significant indicator of gender and reduction of facial height through lower jaw procedures is the simplest way to adjust this parameter. While men are generally perceived to have square jaws, women are perceived to be more feminine with a trapezoidal shape and this can be accomplished with gonial angle and body reduction.24 The chin is similar in that softer features and a narrow tapering is more feminine while a more masculine chin is perceived as boxier and more prominent. We typically obtain preoperative CT scans and use VSP to plan gonial angle ostectomies and genioplasties. We have used a variety of cutting guides in the gonial angle to ensure consistent results. Cutting guides are particularly useful in this area angle as visualization is difficult at best and asymmetric and especially over-resected results are commonly seen without cutting guides. Before embarking on mandibular contouring, the patient should have adequate dental hygiene and lack any significant

dental disease. If not, the patient should be encouraged to consult with a dentist or endodontist as needed prior to surgery. Edentulous patients are not good candidates for lower third FGS.24 If malocclusion is noted and the patient desires corrective procedures, lower third FGS surgeries should be delayed until orthodontist consultation and pre-surgical orthodontic decompensation is completed. Orthognathic surgery can be safely combined with FFS either in a concomitant or staged approach, depending on the surgeon preferences and the permutation of procedures necessary for a given patient. Analysis of the considerations in planning these cases is complex and beyond the scope of this chapter, as most orthognathic procedures favor expanding the facial skeleton for better aesthetic and functional results while feminizing procedures seek to reduce it. In practice, it is only a small number of patients who present for FGS, have a malocclusion and also display an interest in undergoing the full process of orthognathic surgery. Nonetheless, it is prudent to explain all options to patients presenting with bite abnormalities.

Surgical techniques, treatments Angle reduction, mandibular body ostectomy and genioplasty Gonial angle reduction and genioplasty are typically done concurrently with other procedures. If a rhinoplasty is not being performed, nasal intubation is preferred; otherwise options include use of an armored tube, submental tube (if performing open submentoplasty or liposuction), or intraoperative exchange of nasal to oral tube over a bougie. We have used all of these options and find tube exchange the least onerous. For the angle and body, the incision is marked along the gingiva similar to that of a sagittal split osteotomy, while a standard genioplasty incision is used anteriorly. Circumferential mucosal incisions heal poorly and have a high risk of mental nerve avulsion. After incising the gingiva, subperiosteal elevation is performed across the angles, body, and the chin. The mental nerves are identified and protected. The lingual side of the angle is elevated for exposure and ostectomy. A combination of curved periosteal elevator and gauze packing expansion works well to create a space to work. After exposing the angles, ostectomies or burring can be done (Video 9.14.3 ). We use ostectomies if the vertical height of the angle region is excessive and there is a reasonably sized segment to ostectomize that will not leave an overly diagonal ”hatchet” angle. If the problem is sagittal projection only, burr or rasp reduction is favored. Our cutting guides are generally made of titanium and are secured to the mandible with temporary screws. Guides which register to the teeth with occlusal splints have been explored; however, there was too significant a flexing component in the arm connecting the occlusal splint to the angle region. The ergonomics of the angle osteotomy are challenging. We have used piezoelectric saws, right-angled dental burrs, the oscillating intraoral saw and even transbuccal cutting tools and none are ideal. In some patients where the angle curves inward posteriorly, visualization can be particularly difficult; in these cases a trocar can be passed and the smallest available endoscope (e.g., TMJ arthroscope) used to provide greater visualization of the posterior border. See Fig. 9.14.10 for an evolution of the cutting guides.

Lower third and neck

A

B

C

E

421

D

F

Figure 9.14.10  (A–F) Examples of various potential cutting guide designs for angle ostectomy and osseous genioplasty in facial feminization.

Once both angles are addressed and deemed symmetric, we use a power rasp or burr to reduce the mandibular body as planned out in the VSP session, which can be extensive in patients with large external oblique ridge. Once the end of the buccal cortex is reached we typically stop. A sagittal

osteotomy of the body followed by splitting the buccal cortex off is another possible approach but produces more bleeding. The chin is then addressed with genioplasty. As feminine chins are generally tapered and less prominent than masculine chins,

422

SECTION II

CHAPTER 9.14  • Facial feminization

A

B

C

Figure 9.14.11  (A) Example of preoperative virtual surgical plans for jaw feminization. Green indicates mobilized segments while red represents ostectomized bone. (B) Intraoperative view of cutting guide placement in another case where significant sagittal advancement was also required for retrogenia. (C) Intraoperative view after osteotomies and advancement using patient-specific fixation, prior to bone grafting into gaps.

we most commonly reduce chin height and width using a sliding three-piece genioplasty. Another approach is inferior border ostectomy where 8–12 mm of the inferior border is resected, either with or without transverse osteotomy and sagittal advancement. Ostectomy of the inferior border usually accomplishes not only vertical shortening but also significant transverse narrowing. We adopt this approach in some cases when mandible morphology is favorable. However, the increased freedom of the three-piece

ostectomy (which can made arbitrarily narrow, rotated, or advanced depending on surgeon preference) renders it more frequently ideal. This technique also avoids stripping off the muscle attachments of the inferior mandibular border, which may reduce unsightly submental laxity. In VSP planning sessions, we determine the ideal post­operative appearance and reduce the height and width of the chin with precise ostectomies. The osteotomies are made and secured in place with custom plates (Fig. 9.14.11).

Lower third and neck

Postoperative care Patients receiving lower third procedures typically have other concurrent facial procedures performed and are kept overnight for monitoring. A 24-h regimen of dexamethasone is typically completed to reduce swelling. The patient is instructed to advance from a clear liquid to soft diet and use chlorhexidine mouthwash after each meal and before bedtime. Swelling is minimized by encouraging the patient to sleep with the head of the bed elevated and using ice. Elastic jaw compression garments are recommended for the first 4–6 weeks.

Outcomes, prognosis, and complications Patients are generally pleased with lower third procedures as the bony changes can have a striking feminizing effect. Possible complications after these procedures include mental nerve numbness (generally resolved after 4 weeks), asymmetry, infection, resorption of osteotomized bone segments, or injury to teeth roots or the inferior alveolar nerve. However, these complications are not commonly encountered provided adequate planning and experience.56,63–65 Patients should be counseled about tissue laxity from mandibular reduction procedures. Since we began resuspending the platysma from mandibular cortical tunnels, we have had fewer issues with this. In patients under 40, skin contracture and muscle readaptation will result in improvement of any initial submandibular laxity, though this process may take 6 or even 12 months. In older patients this process is unpredictable and they are counseled on the potential future need for a staged facelift.

Chondrolaryngoplasty Introduction The laryngeal prominence (Adam’s apple) can be a significant source of distress for transwomen. This cartilage enlarges in size during puberty and does not respond to introduction of cross-gender hormones, requiring surgical correction. Chondrolaryngoplasty is a safe and effective procedure for reduction of the laryngeal prominence.

Anatomic considerations The origin of the name, “thyroid” is derived from the Greek meaning for “shield.” This cartilaginous structure is formed by the joining of two quadrilateral vertical laminae, which is prominent anteriorly and open posteriorly. The midline and superior-most aspect of the fusion of the two lateral pieces forms the superior thyroid notch. Strap muscles of the neck are attached to the thyroid cartilage along the oblique line, which marks the upper and lateral-most aspect of the thyroid gland. The vocal cords insert into the anterior aspect of the thyroid cartilage and their insertion limits the amount of resection without compromising vocal function.

Surgical techniques, treatments Chondrolaryngoplasty We use a submental approach. The incision is marked based on the highest possible incision where skin stretch makes it reasonable to

Access the reference list online at   Elsevier eBooks+

423

access the cartilage. The incision must not be placed directly over the thyroid cartilage as the scar may tether to cartilage, creating a highly visible deformity when the neck moves during speech. Limiting the size of the incision is critical to aesthetic outcome. Depending on anatomy, an incision length between 23 and 30 mm is used. After the skin is incised and a plane is established, the platysma is entered. The thyroid cartilage is exposed by blunt dissection. Once the thyroid cartilage has been exposed, a Cottle elevator can then be used to strip the perichondrium along the internal and external aspect of the thyroid cartilage. Dissection should not proceed at the thyroepiglottic ligament to avoid damage to vocal cord attachments. Resection of the laryngeal prominence can then be carried out using a #10 blade or a 3-mm diamond burr if the patient is older and the cartilage is more ossified. Next, the prominences around the laryngeal incisure back toward the superior horns are reduced. Once a satisfactory contour is achieved using burring or shaving, the platysma and skin are closed in layers.

Postoperative care If done as a standalone operation, it can be done as an outpatient. Standard wound care instructions should be provided along with the counseling that the patient should expect some voice and neck soreness over the following days.

Outcomes, prognosis, and complications Chondrolaryngoplasty is a well-tolerated procedure and patients are generally very pleased with the outcomes.66 The most common complication is an unsightly scar. If there is significant tethering and indentation, volume can be added with autologous fat or acellular dermal matrix. Numerous authors have reported series of chondrolaryngoplasty without significant complications; subtle voice changes that resolve are common. Other less common complications include permanent voice impairment, dysphagia, neuralgia, and laryngospasm.67

Vocal cord surgery Voice can be a significant outing characteristic and as such, should be addressed when considering FGS. Speech therapy can aid the patient significantly and suffices in the majority of patients; however, phonosurgery is successful in increasing the patient’s natural vocal pitch. Shortening the vocal cord length (open and endoscopic glottoplasty, laser glottoplasty), increasing vocal cord tension (cricothyroid approximation), and reducing vocal cord mass (laser reduction glottoplasty) are the three mainstays with vocal cord shortening yielding the greatest increase in pitch.68 Regardless of the technique, complications shared by each include inadequate change in pitch, reduced vocal range, and reduced volume. Vocal cord shortening procedures entail removing a portion of the anterior thyroid cartilage, excision of a portion of the anterior true and false vocal cord, and reapproximating them, thus creating a new anterior commisure.69 Cricothyroid approximation has fallen out of favor due to its poor longterm outcomes (dropping pitch).68

References

References 1. Capitán L, Santamaría JG. Facial gender confirmation surgery: a protocol for diagnosis, surgical planning, and postoperative management. Plast Reconstr Surg. 2020;145:11. 2. Capitán L, Simon D, Kaye K, Tenorio T. Facial feminization surgery: the forehead. surgical techniques and analysis of results. Plast Reconstr Surg. 2014;34:609–619. 3. Ainsworth TA, Spiegel JH. Quality of life of individuals with and without facial feminization surgery or gender reassignment surgery. Qual Life Res. 2010;19:1019–1024. 4. Altman K. Facial feminization surgery: current state of the art. Int J Oral Maxillofac Surg. 2012;41:885–894. 5. Spiegel JH. Challenges in care of the transgender patient seeking facial feminization surgery. Facial Plast Surg Clin N Am. 2008;16: 233–238. 6. Lundgren TK, et al. Moving transgender care forward within public health organizations: inclusion of facial feminizing surgery in the Swedish national treatment recommendations. Arch Sex Behav. 2016;45:1879–1880. 7. Natghian H, Farnebo F, Lundgren KC. Management of the midface in the transgender patient. J Craniofac Surg. 2019;30:1383–1386. 8. Coon D, et al. Facial Gender Surgery: Systematic Review and Evidence-Based Consensus Guidelines from the International Facial Gender Symposium. Plast Reconstr Surg. 2022;149(1):212–224. 9. Safa B, Lin WC, Salim AM, Deschamps-Braly JC, Poh MM. Current concepts in masculinizing gender surgery. Plast Reconstr Surg. 2019;143:857e–871e. 10. Sayegh F, et al. Facial masculinization surgery and its role in the treatment of gender dysphoria. J Craniofac Surg. 2019;30:1339–1346. 11. Ascha M, et al. Nonsurgical management of facial masculinization and feminization. Aesthet Surg J. 2019;39:NP123–NP137. 12. Deschamps-Braly JC. Approach to feminization surgery and facial masculinization surgery: aesthetic goals and principles of management. J Craniofac Surg. 2019;30:1352–1358. 13. Deschamps-Braly JC, Sacher CL, Fick J, Ousterhout DK. First female-to-male facial confirmation surgery with description of a new procedure for masculinization of the thyroid cartilage (Adam’s apple). Plast Reconstr Surg. 2017;139:883e–887e. 14. Facque AR, Atencio D, Schechter LS. Anatomical basis and surgical techniques employed in facial feminization and masculinization. J Craniofac Surg. 2019;30:1406–1408. 15. Ousterhout D. Feminization of the forehead: contour changing to improve female aesthetics. Plast Reconst Surg. 1987;79:701–711. 16. Oles N, et al. Gender affirming surgery: a comprehensive, systematic review of all peer-reviewed literature and methods of assessing patient-centered outcomes (Part 1: Breast/chest, face, and voice). Ann Surg. 2022;275(1):e52–e66. 17. Spiegel JH. Facial determinants of female gender and feminizing forehead cranioplasty: facial determinants of female gender and feminizing forehead cranioplasty. The Laryngoscope. 2011;121:250–261. 18. Somenek M. Gender-related facial surgical goals. Facial Plast Surg. 2018;34:474–479. 19. Morrison SD, et al. Facial feminization: systematic review of the literature. Plast Reconstr Surg. 2016;37:1759–1770. 20. Berli JU, Loyo M. Gender-confirming rhinoplasty. Facial Plast Surg Clin N Am. 2019;27:251–260. 21. Epstein J, Epstein GK. Hairline-lowering surgery. Facial Plast Surg Clin N Am. 2020;28:197–203. 22. Nusbaum BP, Fuentefria S. Naturally occurring female hairline patterns. Dermatol Surg. 2009;35:907–913. 23. Toledo Avelar LE, Cardoso MA, Santos Bordoni L, de Miranda Avelar L, de Miranda Avelar JV. Aging and sexual differences of the human skull. Plast Reconstr Surg Glob Open. 2017;5:e1297. 24. Morrison SD, Satterwhite T. Lower jaw recontouring in facial gender-affirming surgery. Facial Plast Surg Clin N Am. 2019;27: 233–242. 25. Safer JD, et al. Barriers to healthcare for transgender individuals. Curr Opin Endocrinol Diabetes Obes. 2016;23:168–171.

423.e1

26. Tebbens M, et al. Gender-affirming hormone treatment induces facial feminization in transwomen and masculinization in transmen: quantification by 3D scanning and patient-reported outcome measures. J Sex Med. 2019;16:746–754. 27. Pittman TA, Economides JM. Preparing for facial feminization surgery. Facial Plast Surg Clin N Am. 2019;27:191–197. 28. Raffaini M, Perello R, Tremolada C, Agostini T. Evolution of full facial feminization surgery: creating the gendered face with an all-in-one procedure. J Craniofac Surg. 2019;30:1419–1424. 29. Raffaini M, Magri AS, Agostini T. Full facial feminization surgery: patient satisfaction assessment based on 180 procedures involving 33 consecutive patients. Plast Reconstr Surg. 2016;137:438–448. 30. Morrison SD. Prospective quality-of-life outcomes after facial feminization surgery: an international multicenter study. Plast Reconstr Surg. 2020;145:11. 31. Berli JU, et al. Facial gender confirmation surgery – review of the literature and recommendations for Version 8 of the WPATH Standards of Care. Int J Transgenderism. 2017;18:264–270. 32. Berli JU, Plemons E. The importance of facial gender confirmation surgery. In: Schechter LS, ed. Gender Confirmation Surgery: Principles and Techniques for an Emerging Field. Springer International Publishing; 2020:91–97. http://doi.org/10.1007/978-3-030-29093-1-11. 33. Klassen AF, et al. International phase I study protocol to develop a patient-reported outcome measure for adolescents and adults receiving gender-affirming treatments (the GENDER-Q). BMJ Open. 2018;8:e025435. 34. Bellinga RJ, Capitán L, Simon D, Tenório T. Technical and clinical considerations for facial feminization surgery with rhinoplasty and related procedures. JAMA Facial Plast Surg. 2017;19:175–181. 35. Nouraei SAR, Randhawa P, Andrews PJ, Saleh HA. The role of nasal feminization rhinoplasty in male-to-female gender reassignment. Arch Facial Plast Surg. 2007:9. 36. Tawa P, et al. Three-dimensional custom-made surgical guides in facial feminization surgery: prospective study on safety and accuracy. Aesthet Surg J. 2021(2):sjab032. https://doi.org/10.1093/asj/sjab032. 37. Louis M, Preston S, Coon D. Commentary on: Three-dimensional custom-made surgical guides in facial feminization surgery: a prospective study on safety and accuracy. Aesthet Surg J. 2021;41(11):NP1379–NP1381. https://doi.org/10.1093/asj/sjaa422. 38. Kalmar CL, et al. Trends in utilization of virtual surgical planning in pediatric craniofacial surgery. J Craniofac Surg. 2020;31(7):1900–1905. 39. Khechoyan DY. Surgical outcomes in craniosynostosis reconstruction: the use of prefabricated templates in cranial vault remodelling. J Plast Reconstr Aesthet Surg. 2014;67(1):9–16. 40. Capitán L, et al. The upper third in facial gender confirmation surgery: forehead and hairline. J Craniofac Surg. 2019;30:1393–1398. 41. Brown E, Perrett DI. What gives a face its gender? Perception. 1993;22(7):829–840. 42. Louis M, Travieso R, Oles N, Coon D. Narrative review of facial gender surgery: approaches and techniques for the frontal sinus and upper third of the face. Ann Transl Med. 2021;9606–606. 43. Ousterhout DK. Facial feminization surgery: the forehead. surgical techniques and analysis of results. Plast Reconstr Surg. 2015;136: 560e–561e. 44. Capitán L, Daniel S, Kaye K, Tenório T. Reply: Facial feminization surgery: the forehead. surgical techniques and analysis of results. Plast Reconstr Surg. 2015;136:560e–561e. 45. Capitán L, et al. Facial feminization surgery: simultaneous hair transplant during forehead reconstruction. Plast Reconstr Surg. 2017;139:573–584. 46. Telang PS. Facial feminization surgery: a review of 220 consecutive patients. Indian J Plast. Surg. 2020;53:244–253. 47. Garcia-Rodriguez L, Thain LM, Spiegel JH. Scalp advancement for transgender women:closing the gap. Laryngoscope. 2020;130: 1431–1435. 48. Bared A, Epstein JS. Hair Transplantation techniques for the transgender patient. Facial Plast Surg Clin N Am. 2019;27:227–232. 49. Eggerstedt M. Setbacks in forehead feminization cranioplasty: a systematic review of complications and patient-reported outcomes. Aesthetic Plast Surg. 2020;44(3):743–749.

423.e2

SECTION II

CHAPTER 9.14  • Facial feminization

50. Altman K. Forehead reduction and orbital contouring in facial feminisation surgery for transgender females. Br J Oral Maxillofac Surg. 2018;56:192–197. 51. Lundgren TK, Farnebo F. Midface osteotomies for feminization of the facial skeleton. Plast Reconstr Surg Glob Open. 2017;5:e1210. 52. Terino E. Alloplastic midface augmentation. Aesthet Surg J. 2005;25:512–520. 53. Terino EO, Edward M. The magic of mid-face three-dimensional contour alterations combining alloplastic and soft tissue suspension technologies. Clin Plast Surg. 2008;35:419–450. 54. Terino EO. 3D facial volumization with anatomic alloplastic implants. In: Scuderi N, Toth B, eds. International Textbook of Aesthetic Surgery. Berlin, Heidelberg: Springer; 2016:985–1030. http://doi.org/10.1007/978-3-662-46599-8. 55. Jelks GW, Jelks EB. The influence of orbital and eyelid anatomy on the palpebral aperture. Clin Plast Surg. 1991;18:183–195. 56. Hage JJ, Vossen M, Becking AG. Rhinoplasty as part of genderconfirming surgery in male transsexuals: basic considerations and clinical experience. Ann Plast Surg. 1997;39:266–271. 57. Cho DY, Massie JP, Morrison SD. Ethnic considerations for rhinoplasty in facial feminization. JAMA Facial Plast Surg. 2017;19 243–243. 58. Rohrich RJ, Bolden K. Ethnic rhinoplasty. Clin Plast Surg. 2010;37: 353–370. 59. Insalaco L, Spiegel JH. Safety of simultaneous lip-lift and open rhinoplasty. JAMA Facial Plast Surg. 2017;19:160–161. 60. Spiegel JH. Rhinoplasty as a significant component of facial feminization and beautification. JAMA Facial Plast Surg. 2017;19(3): 181–182.

61. Geissler PJ, Roostaeian J, Lee MR, Unger JJ, Rohrich RJ. Role of upper lateral cartilage tension spanning suture in restoring the dorsal aesthetic lines in rhinoplasty. Plast Reconstr Surg. 2014; 133:7e–11e. 62. Moragas JSM, Vercruysse HJ, Mommaerts MY. “Non-filling” procedures for lip augmentation: a systematic review of contemporary techniques and their outcomes. J Cranio-Maxillofac Surg. 2014;42:943–952. 63. Becking AG, Tuinzing DB, Hage JJ, Gooren LJ. Facial corrections in male to female transsexuals: a preliminary report on 16 patients. J Oral Maxillofac Surg. 1996;54:413–418; discussion 419. 64. Shams MG, Motamedi MHK. Case report: feminizing the male face. Eplasty. 2009;9:e2. 65. Li J, et al. Surgical designs and techniques for mandibular contouring based on categorisation of square face with low gonial angle in orientals. J Plast Reconstr Aesthet Surg. 2012;65:e1–e8. 66. Cohen MB, Insalaco LF, Tonn CR, Spiegel JH. Patient satisfaction after aesthetic chondrolaryngoplasty. Plast Reconstr Surg Glob Open. 2018:6. 67. Wolfort FG, Parry RG. Laryngeal chondroplasty for appearance. Plast Reconstr Surg. 1975;56:371–374. 68. Song TE, Jiang N. Transgender phonosurgery: a systematic review and meta-analysis. Otolaryngol Neck Surg. 2017;156:803–808. 69. Thomas JP, MacMillan C. Feminization laryngoplasty: assessment of surgical pitch elevation. Eur Arch Otorhinolaryngol. 2013;270: 2695–2700.

SECTION II • Aesthetic Surgery of the Face

10 Editors’ perspective: brow and eye Alan Matarasso

The periocular area has different anatomic components within it that contribute to its overall appearance. Broadly speaking, this area consists of the upper and lower eyelids and the eyebrows. Each of these has numerous procedures useful for rejuvenation. Moreover, within each, there are additional components to consider, such as the medial and lateral brow position, the volume and fat position in the upper and lower lids, canthal position, transition zones to the cheek and nasojugal region, the nature of the skin quality and ethnic variations that are encountered. Each of these areas warrants consideration and will require treatment alone or in combination. Consequently, an appropriate diagnosis and management plan, in conjunction with the patient’s anatomy and goals, requires unpacking the common patient refrain of, “why do my eyes look tired?”. The concepts and techniques of brow and eyelid aesthetics have undergone significant philosophical shifts during the last generation of plastic surgeons. For example, some surgeons initially advocated against any type of brow surgery in general or some avoided it in combination with upper eyelid surgery. When brow surgery was performed, just before the turn of this century, the standard operation was a coronal or anterior brow lift. Over the decades, as surgeons focused on patient’s specific concerns, such as corrugator or frontalis hyperactivity, or brow shape and position, and then aligned ourselves better with the anatomy problem, we recognized how aging occurred in this area, so our thought processes evolved. Concomitantly were advances in treatments such as endoscopy and the non-surgical repertoire for effacement of rhytids by chemodenervation (botulinum toxin) or fillers. These advances, as well as the operations that patients were willing to tolerate, essentially made the “open” browlift, with their lengthy incisions and high degree of patient

intolerance, essentially obsolete. Now, depending on myriad factors, patients have numerous brow elevation or reshaping options and treatments for the skin itself, including resurfacing energy devices and injectables. The choice in this region continues to expand, so it is important that surgeons are able to recognize the specific “disagreeable biologic condition” and recommend the appropriate treatment from a wide array of surgical and non-surgical options currently available. Upper and lower eyelid surgery has also changed significantly from operations initially designed to excise all of the fat and skin, to a more judicious approach of fat preservation, repositioning or fat addition, and less-aggressive skin resections. Canthal support of the lower lids is now also done more frequently in primary as well as secondary procedures. Numerous different techniques exist for each of these situations. Furthermore, lower eyelids can require simultaneous skin quality or texture improvement (i.e., resurfacing) along with operations that reduce the quantity of tissue, the volume of fullness (i.e., fat reduction or addition) and blending techniques to transition to the surrounding cheek or nasojugal areas. In contrast to all the modern-day considerations mentioned, it is interesting to realize that as recently as 25–30 years ago, the most common concern opined about the lower lids was should one do a skin-muscle or skin-flap! Aging in the periocular area is due to three separate and closely intertwined areas, that can therefore be treated alone or together. Within each of these three areas are multiple changes that can occur, and each location has numerous treatment options. We again appreciate the vast expertise of our surgeon contributors for their time and effort in advancing our specialty.

SECTION II  •  Aesthetic Surgery of the Face

11 Forehead rejuvenation Richard Warren

Access video and video lecture content for this chapter online at Elsevier eBooks+

SYNOPSIS

ƒ Detailed knowledge of forehead anatomy is the basis for rejuvenation strategies of the forehead region. ƒ Eyebrow position is the net result of forces that depress the brow, forces that raise the brow, and the structures that tether the eyebrow in place. ƒ Brow depression is caused by glabellar frown muscles, the orbicularis, and gravity. Frontalis is the only effective brow elevator. ƒ Attractiveness of the periorbital region is intimately related to eyebrow shape and eyebrow position as it relates to the upper eyelid and the upper lid sulcus. ƒ Aging causes enlargement of the orbital aperture as well as changes in eyebrow shape. In a subset of individuals, there is ptosis of the entire forehead complex. ƒ Key elements of forehead rejuvenation are the attenuation of frown muscle action and the repositioning of ptotic eyebrow elements. The lateral eyebrow is often the only portion requiring elevation. ƒ Forehead rejuvenation can be accomplished using a combination of surgical and non-surgical techniques. ƒ If surgical elevation of the brow complex fails early, it is usually due to lack of soft-tissue release. If it fails late, is usually due to failure of fixation. ƒ Many methods of soft-tissue fixation and bony fixation have been proven effective in maintaining the position of the surgically elevated brow.

Introduction The periorbital region is the most expressive part of the human face. The eyes are central, framed above by the eyebrows, and below by the cheek. Alteration in components of the orbital frame, as well as the eyelids themselves, will profoundly affect facial appearance. The aesthetic balance created by surgery can project strong human emotions, ranging from joy to sadness and from restfulness to fatigue. In the younger individual, aesthetic alteration of the forehead is generally limited to the non-surgical alleviation of

glabellar frown lines and lateral orbital wrinkles. These issues are discussed in Chapter 9.3. Occasionally, surgery is indicated to change the basic shape of a youthful eyebrow to reverse congenitally downturned sad-looking eyebrows. In the older individual, the forehead may become ptotic, especially laterally. In the upper eyelids there may be soft-tissue hooding with protuberance of orbital fat, or the reverse, with recession of fat with loss of upper sulcus volume. Understanding the interplay between these changes in the upper eyelids and the forehead is critical in choosing an appropriate surgical strategy to rejuvenate the upper third of the face (Video Lecture 11.1 ).

Access the Historical Perspective section online at Elsevier eBooks+

Anatomy The forehead is bounded superiorly by the hairline and inferiorly by the supraorbital ridge. The frontal bone underlies forehead soft tissue and is crossed laterally by a curved ridge called the temporal crest (also called the temporal ridge or the superior temporal fusion line of the skull). This is a palpable landmark that separates the temporal fossa and the origin of the temporalis muscle from the forehead portion of the frontal bone (Fig. 11.1). It also marks a change in nomenclature as tissue planes transition from lateral to medial. The deep temporal fascia covering the temporalis muscle attaches along the temporal ridge and continues medially as the periosteum that covers the frontal bone. Similarly, the superficial temporal fascia (also known as the temporal parietal fascia) continues medially as the galea aponeurotica that encompasses the frontalis muscle. The surgical significance of the temporal crest line is that all fascial layers are tethered to bone in a band approximately

426

SECTION II

CHAPTER 11  • Forehead rejuvenation

5 mm wide immediately medial to the palpable ridge. This has been called the zone of fixation.25,26 Where this zone approaches the orbital rim at its inferior end, the fascial attachment widens and becomes more dense, forming the orbital ligament (Fig. 11.2). All fascial attachments in this region must be released from bone when a full-thickness forehead flap is being repositioned. Some fascial structures in this area have been named by different authors, generating some confusion. The superior temporal septum27 and the zone of adhesion16 are alternative

terms used to describe the zone of fixation. The temporal ligamentous adhesion27 describes the lower portion of the zone of fixation and the orbital ligament. The inferior temporal septum27 and the orbicularis-temporal ligament28 both describe the crisscrossing white fibers that loosely attach the superficial to the deep temporal fascia. The inferior temporal septum is a useful landmark during endoscopic dissection from above, because it separates the safe upper zone containing no vital structures from the lower zone where facial nerve branches travel in the cavity’s roof. The medial zygomatic temporal vein (sentinel vein) is also present in this lower zone, adjacent to the lateral orbital rim. The temporal branches pass immediately superior to this vein (Figs. 11.3 & 11.4).

Superior temporal fusion line Zone of fixation (zone of adhesion)

Temporal ridge (temporal crest)

Figure 11.1  Bony anatomy of the forehead and temporal fossa. The palpable temporal ridge separates the temporal fossa from the forehead. The zone of fixation (also called zone of adhesion, superior temporal septum) is a 5-mm-wide band along the temporal ridge where all layers are bound down to periosteum.

Figure 11.3  Endoscopic view of the inferior temporal septum, right side.

Superior temporal septum Zone of fixation (zone of adhesion)

Sentinel vein

Orbital ligament

Inferior temporal septum

Temporal branches of the facial nerve Lateral orbital thickening Periorbital septal of periorbital septum attachment

Figure 11.2  Fascial attachments around the orbital rim. The inferior end of the zone of fixation is the orbital ligament. The lateral orbital thickening is a lateral extension of the septum that extends across the lateral orbital rim onto deep temporal fascia.

Figure 11.4  Endoscopic view of the medial zygomaticotemporal vein (sentinel vein), right side.

Historical perspective

Historical perspective The history of aesthetic brow surgery was thoroughly reviewed by Paul in 2001.1 The first description of brow elevation surgery was a publication by the French surgeon Passot in 1919.2 His technique involved the removal of multiple small skin ellipses, positioning scars in the forehead crease lines and at the frontal hairline. In 1926, Hunt described what appears to have been a full anterior hairline incision for brow-lifting access.3 In 1931, Lexer published a combined forehead and open brow lift with a hairline incision,4 and in 1933, Claoue published a similar extensive approach.5 Interestingly, forehead lifting then fell into disfavor for several decades until 1962 when Gonzalez-Ulloa published in the English literature an open coronal brow lift combined with facelift.6 Shortly thereafter, in Brazil, Vinas presented (1965)7 and subsequently described (1976)8 his advanced concepts of brow elevation. He suggested making a concerted effort to elevate the lateral

426.e1

portion of the brow. He also described a local method of direct brow lifting for certain patients. In 1984, Papillon and colleagues presented a subcutaneous dissection plane from the anterior hairline approach.9 In 1989, Paul described a transblepharoplasty approach.10 The original description of endoscopic brow lifting is attributed to two surgeons, Isse and Vasconez, both of whom presented their method at different venues in 1992.11,12 The first publication of this method was by Chajchir in 1993.13 In 1999, Knize published his “limited incision forehead lift”,14 using a short temple incision without endoscopic assist. By 2003, a reduction in the number of endoscopic brow lifts being done was documented due to uncertainty over the stability of endoscopic brow lifting.15 In the first part of the twenty-first century, other methods appeared to deal with lateral brow relapse.16 Numerous reports demonstrated the success of endoscopic brow lifting using measurements from the brow to the pupil.17–21 In the 2010s there was a resurgence of interest in various subcutaneous techniques.22–24

Anatomy

Galea Knize described galeal anatomy in detail.29 In the forehead, the galea aponeurotica splits into a superficial and deep layer encompassing the frontalis muscle (Fig. 11.5). Inferiorly, the deep galea layer separates further into three separate layers: one layer immediately deep to the frontalis forming the roof of the galeal fat pad, a second layer forming the floor of the galeal fat pad but not adherent to bone, and a third layer adherent to periosteum. The two deepest layers define the glide plane space between the galeal fat pad and the skull. Inferiorly, the septum orbitale divides orbital fat from preseptal fat (also known as retro-orbicularis oculi fat; ROOF). When the eyebrow is raised by frontalis contraction, the soft tissue slides over the glide plane space. The galeal fat pad extends across the entire width of the lower 2 cm of the forehead; medially it surrounds the supraorbital and supratrochlear nerves as well as portions of the frown musculature. The

Galeal aponeurosis Subgaleal space Periosteum

Superficial galea Frontalis muscle

427

galeal fat pad is separated from the preseptal fat (ROOF) by a reflected layer of galea. Laterally, this separation is thought to be variable, with some individuals having a continuous layer of fat from galeal fat pad to the preseptal fat (Fig. 11.6).29

Muscle Eyebrow level is the result of a balance between the muscular forces that elevate the brow, the muscular forces that depress the brow, and the universal depressor: gravity (Fig. 11.7). Brow depressors in the glabella originate from bone medially, inserting into soft tissue. The procerus runs vertically, the depressor supercilii and orbicularis run obliquely, and the corrugator mostly runs transversely. The transverse corrugator supercilii is the largest and most powerful of these muscles. It originates from the orbital rim at its most superomedial corner, with the large transverse head later passing through galeal fat, becoming progressively more superficial until it interdigitates with the orbicularis and frontalis at a skin dimple, which is visible when the patient frowns.30 The orbicularis encircles the orbit, acting like a sphincter. Medially and laterally, the orbicularis fibers run vertically and act to depress brow level. Laterally, orbicularis is the only muscle that depresses brow position (Figs. 11.8 & 11.9). Frontalis is the only elevator of the brow. It originates from the galea aponeurotica superiorly and interdigitates inferiorly with the orbicularis. Contraction raises this muscle mass, and in so doing, lifts the overlying skin which contains the eyebrow. Due to its deficiency laterally, the primary effect of frontalis contraction is on the medial and central portions of the eyebrow.

Sensory nerves Innervation to the upper periorbita is supplied by the supraorbital and supratrochlear nerves, as well as two lesser nerves, the infratrochlear, and zygomaticotemporal (Fig. 11.10).

Deep galea Galeal fat pad Frontalis muscle

Glide plane space Corrugator supercilii muscle

Galeal fat pad Orbital rim Periosteum

Galeal attachment

Preseptal fat (ROOF)

Obicularis oculi muscle

Suborbital fascia

Preseptal fat

Obicularis oculi muscle

Orbital septum

Orbital septum A

Figure 11.5  Relationship of galea to surrounding tissue as it splits to encompass the frontalis muscle, the galeal fat pad, and the glide plane space. The corrugator supercilii traverses through the galeal fat pad as it courses from its deep bony origin to its superficial insertion in the orbicularis and dermis.

Lateral orbital rim with deep galeal attachment

B

Lateral orbital rim with no galeal attachment

Figure 11.6  Lateral orbital rim variation. (A) Galeal attachment tethers the overlying brow. (B) The galeal fat pad is contiguous with retro-orbicularis oculi fat, potentially making the lateral brow prone to ptosis.

428

CHAPTER 11  • Forehead rejuvenation

SECTION II

Supratrochlear nerve Depressor supercilii

Corrugator supercilii

Infratrochlear nerve Superficial branch of supraorbital nerve

Deep branch of supraorbital nerve

Zygomaticotemporal nerve Orbicularis oculi

Procerus

Figure 11.7  Glabellar frown muscles. Zygomaticofacial nerve

Infraorbital nerve

Figure 11.10  Sensory nerves.

Figure 11.8  Lateral orbicularis acts like a sphincter, depressing the lateral brow.

Frontalis muscle

Temporal crest line Orbicularis occuli muscle

Figure 11.9  Frontalis acts to raise the eyebrow complex. On contraction, most movement occurs in the lower third of the muscle, and action is strongest on the medial and central eyebrow.

The infratrochlear nerve exits the orbit medially, supplying sensation to the nasal dorsum and medial orbital rim. It is seldom damaged and rarely a cause of postoperative concern. The zygomaticotemporal nerve exits posterior to the lateral orbital rim, piercing the deep temporal fascia just inferior to the sentinel vein. In brow lifting, with complete release of the lateral orbital rim, it is often avulsed. Consequences of this are minimal and temporary. The supratrochlear nerve usually exits the orbit superomedially, although this is variable, and it occasionally will exit near the supraorbital nerve. It immediately divides into 4–6 branches, which can pass superficial (anterior) to the corrugator, or more frequently, directly through the substance of the corrugator. These branches then become more superficial, innervating the central forehead. The supraorbital nerve exits the superior orbit either through a notch in the rim, or through a foramen superior to the rim. Much variation occurs, with foramina present about 20% of the time.31 The location of the notch or foramen is between 16 and 42 mm from the midline, with a mean of 25 mm. A useful landmark for this is a palpable notch, or failing that, the mid-papillary line. When a foramen is present, it has been found as far as 19 mm above the rim. Because of such variation, blind dissection from above should be discontinued at least 2 cm above the orbital rim. The supraorbital nerve immediately divides into two distinct segments: superficial and deep. The superficial branch pierces orbicularis and frontalis, dividing into several smaller branches, which travel on the superficial surface of the frontalis to innervate the central forehead as far posteriorly as the

Anatomy

first 2 cm of hair. The rest of the scalp, as far back as the vertex, is innervated by the deep branch. The deep branch courses superiorly in a more lateral location, remaining between the periosteum and the deepest layer of galea. As it travels superiorly, it becomes more superficial, piercing frontalis to innervate the skin. It is a double branch approximately 60% of the time.32 An important fact during endoscopic brow lifting is that the deep branch runs in a 1-cm-wide band, which is between 5 mm and 15 mm medial to the palpable temporal ridge (Fig. 11.11).

429

In all forehead lift procedures, dissection planes are designed to protect the temporal branches. This can be done by staying deep to them, which requires dissecting directly on deep temporal fascia in the temple and in the subgaleal or subperiosteal planes over the frontal bone. Alternatively, dissection can be kept superficial to the frontalis, the orbicularis, and the superficial temporal fascia. Facial nerve, temporal branch

Motor nerves The temporal branch of the facial nerve is the only motor nerve of concern in this area. Loss of this branch would result in a brow ptosis and asymmetry due to impaired frontalis action (Fig. 11.12). The anatomy of this nerve has been well described.33–36 The temporal branch enters the temporal fossa as multiple (2–4) fine branches that lie on the periosteum of the middle third of the zygomatic arch. Between 1.5 cm and 3.0 cm above the arch, these branches become more superficial, entering the superficial temporal fascia (temporoparietal fascia), traveling on to innervate the frontalis, superior orbicularis, and glabellar muscles.37 A number of different landmarks are commonly used to predict the course of the temporal branches. These include: 1. The middle third of the palpable zygomatic arch. 2. Parallel and adjacent to the inferior temporal septum. 3. Immediately superior to the sentinel vein (medial zygomaticotemporal vein).

Facial nerve, zygomatic branch

Figure 11.12  Facial nerve branches in the periorbital region. Note the corrugator has dual innervation from the temporal branch and the zygomatic branch. The temporal branch crosses the middle third of the zygomatic arch as 2–4 branches.

Supraorbital nerve, deep branch Supraorbital nerve, superficial branches

Figure 11.11 The deep branch of the supraorbital nerve travels in a 1-cm-wide band between 5 and 15 mm medial to the temporal ridge.  

 

430

SECTION II

CHAPTER 11  • Forehead rejuvenation

Patient presentation Forehead aging Historically, the visible signs of forehead aging have been described in two ways. First, and most obvious, are the furrows caused by the repetitive action of underlying muscles: transverse lines are due to the eyebrow-lifting action of the frontalis, while glabellar frown lines are due to the corrugator, depressor supercilii, and the procerus. The corrugator, being the most transverse of these muscles, causes vertical frown lines; the depressor supercilii, being oblique, causes oblique folds which cut across the orbital rim; and the vertically running procerus causes transverse lines at the radix (Figs. 11.13 & 11.14). Second, it has been assumed that the forehead/eyebrow complex becomes ptotic with age, encroaching on the orbit, causing a pseudo-excess of upper eyelid skin. While consistent with the age-related ptosis of most other body parts, the facts are not so clear.38,39 Studies shown that when observed over time, about one-third of eyebrows remain stable, onethird drop laterally, and one-third seem to rise medially, likely caused by chronic frontalis contraction (Fig. 11.15).40 Subconscious frontalis contraction may be caused by upper lid soft-tissue hooding or senile upper lid ptosis. Both stimulate

the frontalis to raise the eyebrows to open the patient’s line of sight. Also at play is personal habit, exhibited by the brow elevation seen when most individuals are confronted with a mirror, or on facing a camera. Closing the eyes will usually, but not always, relax the frontalis, causing the eyebrows to drop. Frontalis paralysis due to facial nerve injury or botulinum toxin will always drop the level of the eyebrow, which indicates that some resting tone is normal. A final factor in the aging of this area is the shape of the orbital aperture, which appears to enlarge with age, the superomedial brow rising, and the inferolateral orbital rim dropping and receeding.41,42 This could contribute to a rising medial brow, because of soft-tissue attachment and the soft-tissue support provided by the trunk of the supraorbital nerve (Fig. 11.16). As described earlier, the level and shape of the eyebrow is the result of a balancing act between the many forces of brow depression and the only elevator, which is the frontalis muscle. The lateral portion of the brow is particularly sensitive to this interplay because frontalis action is attenuated laterally.43 Against the unrelenting force of gravity and the lateral orbicularis oculi, the principal resistance to lateral brow descent is soft-tissue attachment. This attachment is variable and may be absent, leaving the lateral brow free to move.44 The result is often a gradual ptosis of the lateral third of the brow, relative to the medial brow. The appearance of downturned lateral eyebrows is accentuated if a patient also chronically raises the medial brow. The result is a look of sadness, tiredness, and age. Many patients recognize these changes and treat themselves with make-up, eyebrow plucking, or tattooing in order to make the lateral brow appear higher. Alternatively, they may seek blepharoplasty to deal with lateral soft-tissue hooding, unaware that the ptotic lateral brow is the most significant factor. The unsuspecting surgeon who performs blepharoplasty in this circumstance will see the frontalis relax, unmasking the compensated brow ptosis, causing the medial

Figure 11.13  Patient frowning. The paired vertical folds are caused by the corrugator supercilii and the transverse lines at the nasal radix are caused by the procerus. The paired oblique lines are caused by the depressor supercilii and the medial orbicularis oculi. Laterally, the “crow’s feet” lines are caused by the vertically running fibers of the orbicularis oculi. A

B

Figure 11.14  Patient raising eyebrows. The transverse forehead lines are caused by the frontalis.

Figure 11.15  From age 25 (A) to 50 (B), photographs demonstrate a 3–4 mm rise in the medial and central brows. One possible cause is chronic tone in the frontalis muscle.

Patient presentation

A

431

B

Figure 11.16  (A,B) Orbital changes with age: orbital volume expands, most marked superomedial and inferolateral. (With permission from Kahn DM, Shaw RB. Aging of the bony orbit. A three-dimensional computed tomographic study. Aesthet Surg J. 2008;28:258–264.)

and central brow to fall.45 Patients may perceive that the upper blepharoplasty has “pulled” the eyebrows down.

Aesthetics Traditional teaching has been that the correct eyebrow position is at or above the supraorbital rim. While usually true, this axiom is overly simplistic, because eyebrow height is only one of many variables. The junction of the upper eyelid and brow is aesthetically complex. Studies attempting to define the “ideal” female eye have identified many factors beyond the shape and height of the eyebrow. These include the configuration of the upper eyelid, the volume of the upper sulcus, and the location of the lower lid–cheek junction in relation to the eyebrow location. Other studies have shown that the emotion expressed by people can be affected by altering the shape of their eyebrows, implying that the shape of the brow is more important than its absolute height.46,47 Furthermore, aging of the eyebrow shape and position do not occur in isolation. Surrounding anatomic structures all change over time, including the upper eyelids, the orbit and the lower lid–cheek junction. As described earlier, a common finding in the aging forehead is chronic brow elevation in response to upper eyelid hooding. (see Fig. 11.15B). Gunter observed that the eyebrow and nasojugal fold create an oval shape, and that in an attractive eye, the pupil will lie at the equator of that oval (Fig. 11.17).48 This concept has been expanded by Gülbitti.49 Applying this analysis is a useful exercise to determine if brow position is an issue (Fig. 11.18). Ovals that are vertically wide look aged, while vertically narrow ovals look youthful. There is an intimate relationship between eyebrow position and the upper eyelid because, as the eyebrow is raised, upper lid hooding is lifted and more upper eyelid becomes visible, a feature known as tarsal show. In the attractive female eye, various authors have described the desirable amount of tarsal show as being between 25% and 35% of the distance from the eyelashes to the lower border of the eyebrow, at the lateral border of the iris (see Fig. 11.19).48,50 A number of different factors may change this ratio:   Changing eyebrow height   Lid ptosis or lid retraction   Redundant upper eyelid soft tissue   Loss of upper sulcus fat.

Figure 11.17  An oval formed by the eyebrow above, and the nasojugal fold below, should have the pupil at its equator. (Modified from Gunter J, Antrobus S. Aesthetic analysis of the eyebrows. Plast Reconstr Surg. 1997;99:1808–1816.)

Figure 11.18  On oval analysis of this case, the pupil lies above the natural equator of the oval. This confirms a low-lying eyebrow plus or minus a low-lying nasojugal fold.

432

CHAPTER 11  • Forehead rejuvenation

SECTION II

Peak

2/ 3 1/ 3

Figure 11.19  The modern ideal brow/upper eyelid complex.

To increase tarsal show, any one of these issues can be treated independently or in conjunction with a brow lift. Brow repositioning is a powerful tool but it must be considered in the context of other possibilities such as ptosis repair, blepharoplasty, and fat grafting to the upper lid sulcus. Individualization is a key component to any periorbital rejuvenation. Gender, ethnicity, eye prominence, and overall facial proportions must be considered. For example, Oriental faces look attractive with higher eyebrows than would seem appropriate for the European face. Complicating matters, the “ideal” eyebrow has also changed over time. Renaissance painters tended to portray their subjects with normal eyebrows and relatively hollow upper sulci, while in the 1950s, eyebrows became very high and arched.47 Individual variation aside, there are certain themes that define “the ideal eyebrow” (Fig. 11.19): 1. The medial eyebrow level should lie over the medial orbital rim. 2. The medial border of the eyebrow should be vertically in line with the medial canthus. 3. The eyebrow should rise gently, peaking slightly at least two-thirds of the way to its lateral end; typically this peak lies vertically above the lateral limbus. 4. The lateral tail of the brow should be higher than the medial end. 5. The male brow should be lower and less peaked.

Patient selection Most patients are not aware of the many variables involved in periorbital rejuvenation, and they may not want the multiple procedures required to treat all of these components. For that reason, identifying the main component of every patient’s periorbital aging is important. Old photographs are very helpful in determining which aging changes predominate. Such a review will also help to focus patients’ perspectives on exactly how they have aged and what, if any, rejuvenation they would prefer. Assessment of the patient should be done with the patient’s head in the vertical position; the patient will be sitting or standing. The following issues are evaluated: visual acuity; eyebrow

and orbital symmetry; position of anterior hairline; thickness of scalp hair; transverse forehead lines; glabellar frown lines; thickness of eyebrow hair; eyebrow height; axis of the eyebrow (downward or upward lateral tilt); shape of the eyebrow (flat or peaked); passive and active eyebrow mobility; and the presence of old scars or tattoos. The upper eyelids should be assessed for soft-tissue redundancy, for hollowness, and for lid level (ptosis versus lid retraction). The patient should be examined with eyes open and eyes closed. With the eyes closed, the frontalis can usually be made to relax, revealing the true position and shape of the eyebrows. If the brow is held in this position when the patient opens their eyes, the eyebrow/eyelid relationship without frontalis effect will be revealed. The surgeon can then manually reposition the eyebrows, experimenting with various positions and different vectors of mobilization. It is during the consultation that important decisions are made and a treatment plan is formulated. After physical examination, the patient’s concerns must be corelated with the surgeon’s anatomic findings. Frequently, what the patient feels is a simple problem is multifactorial. If forehead lines are the only area of concern, botulinum toxin may be an excellent first-choice treatment. However, many patients have tried this and are looking for something more permanent. The indications for brow lift surgery may be functional, to help clear visual obstruction, but more commonly the indications are aesthetic. Because the forehead does not age in isolation, common simultaneous procedures are facelift and blepharoplasty. With. some brow lift techniques, frown muscles can be weakened or removed. A patient may be a candidate to have their entire brow complex lifted, or to have only part of the eyebrow raised to improve eyebrow shape. Occasionally, this may involve raising the medial brow only, in the setting of angry-looking eyebrows. Most commonly it involves raising the lateral third to half of the brow, with little or no lift medially. In patients with upper lid hooding who undergo blepharoplasty, a valid goal of brow lift surgery may not be to lift the eyebrows at all, but rather, to maintain brow position when the frontalis inevitably relaxes after blepharoplasty.

Surgical techniques Surgical rejuvenation of the forehead has changed dramatically from the one-size-fits-all approach of an earlier era. As our understanding of anatomy and aging has improved, our available surgical techniques have also evolved. Alongside this evolution, the introduction of botulinum toxin for aesthetic indications has changed many of our fundamental concepts, and for many patients has supplanted interest in aesthetic brow surgery.

Open coronal approach The coronal approach was long considered the “gold standard” against which other techniques were measured. The principal advantage of this approach is the unparalleled surgical exposure, which facilitates release and mobilization of brow soft tissues, as well as the modification of glabellar muscles under direct vision. Surgical results are stable and relatively long-lasting.

Surgical techniques

433

Figure 11.22  Coronal approach showing corrugator muscles.

Figure 11.20  Coronal and anterior hairline approaches.

Figure 11.21  Open coronal flap dissection shown in the subgaleal plane.

The technique involves an incision over the top of the head, classically about 6–8 cm behind the anterior hairline, although this incision can be placed almost anywhere in the hair-bearing scalp (see Fig. 11.20). An incision at the vertex will be at the watershed between posterior and anterior running sensory nerves, thus reducing scalp numbness. However, a more anterior incision involves less scalp dissection, better visibility, and a closer point of traction on the eyebrows (Figs. 11.20–11.22). The incision is made full thickness down to periosteum, and the anterior flap can then be raised in either the subperiosteal, or more commonly, the subgaleal plane. Under direct vision, the flap is elevated anteriorly down to the orbital rim. If glabellar muscles are to be exposed, the galea must be breached on its deep surface, entering the galeal fat pad for access to the muscles (see Fig. 11.21). The frown muscles, corrugator, depressor supercilii, and procerus, can be removed or

weakened as necessary (see Fig. 11.22). Typically, resection of the corrugator requires dissection of the supratrochlear nerve branches that course through the substance of this muscle. It is often advantageous to leave some galeal attachment medially to prevent over-elevation of the medial scalp. Otherwise, for proper brow elevation, there must be a thorough release of the galeal attachments along the central and lateral orbital rims. The zone of fixation will be released as dissection progresses laterally over the deep temporal fascia. The trunk of the supraorbital nerve is identified and preserved. To reposition the brow, the flap is drawn superolaterally, and a full-thickness strip of scalp is excised. Laterally, scalp excision will range from 1 to 3 cm, but centrally, little or no scalp is excised. The scalp is closed directly, approximating galea and skin. Although deeper fixation can be added, the classic open coronal lift relies on scalp excision and galeal sutures to maintain brow position. Disadvantages of the open coronal approach include scalp numbness, some of which may be permanent, a long scar, disruption of hair follicles, and scalp dysesthesia. Inevitably, the anterior hairline will be raised slightly and some hair-bearing scalp will be sacrificed. This technique should be used cautiously or not at all in patients with a high anterior hairline, with thin hair, or in male patients who may eventually lose their hair.

Anterior hairline approach This incision is usually placed along the anterior hairline, until it reaches the hairline laterally, where it transitions into the hair-bearing temporal scalp. Alternatively, it can follow the hairline over its entire extent (see Fig. 11.20). Certain technical details help minimize scar visibility. These include placing the incision within or just posterior to the fine hair of the anterior hairline and beveling the incision parallel to the hair follicles. Alternatively, the principle of cutting across the hair follicles may be used in order to promote growth of hairs through the resulting scar.51 The incision, when made as a slightly wavy line, tends to create a less visible scar. Skin tension is minimized by approximating the galea and doing a meticulous skin closure. From the anterior hairline incision, dissection of the forehead flap can be done in one of three different planes: subperiosteal, subgaleal, or subcutaneous. Regardless of the plane being used, the anterior hairline approach offers the

434

SECTION II

CHAPTER 11  • Forehead rejuvenation

same advantage as the coronal approach, namely excellent surgical exposure, without the disadvantage of moving the anterior hairline posteriorly. In addition, there are two unique advantages. Because there is no undermining of hair follicles, the surgeon has the option of a subcutaneous dissection plane, which is done on the superficial surface of the frontalis muscle. This allows brow elevation without the need to divide any sensory nerves and also provides a potential effacement of deep transverse forehead lines. A modification of this method is a short incision in the widow’s peak, which is used to target only the lateral brow (Fig. 11.23).52 The anterior hairline approach can also be used to lower an excessively high anterior hairline or to lower overly high eyebrows. These problems may be congenital but often are the result of previous brow lift surgery. Hairline lowering involves a posterior dissection past the vertex of the skull, in order to extensively mobilize the scalp. Releasing incisions are made in the galea, and the scalp is advanced, utilizing bony fixation to maintain the new hairline position (Figs. 11.24 & 11.25). If the anterior approach is used to lower the eyebrows, bony fixation is done at the supraorbital rim.53–55

Fibers of frontalis muscle

Figure 11.23  Limited hairline subcutaneous approach.

Figure 11.24  Anterior hairline incision to lower the anterior hairline.

The main disadvantage of the anterior hairline incision is the presence of a permanent scar along the anterior hairline. In addition, if the scalp incision is full thickness, the resulting scalp denervation will be worse than with the coronal approach because the posterior running sensory nerves are transected closer to their origin. Lastly, a full dissection of forehead skin may compromise cutaneous blood flow leading to partial skin necrosis.

Endoscopic approach The endoscopic brow lift involves the same amount of dissection and soft-tissue release as the open coronal approach, but with much smaller access incisions and with visibility provided by an endoscope. More than any other innovation, the introduction of endoscopy to facial aesthetic surgery stimulated the quest for better understanding of forehead and temple anatomy. Basic anatomic principles are integral to the theory of endoscopic brow lifting. Laterally, brow lifting is accomplished by releasing all periorbital galeal attachments and relying on mechanical fixation, not scalp excision, to maintain the scalp in a higher position. Medially, brow lifting happens passively by removing muscular depressors and allowing the frontalis to lift unopposed. The principal advantages of the endoscopic approach are a very good surgical exposure with magnification of the surgeon’s view, and short, undetectable incisions. In addition, the scalp denervation associated with the open coronal approach is largely avoided (Fig. 11.26). Access for the procedure is through three to five small (1–2  cm) incisions placed within the hair-bearing scalp. Medial to the zone of fixation, the dissection plane can be subgaleal, or the more popular subperiosteal approach. Flap dissection can be done blindly at first but is completed under endoscopic control when approaching the orbital rim in order to avoid damaging the supraorbital nerve. Lateral to the zone of fixation, dissection is done against the deep temporal fascia, with the inferior temporal septum and the sentinel vein used as landmarks for the position of the overlying temporal nerve branches. Dissection is kept on the deep temporal fascia in order to avoid these branches. The medial and lateral dissection pockets are then joined by

Figure 11.25  Hairline lowering.

Surgical techniques

435

Temporal pocket – against deep temporal fascia Frontal pocket – subperiosteal

Figure 11.26  Five-port endoscopic approach.

Figure 11.27  Temple approach.

going from lateral to medial. Soft-tissue attachments along the lateral orbital rim and the supraorbital rim are visualized and released. Dissection down the lateral orbital rim may be preperiosteal or subperiosteal but must be done at least as far as and preferably beyond the lateral canthus in order to allow lateral brow elevation. The supraorbital nerve is visualized during orbital rim release. If glabellar musculature is to be removed or avulsed with biting forceps, the supratrochlear nerves are visualized as they pass through the substance of the corrugator supercilii. Care is taken to avoid excessive release of the flap medially to prevent over-elevation medially and to avoid separation of the eyebrows. Once dissected, the forehead flap is drawn superiorly and somewhat laterally. Specific vectors have been described in this regard,56 but the surgeon can make an artistic decision during preoperative planning, with appropriate vectors customized for each individual patient. While some authors have suggested that no fixation is necessary,17 two methods of fixation are normally employed: suture fixation in the lateral dissection pocket from the superficial to the deep temporal fascia and bony fixation in the medial dissection pocket. In an attempt to make the operation more predictable, a wide variety of fixation methods, devices, and techniques have been described, all designed to attach the elevated flap to the skull.57 The main disadvantages of endoscopic brow lifting are the technical demands of using endoscopic equipment, the potential of overly elevating or separating the medial eyebrows, and some uncertainty about maintaining adequate fixation.15

surgical modification of glabellar frown muscle modification is desired, a transpalpebral approach can be used. Disadvantages of this method include limited visibility of the central and medial supraorbital rim, an oblique vector applied to the lateral brow (see Fig. 11.27).

Temple approach A temple approach or “temple lift” involves a full-thickness scalp incision in the temple, lateral to the temporal crest line.58 Dissection is directly on the deep temporal fascia, with release of the lateral orbital rim, the supraorbital rim, and the zone of fixation with or without the use of an endoscope (Fig. 11.27).14 After flap mobilization, fixation is done with sutures between the superficial and deep temporal fascia. If

Transpalpebral approach – muscle modification Using the upper lid blepharoplasty approach, the glabellar frown muscles can be approached directly.59,60 This is an excellent method to attenuate glabellar frown lines in patients who do not require a forehead lift. It can also be used as an adjunct to the patient undergoing an isolated elevation of the lateral third of the brow. The advantage of this method is a hidden incision, which may be used for two purposes, blepharoplasty and frown muscle ablation. Through an upper blepharoplasty incision, the orbicularis is incised and dissection proceeds superiorly between the orbicularis and the orbital septum. The depressor supercilii overlies the darker-colored and more friable corrugator. Medially, a branch of the supratrochlear nerve is dissected and the corrugator is removed lateral to that. When the volume of muscle is significant, a small fat graft can be inserted. Medially in the wound, the depressor supercilii can be partially removed. The procerus can be transected by dissecting across the root of the nose.61 The main disadvantages of this approach include potential damage to sensory nerves (supraorbital and supratrochlear), and increased bruising and edema compared to an isolated upper lid blepharoplasty (Fig. 11.28).

Lateral brow approach The lateral brow approach utilizes a more medial incision than the temple approach. Its location is based on the observation that the most effective vector for elevating the lateral half of the eyebrow is directly along the temporal crest line

436

SECTION II

CHAPTER 11  • Forehead rejuvenation

Corrugator supercilii Depressor supercilii

Supratrochlear nerve branches Supraorbital nerve branches

Figure 11.28  Transpalpebral exposure of the frown musculature.

Figure 11.30  The neurovascular bundle of the deep branch of the supraorbital nerve. The subperiosteal pocket has been developed medially, and the temporal pocket against the deep temporal fascia has been developed laterally. The two pockets are joined along the temporal crest line. When the lateral brow is raised, the neurovascular bundle will telescope up under the scalp closure.

accomplished with deep temporal sutures and by suturing the galea, with no skin tension. Bone fixation is done medial to the neurovascular bundle. The main advantages of this method are those of the endoscopic approach, plus the same strength of fixation provided by a coronal lift. The main disadvantage, compared with the pure endoscopic approach, is a slightly longer incision in the temple (Fig. 11.30).

Cutaneous approaches

Figure 11.29  Preoperative marking for modified lateral brow lift. The planned vector of pull is marked. Laterally, the purple dashed lines mark the expected course of the facial nerve temporal branches. The purple dot represents the sentinel vein. The curved purple line marks the temporal crest line, which is accentuated when the patient clenches her teeth, contracting the temporalis. Medial to the crest line, the black cross-hatched band is the expected course of the deep branch of the supraorbital nerve, in purple. The corrugator supercilii, depressor supercilii, and procerus are marked in black.

(Fig. 11.29). A variety of fixation methods can be utilized.62 Proponents of this approach feel it is directed at the most ptotic portion of the aging brow or congenitally downturned brow.16 The modified lateral brow lift is a hybrid procedure utilizing a 5–6 cm incision in the scalp, approximately 1 cm behind the hairline.16 Because the desired vector is directly along the course of the deep branch of the supraorbital nerve, this procedure is designed to be nerve sparing. Orbital rim release can be done with or without an endoscope. A full-thickness excision of skin is done (like an open coronal lift), but nerve branches are preserved as a neurovascular bundle. Fixation is

The eyebrow is a cutaneous structure, so skin-only approaches have been developed as a logical method to move the eyebrow. Incisions can be placed anywhere on the forehead from the eyebrow to the hairline, with lower incisions providing the best predictability. With the suprabrow approach, often called a “direct brow lift”, skin is removed immediately adjacent to the eyebrow, as in Fig. 11.31. This technique will reposition the eyebrow close to a 1 : 1 ratio for skin excision to eyebrow lift and therefore is arguably the most accurate eyebrow lift available.63 The primary disadvantage is a potentially visible scar, something that can be mitigated with patient selection and careful suture technique.8,22,23 A mid brow approach can be used with an incision placed in a transverse forehead line, and the caudal side undermined and resected (Fig. 11.32). When a subcutaneous lift is attempted from the anterior hairline, the entire height of the forehead skin must be undermined. While successful, the relapse problem is greater which necessitates more skin removal, possibly as much as a 3 : 1 to 4 : 1 ratio for skin removal to eyebrow movement. To address this problem the “gliding brow” lift has been described in which undermining of the forehead skin is followed by shifting the skin and holding it in place with temporary, externally placed sutures. No skin is removed (Fig. 11.33) (see Videos 11.1–11.4 ). The advantages of a cutaneous ssapproach are: the surgery is relatively easy to master, it is well tolerated by the patient, there is no scalp denervation and there is no risk to motor nerves. Certain individuals, especially men with deep forehead creases or thick eyebrows, are especially good

Surgical techniques

437

A

A

B

B

Figure 11.32  The patient is shown (A) before and (B) 6 months after a right-sided cutaneous brow lift using a mid-brow transverse crease incision.

C

Figure 11.33  This 53-year-old woman has undergone a gliding brow lift using an open incision. No skin was excised. The hemostatic net suture is shown. The net sutures will be removed 3 days postoperatively.

D

Figure 11.31  The patient is shown (A) before and (B) after a direct cutaneous brow lift and upper lid blepharoplasty. The skin excision is shown in (C) and the resulting 12-month scar in (D).

candidates for these procedures because there are places to hide the incisions. Also, cutaneous procedures can easily be repeated if necessary. The principal disadvantages of these methods are a visible scar and the fact that, over time, brow-depressing forces will once again stretch out the skin, causing a recurrence of brow ptosis. In this regard, the closer the incision is to the eyebrow, the more predictable will be the surgical result.

438

SECTION II

CHAPTER 11  • Forehead rejuvenation

Transpalpebral browpexy During upper lid blepharoplasty, the ptotic lateral brow can be addressed through the same upper lid incision.64,65 The lateral portion of the superior orbital rim is easily exposed, and dissection proceeds superiorly over the frontal bone, superficial to the periosteum. Dissection should continue for 2–4 cm above the orbital rim, or at least 1 cm above the level of planned fixation. Several sutures are then used to tether the mobilized brow in a more superior position, fixating the underside of the orbicularis to the periosteum. Alternative methods of fixation to bone can also be used. Overly tight sutures must be avoided because of suture dimpling in the eyebrow. A more modest pexy is achieved if the superior cut edge of orbicularis oculi is simply sutured to the orbital rim, with no superior dissection at all.66 This maneuver acts like a hammock to hold the ROOF in its anatomic position. Advantages of transpalpebral browpexy are the ease of the procedure and a hidden scar. The principal disadvantage is the limited effect achieved and questionable longevity.

Suture suspension browpexy

Lesser procedures generally produce lesser results, but for the individual patient with appropriate expectations, this may be adequate. More involved procedures afford the opportunity for greater anatomic intervention, more dramatic results, and potentially greater longevity. The aesthetic results obtained with brow rejuvenation depend on our understanding of what portion of the brow is being targeted, coupled with the fact that shape is more important than the actual height of the eyebrow. In Fig. 11.34, aesthetic improvement has been achieved by targeting only the lateral half of the eyebrow. In Fig. 11.35, a less aesthetic outcome has resulted from inappropriate lifting of the medial brow. As discussed earlier, the aesthetics of the upper lid–brow junction encompasses many variables other than eyebrow shape and height. The patient who is a candidate for brow lift surgery may also benefit from simultaneous procedures such as blepharoplasty, periorbital fat grafting, or eyelid ptosis repair (Fig. 11.36 ). The key step in determining the correct constellation of surgical procedures is to make the correct aesthetic diagnosis at the outset.

A number of methods have been developed to elevate the brow only using sutures, with no dissection at all. Methods include barbed sutures or suture loops that are placed blindly through subcutaneous tunnels. The obvious advantage of these methods is extreme simplicity and relative safety, while the principal drawback is a concern about the degree and longevity of their effect. Nevertheless, proponents feel that the results, while modest, are justifiable because of the minimal surgical invasion required.67,68

Postoperative care Postoperative care for minor brow procedures is limited to head elevation, cold packs, ointment application, and analgesics. More extensive procedures (e.g., open coronal lift, endoscopic lift) will require dressings and the possibility of drains for 24 hours. Use of bupivacaine to block the supraorbital and supratrochlear nerves is very helpful to decrease the incidence and severity of postoperative headache. Patients can shower after 48 hours, with scalp suture removal in 7–10 days. After initial healing, measures can be adopted to prevent relapse of lateral brow ptosis. The use of botulinum toxin in the lateral orbicularis is helpful, as is the use of sunglasses and sun avoidance to prevent squinting in the first postoperative month.

A

B

Figure 11.34  Young woman with congenitally downturned lateral eyebrows. She is shown (A) before and (B) 6 months after a modified lateral brow lift.

Outcomes The surgical result of forehead rejuvenation depends on the type of deformity, the procedure done, and the quality of its execution. One unsolved issue with brow lift surgery is predictability. While upper lid blepharoplasty is accurate to the millimeter, brow lifting is not. A degree of relapse is inevitable with all techniques and this varies with the method used and the unique tissue characteristics of every patient. Over time, it is incumbent on surgeons to critically analyze their own results to better anticipate what can be accomplished in their hands and to give patients a more realistic idea of what can be expected.

Figure 11.35  Over-elevated medial brow after endoscopic brow lift.

Outcomes

A

B

Figure 11.36  A middle-aged woman who has unilateral brow ptosis, vertical orbital dystocia, and fat atrophy in the upper lid sulcus. She is shown (A) before and (B) 12 months after a right-sided endoscopic brow lift, bilateral upper sulcus fat grafting, and excisional upper eyelid blepharoplasty.

438.e1

Secondary procedures

439

Figure 11.38  Temporary neurapraxia of left temporal branch after coronal brow lift.

Figure 11.37  Scar alopecia after coronal brow lift.

Complications In addition to the aesthetic issues mentioned above, surgical complications of brow rejuvenation include scar alopecia, hematomas, infections, contour deformities, and nerve damage. Localized alopecia is caused when hair follicles are damaged by surgical incisions, electrocautery, or wound tension. Hair loss may be temporary, but if permanent, can be treated with simple scar excision or hair grafting (Fig. 11.37). Hematomas are uncommon and will resolve if they are small; however, a significant hematoma should be treated with surgical drainage. Infections are rare, consistently reported at less than 1%, and treated with wound care and appropriate antibiotics.18 Contour deformities can occur in areas of muscle excision; these problems are ideally prevented by the intraoperative utilization of filling material such as fat or temporal fascia. If identified late, similar tissue can be added at a separate procedure. Sensory nerve damage is a common problem and is universal with some types of procedures. With coronal incisions, all posterior-running sensory nerves are routinely transected. Initially, the resulting scalp denervation is profound and will extend to the vertex, but will gradually recover, often continuing to improve over many years. With limited incisions, such as endoscopic ports or lateral brow lifts, sensory change is less of an issue, but sensory nerves may still be traumatized due to traction, cautery, or instrumentation. The expectation is that normal sensation will likely return over time. With frown muscle ablation, temporary neurapraxia is normal, with sensory return typically appearing by 2–3 weeks.

Similarly, temporary neurapraxia of the supraorbital nerve is very common after a deep surgical release of the supraorbital rim. The only motor nerve of concern in the forehead is the temporal branch of the facial nerve, and damage to this nerve is the most worrisome local complication in brow lift surgery. Temporary neurapraxias are relatively common; fortunately, permanent damage to the temporal branch is rare. Should a neurapraxia develop, watchful waiting is the initial approach; possible interventions are described below (Fig. 11.38).

Secondary procedures The most common reason for revision surgery after brow surgery is to correct aesthetic deformities. The most common version of this problem is relapse and the loss of initial aesthetic effect. This situation can often be resolved to the patient’s satisfaction with a conservative upper lid blepharoplasty. However, if the loss of effect is significant, a repeat brow lift procedure may be necessary, preferably using a different technique with a different dissection plane and a different method of fixation. When overly aggressive brow lift surgery has been done, the most frequent result is over-elevation of the medial brow (see Fig. 11.33). If it is minimal, botulinum toxin injection in the central frontalis will help attenuate the problem. Alternatively, if the condition is pronounced, the medial brow can be surgically lowered. This requires a full release of the scalp’s attachment to the underlying skull, lowering of the medial brow, and bone anchoring to the orbital rim.55 Successful reversal of an overdone brow lift is typically more difficult to achieve than the original brow lift itself. Another common variation of unfavorable brow shape occurs when the medial brow has been appropriately elevated, but the lateral brow remains unelevated, causing a laterally downturned appearance. Such a scenario can be treated with an isolated lateral brow lift. Fortunately, true complications are uncommon and minor issues, such as scar alopecia and contour deformities in the glabella, are treatable with simple procedures.

440

SECTION II

CHAPTER 11  • Forehead rejuvenation

In the case of a temporal branch palsy that does not improve with time, treatment options include the use of botulinum toxin to the frontalis on the normal side, or alternatively, a repeat brow lift on the affected side. Lastly, like any surgery for age-related change, the surgical effects of a brow lift may become attenuated over time. In order to maintain a longstanding effect, revision surgery may be necessary.

Access the reference list online at   Elsevier eBooks+

Bonus images for this chapter can be found online at Elsevier eBooks+ Fig. 11.36 A middle-aged woman who has unilateral brow ptosis, vertical orbital dystocia, and fat atrophy in the upper lid sulcus. She is shown (A) before and (B) 12 months after a right-sided endoscopic brow lift, bilateral upper sulcus fat grafting, and excisional upper eyelid blepharoplasty.

References

References 1. Paul MD. The evolution of the brow lift in aesthetic plastic surgery. Plast Reconstr Surg. 2001;108:1409–1424. In this paper, the author

thoroughly reviews the published history of brow lift surgery, from 1919 to 2001.

2. Passot R. La chururgie esthetique de rides du visage. Presse Med. 1919;27:258–260. 3. Hunt HL. Plastic Surgery of the Head, Face, and Neck. Philadelphia, PA: Lea & Febiger; 1926. 4. Lexer E. Die Gesamte Wiederherstellungs-Chirurgie. Vols. 1 and 2. Leipzig: Jahann Ambrosius Barth; 1931. 5. Claoue C. La ridectomie cervico-faciale par accrochage parietotemporo-occipital et resection cutanee. Bull Acad Med (Paris). 1933;109:257–265. 6. Gonzalez-Ulloa M. Facial wrinkles: integral elimination. Plast Reconstr Surg. 1962;29:658–673. 7. Vinas JC. Plan general de la ritidoplastia y zona tabu. Transactions of the 4th Brazilian Congress on Plastic Surgery, Porto Alegre, October 5. 1965;8:32. 8. Vinas JC, Caviglia C, Cortinas JL. Forehead rhytidoplasty and brow lifting. Plast Reconstr Surg. 1976;57:445–454. 9. Papillon J, Perras C, Tirkanits B. A comparative analysis of forehead lift techniques. Presented at the Annual Meeting of the American Society for Aesthetic Plastic Surgery, Boston, 1984. 10. Paul MD. The surgical management of upper eyelid hooding. Aesthetic Plast Surg. 1989;13:183–187. 11. Isse NG. Endoscopic forehead lift. Presented at the Annual Meeting of the Los Angeles County Society of Plastic Surgeons, Los Angeles, September 12, 1992. 12. Vasconez LO. The use of the endoscope in brow lifting. A video presentation at the Annual Meeting of the American Society of Plastic and Reconstructive Surgeons, Washington, DC, 1992. 13. Chajchir A. Endoscopia en cirugia plastica y estetica. In: Gonzalez Montaner LJ, Huriado Hoyo E, Altman R, et al., eds. El Libro de Oro en Homenaje al Doctor Carlos Reussi. Buenos Aires: Associacion Medica Argentina; 1993:74. 14. Knize DM. Limited incision foreheadplasty. Plast Reconstr Surg. 1999;103:271–284. 15. Chiu ES, Baker DC. Endoscopic brow lift: a retrospective review of 628 consecutive cases over 5 years. Plast Reconstr Surg. 2003;112:628–633. 16. Warren RJ. The modified lateral brow lift. Aesthet Surg J. 2009;29: 158–166. 17. Troilius C. Subperiosteal brow lifts without fixation. Plast Reconstr Surg. 2004;114:1595–1603. 18. Jones BM, Grover R. Endoscopic brow lift: a personal review of 538 patients and comparison of fixation techniques. Plast Reconstr Surg. 2004;113:1242–1250. 19. Swift RW, Nolan WB, Aston SJ, et al. Endoscopic brow lift: objective results after 1 year. Aesthet Surg J. 1999;19:287–292. 20. Guyuron B, Kopal C, Michelow BJ. Stability after endoscopic forehead surgery using single-point fascia fixation. Plast Reconstr Surg. 2005;116:1988–1994. 21. Graf RM, Tolazzi ARD, Mansur AEC, et al. Endoscopic periosteal brow lift: evaluation and follow-up of eyebrow height. Plast Reconstr Surg. 2008;121:609–616. 22. Pelle-Ceravolo M, Angelini M. Transcutaneous brow shaping: a straightforward and precise method to lift and shape the eyebrows. Aesth Surg J. 2017;37(8):863–875. 23. Viterbo F, Auersvald A, O’Daniel TG. Gliding brow lift (GBL): a new concept. Aesthet Plast Surg. 2019;43:1536–1546. 24. Mahmood U, Baker JL. Lateral subcutaneous brow lift: updated technique. Aesthet Surg J. 2015;35(5):621–624. 25. Knize DM. An anatomically based study of the mechanism of eyebrow ptosis. Plast Reconstr Surg. 1996;97:1321–1333. In this

paper, the author presents the results of careful anatomic dissections to delineate the fascial structures that govern eyebrow stability. Surgical implications are described in the second paper in the same journal.

440.e1

26. Knize DM. Limited-incision forehead lift for eyebrow elevation to enhance upper blepharoplasty. Plast Reconstr Surg. 1996;97:1334–1342. 27. Moss CJ, Mendelson BC, Taylor I. Surgical anatomy of the ligamentous attachments in the temple and periorbital regions. Plast Reconstr Surg. 2000;105:1475–1490. The authors describe a

different way of describing fascial structures surrounding the orbit and creating structural layers in the temple. A number of anatomic terms are introduced for the first time.

28. Isse N. Endoscopic anatomy of the forehead and temporal fossa. In: Knize DM, ed. Forehead and Temporal Fossa: Anatomy and Technique. Philadelphia, PA: Lippincott Williams & Wilkins; 2001:73. 29. Knize DM. Galea aponeurotica and temporal fascias. In: Knize DM, ed. Forehead and Temporal Fossa: Anatomy and Technique. Philadelphia PA: Lippincott Williams & Wilkins; 2001:45. This text thoroughly

presents the anatomy of the temporal fossa, the forehead and the soft tissues that relate to the eyebrows. Knize combines several anatomical studies to summarize this anatomy, while several additional authors contribute to the technique portions of the book.

30. Janis JE, Ghavami A, Lemmon JA, et al. Anatomy of the corrugator supercilii muscle: part I. Corrugator topography. Plast Reconstr Surg. 2007;120:1647–1653. 31. Beer GM, Putz R, Mager K, et al. Variations of the frontal exit of the supraorbital nerve: an anatomic study. Plast Reconstr Surg. 1998;102:334–341. 32. Knize DM. A study of the supraorbital nerve. Plast Reconstr Surg. 1995;96:564–569. 33. Furnas DW. Landmarks for the trunk and the temporofacial division of the facial nerve. Br J Surg. 1965;52:694–696. 34. Pitanguy I, Ramos AS. The frontal branch of the facial nerve: the importance of its variation in face lifting. Plast Reconstr Surg. 1966;38:352–356. 35. Stuzin JM, Wagstrom L, Kawamoto HK, et al. Anatomy of the frontal branch of the facial nerve: the significance of the temporal fat pad. Plast Reconstr Surg. 1989;83:265–271. 36. Gosain AK, Sewall SR, Yousif NJ. The temporal branch of the facial nerve: how reliably can we predict its path? Plast Reconstr Surg. 1997;99:1224–1233. 37. Agarwal CA, Mendenhall MS, Foreman KB, et al. The course of the frontal branch of the facial nerve in relation to fascial planes: an anatomic study. Plast Reconstr Surg. 2010;125:532–537. 38. Van Den Bosch W, Leenders I, Mukler P. Topographic anatomy of the eyelids and the effects of sex and age. Br J Ophthamol. 1999; 83:348–352. 39. Matros E, Garcia JA, Yaremchuk MJ. Changes in eyebrow shape and position with aging. Plast Reconstr Surg. 2009;124:1296–1301. 40. Lambros V. Observations on periorbital and midface aging. Plast Reconstr Surg. 2007;120:1367–1376. 41. Pessa JE, Chen Y. Curve analysis of the aging orbital aperture. Plast Reconstr Surg. 2002;109:751–755. 42. Kahn DM, Shaw RB. Aging of the bony orbit: a three-dimensional computed tomographic study. Aesthet Surg J. 2008;28:258–264. 43. Lemke BN, Stasior OG. The anatomy of eyebrow optosis. Arch Ophthalmol. 1982;100:981–986. 44. Knize DM. Muscles that act on glabellar skin: a closer look. Plast Reconstr Surg. 2000;105:350–361. 45. Flowers RS, Duval C. Blepharoplasty and periorbital aesthetic surgery. In: Aston SJ, Beasley RW, Thorne CH, eds. Grabb and Smith's Plastic Surgery. 5th ed. Philadelphia, PA: Lippincott-Raven; 1997:612. 46. Knoll BI, Attkiss KJ, Persing JA. The influence of forehead, brow, and periorbital aesthetics of perceived expression in the youthful face. Plast Reconstr Surg. 2008;121:1793–1802. 47. Warren RJ. Endoscopic brow lift: five-portal approach. In: Nahai F, Saltz R, eds. Endoscopic Plastic Surgery. 2nd ed. St Louis, MO: Quality Medical Publishing; 2008:212. 48. Gunter J, Antrobus S. Aesthetic analysis of the eyebrows. Plast Reconstr Surg. 1997;99:1808–1816. The authors analyze the features

of periorbital attractiveness. They conclude that eyebrow aesthetics must be considered in concert with the entire periorbital area, including the eyelids. They describe novel ways to analyze eyes for attractiveness and identify eight features of attractive eyes.

440.e2

SECTION II

CHAPTER 11  • Forehead rejuvenation

49. Gülbitti HA, Bouman YK, Marten TJ, Van der Lei B. The orbital oval balance principle: a morphometric clinical analysis. Plast Reconstr Surg. 2018;142(4):451e–461e. 50. Vaca EE, Bricker JT, Helenowsky I, Park ED, Alghoul MS. Identifying aesthetically appealing upper eyelid topographic proportions. Aesthet Surg J. 2019;39(8):28:824–834. 51. Camirand A, Doucet J. A comparison between parallel hairline incisions and perpendicular incisions when performing a face lift. Plast Reconstr Surg. 1997;99:10–15. 52. Miller TA, Rudkin G, Honig J, et al. Lateral subcutaneous brow lift and interbrow muscle resection: clinical experience and anatomic studies. Plast Reconstr Surg. 2000;105:1120–1127. 53. Guyuron B, Belmand RA, Green R. Shortening the long forehead. Plast Reconstr Surg. 1990;103:218–223. 54. Marten T. Hairline lowering during foreheadplasty. Plast Reconstr Surg. 1999;103:224–236. 55. Yaremchuk MJ, O’Sullivan N, Benslimane F. Reversing brow lifts. Aesthet Surg J. 2007;27:367–375. 56. Eaves FF. Endoscopic brow lift surgery. In: Bostwick J, Eaves FF, Nahai F, eds. Endoscopic Plastic Surgery. St Louis, MO: Quality Medical Publishing; 1994. 57. Rohrich RJ, Beran SJ. Evolving fixation methods in endoscopically assisted forehead rejuvenation: controversies and rationale. Plast Reconstr Surg. 1997;100:1575–1582. 58. Gleason MC. Brow lifting through a temporal scalp approach. Plast Reconstr Surg. 1973;52:141–144. 59. Knize DM. Transpalpebral approach to the corrugator supercilii and procerus muscles. Plast Reconstr Surg. 1995;95:52–62.

60. Guyuron B, Michlow BJ, Thomas T. Corrugator supercilii muscle resection through blepharoplasty incision. Plast Reconstr Surg. 1995;96:691–696. 61. Guyuron B, Son JH. Transpalpebral corrugator resection: 25-year experience, refinements and additional indications. Aesthet Plast Surg. 2017;41:339–345. 62. Tucillo F, Jacovella P, Zimman O, et al. An alternative approach to brow lift fixation: temporoparietalis fascia, galeal, and periosteal imbrication. Plast Reconstr Surg. 2007;120:1433–1434. 63. Castañares S. Forehead wrinkles, glabellar frown and ptosis of the eyebrows. Plast Reconstr Surg. 1964;34:406–413. 64. Sokol AB, Sokol TP. Transblepharoplasty brow suspension. Plast Reconstr Surg. 1982;69:940–944. 65. McCord CD, Doxanas MT. Browplasty and browpexy: an adjunct to blepharoplasty. Plast Reconstr Surg. 1990;86:248–254. 66. Zarem HA, Resnick RM, Carr DG. Browpexy: lateral orbicularis muscle fixation as an adjunct to upper blepharoplasty. Plast Reconstr Surg. 1997;100:1258–1261. 67. Ruff GL. Suture suspension for face and neck. In: Aston SJ, Steinbrech DS, Walden JL, eds. Aesthetic Plastic Surgery. Philadelphia, PA: Saunders Elsevier; 2009. 68. Tiryaki T. Shuttle lifting of the face: a percutaneous purse string suture suspension method for facial rejuvenation. Presented at 19th International Society of Aesthetic Plastic Surgery, February 10–13, 2008, Melbourne, Australia.

SECTION II  •  Aesthetic Surgery of the Face

12 Endoscopic brow lift Renato Saltz and Eric W. Anderson

Access video lecture content for this chapter online at Elsevier eBooks+

SYNOPSIS

ƒ Advances in endoscopic brow lift technique provide a more precise and safer procedure to the aesthetic facial surgeon. ƒ Brow shape, position, and hyperactivity of the frontalis and corrugator muscles are an integral part of periocular rejuvenation. ƒ An upper blepharoplasty should not be indicated or performed for treatment of periocular aging until the brow position and symmetry is fully evaluated and treated. ƒ Modern and safe facial surgeons must incorporate endoscopic techniques in their practices – a gold standard treatment for periocular rejuvenation.

Introduction The endoscopic approach for forehead rejuvenation and brow lift has many advantages. It provides excellent exposure for release of periorbital soft tissues combined with endoscopic magnification, shorter scars, and reduced risk of alopecia and scalp sensory changes compared with the traditional open coronal brow lift. The technique has improved over the last 15 years with better fixation devices, a better understanding of the longevity, and decreased complications of the procedure. The endoscopic brow lift offers the patient a much easier and safer solution for the aging forehead, the active wrinkles from corrugator and frontalis hyperactivity, and the ptotic, asymmetric brow (Video Lecture 12.1 ).

Anatomic considerations The anatomy of the forehead and periorbital regions should be appreciated by the surgeon. The temporal ridge is bound by the temporal line of fusion, which is a deep bony point of fixation of the overlying soft tissues. To mobilize the lateral brow and temporal region, the temporal line of fusion should

be released to the level of the supraorbital rim. There are also supraorbital ligamentous attachments that require release to elevate the brow and forehead (Fig. 12.1). The nerves encountered during endoscopic brow lift include the two main sensory nerves, supratrochlear and supraorbital, and main motor branch of the facial nerve, the frontal branch. Care is taken to appreciate and preserve these nerves during dissection. Subgaleal dissection lateral to the temporal line of fusion will maintain the plane of dissection deep to the frontal branch. Inferior lateral dissection to the level of the sentinel veins while remaining on the superficial layer of the deep temporal fascia also protects the frontal branch from direct division or traction neuropraxia. The neurovascular bundles for the supratrochlear and supraorbital nerves exit the orbit 1.5 and 2.5 cm from midline, respectively; appreciation allows gentle division of the periosteum at the location to avoid injury to the nerves (Fig. 12.2). The muscles of the forehead include the frontalis, procerus, corrugator supercilii with oblique and transverse heads, the depressor supercilii, and the orbicularis muscles. The sole brow elevator is the frontalis muscle while the other muscles act as varying degrees of brow depressors. While release and physical repositioning of the brow and forehead elevate the brow, division and weakening of the brow depressors also correct dynamic ptosis and glabellar frown lines (Fig. 12.3).

Brow considerations The ideal shape and position of the brow has changed over the years through different cultures and fashions. Therefore, brow aesthetics cannot be generalized and must be evaluated in relation to gender, ethnicity, orbital shape, and overall facial aging and proportion. Currently, ideal brow aesthetics are considered to be medial brow positioned at the level of the orbital rim, above the medial canthus, with a gentle peak at the lateral limbus and the lateral tail higher than the medial (Fig. 12.4). With facial aging, the eyebrows gradually fall and

SECTION II

442

CHAPTER 12  • Endoscopic brow lift

Superior temporal fusion line Zone of fixation

Inferior temporal fusion line

Temporal ridge

Supraorbital nerve Supratrochlear nerve

Figure 12.1  Structural landmarks in the brow. The temporal fusion line lies at the junction of the periosteum and the deep temporal fascia. It must be released to achieve brow mobility. The orbital retaining ligament, situated at the lateral supraorbital rim, must also be released. (Reproduced from Saltz R, Codner M. Endoscopic brow lift. In: Nahai FR, Nahai F, Codner M, eds. Techniques in Aesthetic Plastic Surgery: Minimally Invasive Facial Rejuvenation. Philadelphia: Saunders Elsevier; 2009.)

Orbital ligament

Zygomaticotemporal nerve

Supraorbital nerve Supratrochlear nerve

Frontal branch nerves Sentinel vein Temporal branches of the facial nerve

Figure 12.2  Sensory and motor nerve supply to the brow. The supraorbital and supratrochlear nerves are protected during dissection. The frontal branches of the facial nerve lie anterior to the deep temporal fascia. (Reproduced from Saltz R, Codner M. Endoscopic brow lift. In: Nahai FR, Nahai F, Codner M, eds. Techniques in Aesthetic Plastic Surgery: Minimally Invasive Facial Rejuvenation. Philadelphia: Saunders Elsevier; 2009.)

Surgical technique

Frontalis

Procerus

443

lose volume, encroaching on the orbit and bunching the skin over the lateral orbital rim, creating what is known as “temporal hooding”. Eyebrow ptosis, eyebrow asymmetry, temporal hooding, and forehead wrinkles are all indications for forehead rejuvenation and a brow lift (Fig. 12.5).

Patient selection

Orbicularis

Corrugator

Figure 12.3  Brow musculature. The muscles involved with brow movement are illustrated. The corrugators and procerus contribute to vertical and transverse brow furrows, respectively. (Reproduced from Saltz R, Codner M. Endoscopic brow lift. In: Nahai FR, Nahai F, Codner M, eds. Techniques in Aesthetic Plastic Surgery: Minimally Invasive Facial Rejuvenation. Philadelphia: Saunders Elsevier; 2009.)

Since the introduction of the endoscopic approach in 1993 by Core and Vasconez, implementation of open coronal brow lift has declined. Over 80% of facial rejuvenation cases today include brow lift through an endoscopic technique. The ideal candidate for endoscopic technique has a flat forehead (flat frontal bone), no receding hairline (low hairline) and no redundant forehead skin. High hairline or male pattern baldness can increase the challenge of operative visualization and the removal of glabellar muscles. Alternative techniques for forehead rejuvenation include open coronal, lateral temporal brow lift, direct approach through the brow, transpalpebral brow lift with direct excision of the corrugator muscles and neurotoxin injections. During patient selection, the two key problems to address are eyebrow ptosis and frown lines, frontal and glabellar. Brow ptosis is a combination of soft-tissue descent, soft-tissue deflation and loss of lid crease. There is no frontalis muscle lateral to the temporal crest suggesting that 25–30% of the brow tail has no “levator mechanism”.

Surgical technique

A

B

Figure 12.4  Brow aesthetics. (A) The ideal brow position for females lies above the supraorbital rim with its highest peak vertically in line with the lateral limbus. (B) The lateral brow lies in an oblique line connecting the ala and lateral canthus. (Reproduced from Saltz R, Codner M. Endoscopic brow lift. In: Nahai FR, Nahai F, Codner M, eds. Techniques in Aesthetic Plastic Surgery: Minimally Invasive Facial Rejuvenation. Philadelphia: Saunders Elsevier; 2009.)

Vertical frown lines: Corrugator Brow ptosis Crow’s feet: Orbicularis oculi

After adequate informed consent, the patient is marked for surgery in a standing or sitting position. A temporal incision is marked along a vector line from the nasal ala crossing the lateral canthus and continuing to a point approximately 2 cm behind the temporal hairline. A 2-cm curved line is then marked medial to that point in both temporal areas. Paramedian incisions are 1-cm vertical lines posterior to the anterior frontal hairline placed in the axis of mid-pupil line extended superiorly (Fig. 12.6). The location of the supratrochlear and supraorbital nerves are identified and marked. The location of the deep branch of the supraorbital nerve as it reaches the hairline is also marked approximately 1 cm medial to the temporal crest line. If the patient has brow asymmetry on preoperative evaluation,

Oblique frown lines: Corrugator oblique head (variable) Depressor supercilii Orbicularis oculi Transverse frown lines: Procerus

Figure 12.5 Age-related changes in the brow. These involve brow descent, furrowing, vertical and transverse frown lines, and crow’s feet. (Reproduced from Saltz R, Codner M. Endoscopic brow lift. In: Nahai FR, Nahai F, Codner M, eds. Techniques in Aesthetic Plastic Surgery: Minimally Invasive Facial Rejuvenation. Philadelphia, PA: Saunders Elsevier; 2009.)  

444

SECTION II

CHAPTER 12  • Endoscopic brow lift

Figure 12.6  Preoperative markings. Four-port approach preferred with two temporal and two paramedian incisions. The temporal incisions are placed in a vector from the nasal ala in the direction of the lateral canthus, usually 2 cm behind the temporal hairline. The paramedian incisions are placed in the mid-pupil axis, behind the hairline. (From Saltz R, Ohana B. Thirteen years of experience with the endoscopic midface lift. Aesthet Surg J. 2012; 32(8): 927–936; with permission.)

careful examination should be performed for true brow asymmetry or underlying unilateral upper lid ptosis, which causes ipsilateral elevation of the brow to compensate. In the latter situation, repair of the eyelid ptosis often equalizes brow position, thus avoiding overcorrection of one brow compared to the other. Most commonly, the patient is placed under general anesthesia using an endotracheal tube secured to the maxillary incisors with dental floss. Infiltration is achieved using a mixture of 20 mL of 2% lidocaine, 20 mL of 0.25% Marcaine and 1 mL of epinephrine in 160 cc of normal saline. Infiltration is completed with 20-gauge spinal needle in a tumescent fashion. The patient is prepped and draped in a sterile head wrap; an endotracheal tube is also wrapped with sterile plastic drape for easy manipulation inside the sterile field. While the use of the endoscopic brow lift has nearly eliminated the need for open coronal brow lifts, there are additional equipment requirements (Fig. 12.7). Equipment should be tested prior to induction of general anesthesia and back-up equipment should be available. The endoscopic equipment on the cart includes a monitor, high-definition camera with ability to record the procedure as well as take photographs, electrocautery base unit and suction. The additional equipment on the field includes a 4–5-mm endoscope, 30° Hopkin rod with an endoscopic sheath camera connector, endoscopic dissectors, endoscopic forceps and rongeurs, and a malleable Durden suction cautery. Many different devices can be used for fixation: a drill for cortical tunnels, a drill

for temporary screw fixation, a drill for use of the Endotine devices, or a variety of other fixation methods. The endoscopic cart should be positioned at the foot of the bed with the surgeon positioned at the head of the bed. The procedure begins approximately 20 min after infiltration is completed to obtain maximum vascular constriction. The temporal incision allows visualization and dissection on top of the deep temporal fascia. Blunt dissection is completed in the temporal areas as well as the subperiosteal plane over the frontal bone. Both areas are then communicated after division of soft tissues over the temporal crest (Fig. 12.8). At this point, a 4-mm 30° scope is introduced to continue the dissection. The sentinel veins are identified and preserved (Fig. 12.9). The “fusion ligament” is identified and divided using endoscopic scissors. The dissection continues medially, where the supraorbital nerve is identified and preserved. The periosteal attachments are not transected in the midline, between the corrugator muscles, to minimize medial brow elevation and the so-called “surprised look.” At this point, the corrugator fibers are identified and completely excised (Fig. 12.10). Manual palpation and gentle pressure over the skin avoids trauma to the dermis and possible indentations during endoscopic corrugator resection. In cases of very thin skin and possible indentation, immediate placement of fat grafts with suture fixation is recommended. At this point, the surgeon should assess lateral brow mobility to assure both are equally mobile and symmetrical. Temporal fixation is achieved using three interrupted polydioxanone sutures (PDS) from the superficial temporal fascia and galea in a superior lateral vector to the deep temporal fascia. PDS suture is placed using a sharp percutaneous needle. The central portion of the inferior scalp flap may be excised in triangular fashion to prevent redundancy at the lateral brow. Fixation of the paramedian incisions is achieved with the Endotine device (Coapt Systems, Inc., Palo Alto, CA, US) (Fig. 12.11). At this point, still under general anesthesia, the patient is examined in a sitting position for final brow position and brow symmetry. Measurements for comparison include the mid-pupil to top of the mid-brow and the lateral canthus to the tail of the brow. Measurements are recorded and documented in the operative report for future comparison. The incisions are then closed with 4-0 plain gut. The hair is shampooed, and the patient is extubated and taken to the recovery room. Endoscopic release of the temporal and zygomatic retaining ligaments allows one to extend dissection inferiorly to the midface in a safe plane expanding the application of endoscopic technique to midface rejuvenation. Also, endoscopically releasing the zygomatic ligaments facilitates the superficial musculo-aponeurotic system (SMAS) open dissection when performing concomitant facelift. This allows SMAS and sub-SMAS elevation with subsequent fixation in a much safer approach and decreases operative time.

Postoperative care The patient should be treated with analgesics for the first 48–72 h with ice compresses to decrease pain and headaches. The patient’s head should be kept elevated to decrease venous congestion and improve the lymphatic drainage. Lymphatic massage performed in the first 72 h by a certified lymphatic massage therapist can decrease swelling and bruising, improve patient comfort and expedite recovery.

Postoperative care

445

Operating Room SETUP

Assistant

Back table Anesthesiologist Scrub nurse

vid

eo e e nd clu quipm osco p din g m ent ic on ito r)

(in

Figure 12.7  Surgical table and equipment. (From Foad N., et al. Endoscopic Plastic Surgery. QMP. New York: Thieme Medical Publishers, Inc.; 2008, with permission.)

446

SECTION II

CHAPTER 12  • Endoscopic brow lift

Sentinel vein Temporal crest

Sentinel vein Temporal crest

A

Plane of dissection Extent of dissection

TPF

DTF

Fat Temporalis muscle

Skin

Masseteric fascia (over masseter muscle)

Zygomaticus major and minor muscles

B

Extent of dissection

Masseteric fascia (over masseter muscle)

C

Zygomaticus major and minor muscles

Figure 12.8  Forehead dissection. (A) Starts with release of temporal zone using periosteal dissectors on the surface of the deep temporal fascia in the lateral area and on the periosteum in the medial area. After these pockets are completed, the temporal line of fusion is released in a lateral-to-medial direction. This “blind” dissection is kept approximately 1 cm above the supraorbital rim. The index finger of the contralateral hand stays on top of the supraorbital rim to protect the orbit. The 30°-angle 4-mm endoscope is only introduced after the temporal and forehead regions are completely released. (B, C) The temporal pocket is developed easily and safely by smooth dissection on top of the deep temporal, above the temporalis muscle and below the superficial temporal fascia, thus protecting the intermediate fat pad and the frontal branch of the facial nerve. DTF, Deep temporal fascia; LZTN, lateral zygomatic temporal nerve; MZTN, medial zygomatic temporal nerve; TPF, temporal parietal fascia, also known as superficial temporal fascia; ZFN, zygomatic facial nerve. (From Saltz R, Lolofie A. My evolution with endoscopic brow-lift surgery. Facial Plast Surg Clin North Am. 2021;29(2):163–178)

Outcomes, prognosis and complications

447

Outcomes, prognosis and complications

Figure 12.9  Sentinel vein. The sentinel vein is encountered during endoscopic dissection. The identification of the sentinel vein identifies a standard landmark for the frontal branch of the facial nerve. Dissection should not proceed beyond this. (Reproduced from Saltz R, Codner M. Endoscopic brow lift. In: Nahai FR, Nahai F, Codner M (eds). Techniques in Aesthetic Plastic Surgery: Minimally Invasive Facial Rejuvenation. Philadelphia: Saunders Elsevier; 2009.)

Despite the advantages, the endoscopic approach for forehead rejuvenation and brow lift is not without complication. Relapse has declined over the years due to increased and better use of permanent fixation. The “surprised look” has been eliminated by preserving a bridge of periosteum in the midline and avoiding fixation at the paramedian incisions in patients that have very mobile medial brows or a hyperactive medial frontalis muscle. Alopecia was eliminated after eliminating percutaneous screw fixation and changing to the completely buried, absorbable Endotine devices. The alopecia was caused by improper pressure in the scalp skin with screw fixation and staple technique. Anecdotal reports have blamed the cortical tunnel technique for fixation as a potential cause of intracranial bleeding during an endoscopic brow lift. Injury to the supratrochlear and supraorbital nerves causing temporary paresthesia is another potential complication. It can be minimized by appropriate scalp incision placement avoiding

Supraorbital nerves Orbicularis muscle seen after corrugator removal

Corrugator muscle Supratrochlear nerves

Vein

Vein

Nerves Supraorbital nerves

Supraorbital nerves

Corrugator muscle

Corrugator muscle Supratrochlear nerves

Vein

Vein

Supratrochlear nerves

Vein

Takahashi forceps

Figure 12.10  Corrugator muscle. The corrugator muscles may be resected endoscopically with grasping forceps, taking care not to injure the supraorbital or supratrochlear nerves. (From Saltz R, Lolofie A. My evolution with endoscopic brow-lift surgery. Facial Plast Surg Clin North Am. 2021;29(2):163–178)

448

SECTION II

CHAPTER 12  • Endoscopic brow lift

A

B

Figure 12.11  Endotine fixation. (A) The Endotine divot hole is drilled through the first layer of calvarial bone and situated at the caudal extent of the incision. The Endotine is snapped into place. (B) The scalp can then be repositioned vertically and held in place by fixation tines. (Reproduced from Saltz R, Codner M. Endoscopic brow lift. In: Nahai FR, Nahai F, Codner M, eds. Techniques in Aesthetic Plastic Surgery: Minimally Invasive Facial Rejuvenation. Philadelphia: Saunders Elsevier; 2009.)

A

B

Figure 12.12  This patient is shown (A) before and (B) after endoscopic brow lift, demonstrating an increased brow–lash distance and an aesthetically pleasing arch to the eyebrow. (Reproduced from Saltz R, Codner M. Endoscopic brow lift. In: Nahai FR, Nahai F, Codner M, eds. Techniques in Aesthetic Plastic Surgery: Minimally Invasive Facial Rejuvenation. Philadelphia: Saunders Elsevier; 2009.)

trauma to the deep branch of the supraorbital nerve as well as gentle tissue manipulation using the endoscope. The subperiosteal dissection retains the vascular blood supply within the forehead flap; therefore, subperiosteal dissection maximizes flap blood supply and minimizes trauma to the deep branch of the supraorbital nerve. Temporary paresthesia and some irregularities of the frontalis muscle are occasionally seen but usually improve within 2–3 weeks. Correction of eyelid ptosis with tarsolevator advancement corrects lid positions as well as brow asymmetry from compensatory brow elevation.

Final considerations Endoscopic, minimally invasive surgery does not mean minimal results (Figs. 12.12–12.18). Endoscopic brow lift results and morbidity must match those of direct or “open” approaches. Minimal access is better when combined with a quicker recovery, fewer complications, and sustainable

long-term results. Better operative visibility equals increased precision. Endoscopy is now the standard of care in many specialties for these reasons. The endoscopic brow lift can be summarized into four easy key surgical steps: 1. Blunt subperiosteal dissection over deep temporal fascia and frontal bone down to the supraorbital rim. 2. Meticulous division and spreading of the supraorbital rim periosteum under endoscopic visualization. 3. Corrugator muscle resection under endoscopic visualization. 4. Fixation in the temporal and paramedian wounds. Introduction of non-endoscopic procedures for forehead rejuvenation like short scar temporal, transblepharoplasty and anterior hairline approaches are all “blind.” They offer operative time similar to an endoscopic approach, however, blindly dissect around potential anomalous variations of the supraorbital nerve and require larger incisions with potential

Final considerations

Figure 12.13  Endoscopic brow lift combined with transconjunctival lower blepharoplasty. Ultratines used for paramedian fixation and 3-0 polydioxanone sutures for temporal fixation. Follow-up at 1 year.

449

Figure 12.14  Endoscopic brow lift combined with endoscopic midface lift using two temporal and two paramedian scalp incisions. Fixation of the brow with Ultratines and fixation of the midface with the endomidface device. Follow-up at 1 year.

450

SECTION II

CHAPTER 12  • Endoscopic brow lift

Figure 12.15  Endoscopic brow lift combined with upper and lower blepharoplasty (transconjunctival) and neck liposuction. Endotines used for paramedian fixation; 3-0 polydioxanone sutures for temporal fixation. Follow-up at 2 years.

Figure 12.16  Endoscopic brow lift via two temporal and two paramedian scalp incisions combined with facelift and necklift. Endotines used for paramedian fixation; 3-0 polydioxanone sutures for temporal fixation. Follow-up at 1 year.

Final considerations

451

A

B

C

Figure 12.17  (A,B,C) Endoscopic brow lift via two temporal and two paramedian scalp incisions combined with facelift and necklift. Endotines used for paramedian fixation; 3-0 polydioxanone sutures for temporal fixation. Follow-up at 1 year.

452

SECTION II

CHAPTER 12  • Endoscopic brow lift

B

A

C

Figure 12.18  (A,B,C) Endoscopic brow lift via two temporal and two paramedian scalp incisions combined with facelift and necklift. Endotines used for paramedian fixation; 3-0 polydioxanone sutures for temporal fixation. Follow-up at 1 year.

damage to the deep branch of supraorbital nerve risking sensory loss and unnecessary scars. The non-endoscopic, blind temporal approach is applicable in selected patients without forehead rhytids; corrugator release is unnecessary and only lateral lift is needed. Endoscopic brow lift is a time-tested method of providing highly accurate, precise, safe, long-lasting, and aesthetically

Access the reference list online at   Elsevier eBooks+

focused rejuvenation of the forehead and periocular region. When performed by a properly trained surgeon it is safe and the easiest “gateway” to the midface. The endoscopic midface lift technique is minimally invasive and ideal for younger patients with periocular and midface aging that are not candidates for facelift surgery and want long-term results that fillers or fat grafting cannot provide.

Further reading

Further reading Bostwick J, III, Nahai F, Eaves F. III Endoscopic Brow Lift in Endoscopic Plastic Surgery. St. Louis: Quality Medical Publishing; 1996. Chajchir A. Endoscopic subperiosteal forehead lift. Aesthetic Plast Surg. 1994;18:269–274. Core GB, Vasconez LO, Askren C, et al. Coronal face lift with endoscopic techniques. Plastic Surg Forum. 1992;15:227–229. Daniel RK, Tirkanits B. Endoscopic forehead lift: an operative technique. Plast Reconstr Surg. 1996;98:1148–1157. Del Campo AF, Lucchesi R, Cedillo Ley MP. The endo-facelift: basics and options. Clin Plast Surg. 1997;24:309–327. Isse NG. Endoscopic forehead lift. Presented at the Annual Meeting of the Los Angeles County Society of Plastic Surgeons, Los Angeles, Sept 12, 1992. Isse NG. Endoscopic facial rejuvenation: endoforehead, the functional lift. Case reports. Aesthetic Plast Surg. 1994;18:21–29. Isse NG. Endoscopic forehead lift: evolution and update. Clin Plast Surg. 1995;22:661–673. Knize DM. Limited-incision forehead lift for eyebrow elevation to enhance upper blepharoplasty. Plast Reconstr Surg. 1996;97:1334–1342. Mackay GJ, Nahai F. The endoscopic forehead lift. Operative techniques in plastic and reconstructive surgery. Plast Reconstr Surg. 1995;2:137–144. Matarasso A, Matarasso SL. Endoscopic surgical correction of glabellar creases. Dermatol Surg. 1995;21:695.

452.e1

Nahai F, Saltz R, eds. Endoscopic Plastic Surgery. St. Louis: Quality Medical Publishing; 2008. Paul MD. Subperiosteal transblepharoplasty forehead lift. Aesthetic Plast Surg. 1996;20:129–134. Paul M. The evolution of the brow lift in aesthetic plastic surgery. Plast Reconstr Surg. 2001;108:1409–1424. Ramirez OM. The anchor subperiosteal forehead lift. Plast Reconstr Surg. 1995;95:993–1003. Ramirez OM. Endoscopically assisted biplanar forehead lift. Plast Reconstr Surg. 1995;96:323–333. Rohrich RJ, Beran SJ. Evolving fixation methods in endoscopically assisted forehead rejuvenation: controversies and rationale. Plast Reconstr Surg. 1997;100:1575–1582. Saltz R. Forehead rejuvenation. In: Lin SJ, Mustoe TA, eds. Aesthetic Head and Neck Surgery: McGraw-Hill Plastic Surgery Atlas. New York: McGraw-Hill; 2013. Saltz R, Codner M. Endoscopic brow lift. In: Nahai FR, Nahai F, Codner M, eds. Techniques in Aesthetic Plastic Surgery: Minimally Invasive Facial Rejuvenation. Philadelphia: Saunders Elsevier; 2009. Saltz R, et al. Endoscopic mid-face lift. In: Stephen HM, ed. Year Book of Plastic, Reconstructive, and Aesthetic Surgery. St. Louis: Mosby; 2006. Trinei FA, Januszkiewicz J, Nahai F. The sentinel vein: an important reference point for surgery in the temporal region. Plast Reconstr Surg. 1998;101:27–32. Vasconez LO. The use of the endoscope in brow lifting. A video presentation at the Annual Meeting of the American Society of Plastic and Reconstructive Surgeons. Washington, DC, 1992.

 

SECTION II •  Aesthetic Surgery of the Face

13 Blepharoplasty Julius Few Jr. and Marco Ellis

Access video and video lecture content for this chapter online at Elsevier eBooks+ 

SYNOPSIS

ƒ Blepharoplasty is a vital part of facial rejuvenation. The traditional removal of tissue may or may not be the preferred approach when assessed in relation to modern cosmetic goals. ƒ A thorough understanding of orbital and eyelid anatomy is necessary to understand aging in the periorbital region and to devise appropriate surgical strategies. ƒ Preoperative assessment includes a review of the patient’s perceptions, assessment of the patient’s anatomy, and an appropriate medical and ophthalmologic examination. ƒ Surgical techniques in blepharoplasty are numerous and should be tailored to the patient’s own unique anatomy and aesthetic diagnosis. ƒ Interrelated anatomic structures including the brow and the infraorbital rim may need to be surgically addressed for an optimal outcome.

Introduction Properly performed aesthetic periorbital surgery is one of the most rejuvenating of all facial surgeries performed today. Properly conceived and executed, it proves a tremendous source of joy for both surgeon and patient. Done poorly, it can lead to a lifetime of disfigurement and functional problems for the patient, sleepless nights for the surgeon, and dissatisfaction for both participants. The problem is magnified because aesthetic periorbital surgical procedures are among the most commonly performed in plastic surgery practices. Traditional methods of aesthetic periorbital surgery often produce suboptimal results. A departure from the standard techniques of the past is recommended. Most plastic surgeons know there is a better way, and those who persist with traditional techniques may soon be deviating from a new standard of surgical care. It is this new standard that is advocated in this chapter. When they are understood and adopted, these new standards eliminate the classic complications and risks associated with traditional techniques.

Instead of the common practice of excising precious upper and, to a somewhat lesser degree, lower eyelid tissue, it is preferable to focus on restoration of attractive, youthful anatomy. To expect that the simple removal of tissue will always result in beautiful or youthful eyes is unrealistic, because this may not fully correct the aging eye deformity. One should first conceptualize the desired outcome, then select and execute procedures accurately designed to achieve those specific goals. For this task to be accomplished, several important principles are advocated (Box 13.1). Enthusiastically embraced, this approach is likely to result in excellent aesthetic quality of surgical outcomes.

Access the Historical Perspective section online at Elsevier eBooks+

Basic science/disease process Essential and dynamic anatomy It is an absolute necessity that the surgeon understands the essential and dynamic periorbital anatomy to effect superior aesthetic and functional surgical results. No surgeon should perform surgery without fully understanding the aesthetic and functional consequences of the choices.2–5

Osteology and periorbita The orbits are pyramids formed by the frontal, sphenoid, maxillary, zygomatic, lacrimal, palatine, and ethmoid bones (Fig. 13.1). The periosteal covering, or periorbita, is most firmly attached at the suture lines and the circumferential anterior orbital rim. The investing orbital septum, in turn, attaches to the periorbita of the orbital rim, forming a thickened perimeter known as the arcus marginalis. This

Historical perspective

Historical perspective As far back as the tenth and eleventh centuries, Arabian surgeons Avicenna and Ibn Rashid described the significance of excess skin folds in impairing eyesight.1 Even at an early date, surgeons had excised upper eyelid skin to improve vision. Texts published in the eighteenth and nineteenth centuries were the first to describe and illustrate the upper eyelid aging deformities. The term “blepharoplasty” was coined by Von Graefe in 1818 to describe reconstructive procedures employed following oncologic excisions. Several European surgeons developed reconstructive techniques for eyelid defects in the latter half of the nineteenth century. Graefe and Mackenzie would be credited with applying these reconstructive principles and publishing the first, reproducible cases of upper blepharoplasty. The concepts of herniated orbital fat pads were described shortly thereafter by Sichel and Bourguet, respectively. Orbital fat pads were originally considered to be “circumscribed tumors” of fat that made movement of the upper lid more difficult. It was a rare condition found “most often in children”. Cosmetic blepharoplasty entered a period of rapid growth and research in the 1920s and 1930s. Contributions were made that described nearly 13 different approaches and closure methods. Recent variations in technique appear to have a basis in these early techniques, which have cycled in popularity over the past decade.

453.e1

454

SECTION II

CHAPTER 13  • Blepharoplasty

Medial canthal tendon Medial check retinaculum Fossa for lacrimal sac

BOX 13.1  Principles for restoration of youthful eyes • Control of periorbital aesthetics by proper brow positioning, corrugator muscle removal, and lid fold invagination when beneficial. • Restoration of tone and position of the lateral canthus and, along with it, restoration of a youthful and attractive intercanthal axis tilt. • Restoration of the tone and posture of the lower lids. • Preservation of maximal lid skin and muscle (so essential to lid function and aesthetics) as well as orbital fat. • Lifting of the midface through reinforced canthopexy, preferably enhanced by composite malar advancement. • Correction of suborbital malar grooves with tear trough (or suborbital malar) implants, obliterating the deforming tear trough (bony) depressions that angle down diagonally across the cheek, which begin below the inner canthus. • Control of orbital fat by septal restraint or quantity reduction. • Removal of only that tissue (skin, muscle, fat) that is truly excessive on the upper and lower lids, sometimes resorting to unconventional excision patterns. • Modification of skin to remove prominent wrinkling and excision of small growths and blemishes.

Supraorbital fissure

Frontal bone

Supraorbital foramen Superior orbital ridge

Optic foramen Ethmoid Lacrimal bone and fossa Maxilla

Greater wing of sphenoid Zygomatic Infraorbital fissure

Infraorbital foramen Zygomaticofacial foramen

Figure 13.1  Orbital bones. Frontal view of the orbit with foramina.

structure reduces the perimeter and diameter of the orbital aperture and is thickest in the superior and lateral aspects of the orbital rim.6 Certain structures must be avoided during upper lid surgery. The lacrimal gland, located in the superolateral orbit deep to its anterior rim, often descends beneath the orbital rim, prolapsing into the postseptal upper lid in many persons. During surgery, the gland can be confused with the lateral extension of the central fat pad destined for removal during aesthetic blepharoplasty. The trochlea is located 5 mm posterior to the superonasal orbital rim and is attached to the periorbita. Disruption of this structure can cause motility problems.7

Orbicularis Lateral canthal tendon Lateral check retinaculum

Tenon’s capsule Medial rectus and sheath Lateral rectus and sheath Periorbita

Figure 13.2  Horizontal section of the orbit showing the lateral retinaculum formed by the lateral horn of the levator, lateral canthal tendon, tarsal strap, the Lockwood suspensory ligament, and lateral rectus check ligaments.

Lateral retinaculum Anchored to the lateral orbit is a labyrinth of connective tissues that are crucial to maintenance of the integrity, position, and function of the globe and periorbital. Understanding how to effectively restore these structures is key to periocular rejuvenation by canthopexy. These structures, known as the lateral retinaculum, coalesce at the lateral orbit and support the globe and eyelids like a hammock (Fig. 13.2).8–10 The lateral retinaculum consists of the lateral canthal tendon, tarsal strap, lateral horn of the levator aponeurosis, the Lockwood suspensory ligament, Whitnall’s ligament, and check ligaments of the lateral rectus muscle. They converge and insert securely into the thickened periosteum overlying Whitnall’s tubercle. Controversy exists surrounding the naming of the components of the lateral canthal tendon. Recent cadaveric dissections suggest that the lateral canthal tendon has dual insertions. A superficial component is continuous with the orbicularis oculi fascia and attaches to the lateral orbital rim and deep temporal fascia by means of the lateral orbital thickening. A deep component that connects directly to Whitnall’s tubercle is classically known as the lateral canthal tendon (Fig. 13.3).11 In addition, the tarsal strap is a distinct anatomic structure that inserts into the tarsus medial and inferior to the lateral canthal tendon.12 In contrast to the canthal tendon, the thick tarsal strap is relatively resistant to laxity changes seen with aging. The tarsal strap attaches approximately 3 mm inferiorly and 1 mm posteriorly to the deep lateral canthal tendon, approximately 4–5 mm from the anterior orbital rim. It shortens in response to lid laxity, benefiting from release during surgery to help achieve a long-lasting restoration or elevation canthopexy (Fig. 13.4). Adequate release of the tarsal strap permits a tension-free canthopexy, minimizing the downward tethering force of this fibrous condensation. This release along with a superior reattachment of the lateral canthal tendon is key to a successful canthopexy.

Medial orbital vault A hammock of fibrous condensations suspends the globe above the orbital floor. The medial components of the apparatus include medial canthal tendon, the Lockwood suspensory

Basic science/disease process

Temporalis Zygomatic bone

455

Orbicularis fascia Lateral orbital thickening Lateral canthal tendon

Frontal bone

Coronoid process of mandible

Maxilla bone

Tarsal plates

Figure 13.3  Lateral canthal tendon has separate superficial and deep components. The deep component attaches inside the orbital rim at Whitnall’s tubercle. The superficial component passes from the tarsal plates to the periosteum of the lateral orbital rim and lateral orbital thickening. Both components are continuous with both superior and inferior lid tarsal plates. (Modified from Muzaffar AR, Mendelson BC, Adams WP Jr. Surgical anatomy of the ligamentous attachments of the lower lid and lateral canthus. Plast Reconstr Surg. 2002;110:873–884.)

Posterior limb, medial canthal tendon Superior limb, medial canthal tendon

Anterior limb, medial canthal tendon Lacrimal fossa

Whitnall’s tubercle Lateral canthal tendon

Anterior and posterior lacrimal crests

“Tarsal strap”

Figure 13.5  The medial canthal tendon envelops the lacrimal sac. It is tripartite, with anterior, posterior, and superior limbs. Like the lateral canthal tendon, its limbs are continuous with tarsal plates. The components of this tendon along with its lateral counterpart are enveloped by deep and superficial aspects of the orbicularis muscle. (Modified from Spinelli HM. Atlas of Aesthetic Eyelid and Periocular Surgery. Philadelphia, PA: Saunders; 2004:13.)

Orbital septum

Tarsus

Figure 13.4  The deep portion of the lateral canthal tendon inserts securely into the thickened periosteum overlying Whitnall’s tubercle. The tarsal strap is a distinct anatomic structure that suspends the tarsus medial and inferior to the lateral canthal tendon to the lateral orbital wall, approximately 4–5 mm from the orbital rim.

ligament, and check ligaments of the medial rectus. The medial canthal tendon, like the lateral canthal tendon, has separate limbs that attach the tarsal plates to the ethmoid and lacrimal bones.13 Each limb inserts onto the periorbital of the apex of the lacrimal fossa. The anterior limb provides the bulk of the medial globe support (Fig. 13.5).

Forehead and temporal region The forehead and brow consist of four layers: skin, subcutaneous tissue, muscle, and galea. There are four distinct brow muscles: frontalis, procerus, corrugator superciliaris, and orbicularis oculi (Fig. 13.6). The frontalis muscle inserts

predominately into the medial half or two-thirds of the eyebrow (Fig. 13.7), allowing the lateral brow to drop hopelessly ptotic from aging, while the medial brow responds to frontalis activation and elevates, often excessively, in its drive to clear the lateral overhang. Constant contraction of the frontalis will give the appearance of deep horizontal creases in the forehead (Fig. 13.8).3 The vertically oriented procerus is a medial muscle, often continuous with the frontalis, arising from the nasal bones and inserting into the subcutaneous tissue of the glabellar region. It pulls the medial brow inferiorly and contributes to the horizontal wrinkles at the root of the nose. More commonly, these wrinkles result from brow ptosis and correct spontaneously with brow elevation. The obliquely oriented corrugator muscle arises from the frontal bone and inserts into the brow tissue laterally, with some extensions into orbicularis and frontalis musculature, forming vertical glabellar furrows during contraction. Wrinkles from procerus and corrugators contraction can worsen significantly after upper lid tissue excision as a result

456

SECTION II

CHAPTER 13  • Blepharoplasty

Superciliary corrugator Frontalis

Diagonal lines

Procerus

Orbicularis oculi Pretarsal orbicularis Preseptal orbicularis

Figure 13.6  Facial muscles of the orbital region. Note that the preseptal and pretarsal orbicularis muscles fuse with the medial and lateral canthal tendons.

Frontalis

Figure 13.8  Frontalis action. The frontalis muscle inserts into the medial twothirds of the brow. Exaggerated medial brow elevation is required to clear the lateral overhang and to eliminate visual obstruction. Constant contraction of the frontalis will give the appearance of deep horizontal creases in the forehead. This necessarily means that when the lateral skin is elevated or excised, the over-elevated and distorted medial brow drops profoundly.

Levator palpebrae Superior rectus

Orbicularis oculi Müller’s muscle

Upper tarsal plate

Capsulopalpebral fascia Lockwood suspensory ligament

Inferior rectus

Figure 13.7  The frontalis muscle inserts predominantly into the medial half or twothirds of the eyebrow. The medial brow responds to frontalis activation and elevates, often excessively, in its drive to clear lateral overhang.

Figure 13.9  Eyelid anatomy. Each eyelid consists of an anterior lamella of skin and orbicularis muscle and a posterior lamella of tarsus and conjunctiva. The orbital septum forms the anterior border of the orbital fat.

of the frontalis muscles relaxing after being relieved of the need to clear the obstructing lid skin.14

There is much similarity between upper and lower eyelid anatomy. Each consists of an anterior lamella of skin and orbicularis muscle and a posterior lamella of tarsus and conjunctiva (Fig. 13.9).15 The orbicularis muscle, which acts as a sphincter for the eyelids, consists of orbital, preseptal, and pretarsal segments. The pretarsal muscle segment fuses with the lateral canthal tendon and attaches laterally to Whitnall’s tubercle. Medially it forms two heads, which insert into the anterior and posterior lacrimal crests (see Fig. 13.6).

Eyelids The eyelids are vital, irreplaceable structures that serve to protect the globes. Their shutter-like mechanism is essential to clean, lubricate, and protect the cornea. Any disruption or restriction of eyelid closure will have significant consequences for both the patient and the surgeon.

Basic science/disease process

Upper eyelid The orbital septum originates superiorly at the arcus and forms the anterior border of the orbit. It joins with the levator aponeurosis, just superior to the tarsus. The sling formed by the union of these two structures houses the orbital fat. The levator palpebrae superioris muscle originates above the annulus of Zinn. It extends anteriorly for 40 mm before becoming a tendinous aponeurosis below Whitnall’s ligament.7,16 The aponeurosis fans out medially and laterally to attach to the orbital retinacula. The aponeurosis fuses with the orbital septum above the superior border of the tarsus and at the caudal extent of the sling, sending fibrous strands to the dermis to form the lid crease. Extensions of the aponeurosis finally insert into the anterior and inferior tarsus. As the levator aponeurosis undergoes senile attenuation, the lid crease rises into the superior orbit from its remaining dermal attachments while the lid margin drops. Müller’s muscle, or the supratarsal muscle, originates on the deep surface of the levator near the point where the muscle becomes aponeurotic and inserts into the superior tarsus. Dehiscence of the attachment of the levator aponeurosis to the tarsus results in an acquired ptosis only after the Müller’s muscle attenuates and loses its integrity.14

457

In the Asian eyelid, fusion of the levator and septum commonly occurs at a lower level, allowing the sling and fat to descend farther into the lid.15,16 This lower descent of fat creates the characteristic fullness of their upper eyelid. In addition, the aponeurotic fibers form a weaker attachment to the dermis, resulting in a less distinct lid fold (Fig. 13.10).

Septal extension The orbital septum has an adhesion to the levator aponeurosis above the tarsus. The septum continues beyond this adhesion and extends to the ciliary margin. It is superficial to the preaponeurotic fat found at the supratarsal crease. The septal extension is a dynamic component to the motor apparatus, as traction on this fibrous sheet reproducibly alters ciliary margin position (Fig. 13.11). The septal extension serves as an adjunct to, and does not operate independent of, levator function, as mistaking the septal extension for levator apparatus and plicating this layer solely results in failed ptosis correction.17

Lower eyelid The anatomy of the lower eyelid is somewhat analogous to that of the upper eyelid. The retractors of the lower lid, the

6–8 mm Occidental

A

Deep set (levator dehiscence)

8–13 mm

B

Figure 13.10 The anatomic variations in the upper eyelid displayed by different ethnic groups and the changes associated with senescence within each group allow for a convergence of anatomy. (A) In European ethnicities, the upper eyelid has levator extensions inserting onto the skin surface to define a lid fold that averages 6–8 mm above the lid margin. The position of the levator–skin linkage and the anteroposterior relationship of the preaponeurotic fat determine lid fold height and degree of sulcus concavity or convexity (as shown on the right half of each anatomic depiction). (B) In the case of levator dehiscence from the tarsal plate, the upper lid crease is displaced superiorly. The orbital septum and preaponeurotic fat linked to the levator are displaced superiorly and posteriorly. These anatomic changes create a high lid crease, a deep superior sulcus, and eyelid ptosis. (continued)  

 

458

SECTION II

CHAPTER 13  • Blepharoplasty

Baggy eyelid

0 to minimum

C

Asian

0 to minimum

D

Figure 13.10, cont’d (C) In the aging eyelid, the septum becomes attenuated and stretches. The septal extension loosens which allows orbital fat to prolapse forward and slide over the levator into an anterior and inferior position. Clinically, this results in an inferior displacement of the levator–skin attachments and a low and anterior position of the preaponeurotic fat pad. (D) The youthful Asian eyelid anatomically resembles the senescent upper lid with a low levator–skin zone of adhesion and inferior and anteriorly located preaponeurotic fat. The characteristic, but variable, low eyelid crease and convex upper eyelid and sulcus are classic. (Modified from Spinelli HM. Atlas of Aesthetic Eyelid and Periocular Surgery. Philadelphia, PA: Saunders; 2004:59.)

capsulopalpebral fascia, correspond to the levator above. The capsulopalpebral head splits to surround and fuse with the sheath of the inferior oblique muscle. The two heads fuse to form the Lockwood suspensory ligament, which is analogous to Whitnall’s ligament. The capsulopalpebral fascia fuses with the orbital septum 5 mm below the tarsal border and then inserts into the anterior and inferior surface of the tarsus.18 The inferior tarsal muscle is analogous to Müller’s muscle of the upper eyelid and also arises from the sheath of the inferior rectus muscle. It runs anteriorly above the inferior oblique muscle and also attaches to the inferior tarsal border. The combination of the orbital septum, orbicularis, and skin of the lower lid acts as the anterior barrier of the orbital fat. As these connective tissue properties relax, the orbital fat is allowed to herniate forward, forming an unpleasing, full lower eyelid. This relative loss of orbital volume leads to a commensurate, progressive hollowing of the upper lid as upper eyelid fat recesses.19 The capsulopalpebral fascia and its overlying conjunctiva form the posterior border of the lower orbital fat. Transection of the capsulopalpebral fascia during lower lid procedures, particularly transconjunctival blepharoplasty, releases the retractors of the lower eyelid, which can reduce downward traction and allow the position of the lower lid margin to rise.

Retaining ligaments A network of ligaments serves as a scaffold for the skin and subcutaneous tissue surrounding the orbit. The orbital

retaining ligament directly attaches the orbicularis at the junction of its orbital and preseptal components to the periosteum of the orbital rim and, consequently, separates the prezygomatic space from the preseptal space. This ligament is continuous with the lateral orbital thickening, which inserts onto the lateral orbital rim and deep temporal fascia. It also has attachments to the superficial lateral canthal tendon (see Fig. 13.3; Figs. 13.12 & 13.13).20 Attenuation of these ligaments permits descent of orbital fat onto the cheek. A midfacelift must release these ligaments to achieve a supported, lasting lift.21

Blood supply The internal and external carotid arteries supply blood to the orbit and eyelids (Fig. 13.14). The ophthalmic artery is the first intracranial branch of the internal carotid; its branches supply the globe, extraocular muscles, lacrimal gland, ethmoid, upper eyelids, and forehead. The external carotid artery branches into the superficial temporal and maxillary arteries. The infraorbital artery is a continuation of the maxillary artery and exits 8 mm below the inferomedial orbital rim to supply the lower eyelid.22 The arcade of the superior and inferior palpebral arteries gives a rich blood supply to the eyelids. The superior palpebral artery consists of a peripheral arcade located at the superior tarsal border – the area where surgical dissection occurs to correct lid ptosis and to define lid folds. Damage to a vessel within this network commonly results in a hematoma of Müller’s muscle, causing lid ptosis for 2–8 weeks

Basic science/disease process

459

Globe

Orbicularis Septum orbitale Orbital septum Müller’s muscle Levator aponeurosis Septal extension Tarsus

Orbitomalar ligament Prezygomatic space Orbicularis oculi

Figure 13.13  The orbital retaining ligament directly attaches the orbicularis oris at the junction of its pars palpebrarum and pars orbitalis to the periosteum of the orbital rim and, consequently, separates the prezygomatic space from the preseptal space. (Modified from Muzaffar AR, Mendelson BC, Adams WP Jr. Surgical anatomy of the ligamentous attachments of the lower lid and lateral canthus. Plast Reconstr Surg. 2002;110:873–884.)

Supraorbital artery

Medial palpebral artery (superior) 1. Peripheral arcade 2. Marginal arcade

Superficial temporal artery

Figure 13.11  The orbital septum has an adhesion to the levator aponeurosis above the tarsus. The septal extension begins at the adhesion of the orbital septum to the levator and extends to the ciliary margin. It is superficial to the preaponeurotic fat found at the supratarsal crease. (Modified from Reid RR, Said HK, Yu M, et al. Revisiting upper eyelid anatomy: introduction of the septal extension. Plast Reconstr Surg. 2006;117:65–70.)

Supratrochlear artery Dorsal nasal artery Angular artery Medial palpebral artery (inferior) Lateral nasal artery Inferior palpebral artery

Lacrimal artery

Zygomaticofacial artery Transverse facial artery Infraorbital artery

Orbicularis retaining ligament Corrugator supercilii Frontal bone

Maxilla bone Nasal bone

Facial artery

Figure 13.14  Arterial supply to the periorbital region. Orbicularis oculi

postoperatively. Likewise, on the lower lid, the inferior palpebral artery lies at the inferior border of the inferior tarsus. The supratrochlear, dorsal nasal, and medial palpebral arteries all traverse the orbit medially. Severing these arteries during fat removal, without adequately providing hemostasis, may lead to a retrobulbar hematoma, a vision-threatening complication of blepharoplasty.

Innervation: trigeminal nerve and facial nerve

Lateral orbital thickening

Zygomatic bone

Orbicularis retaining ligament

Figure 13.12  The orbicularis muscle fascia attaches to the skeleton along the orbital rim by the lateral orbital thickening in continuity with the orbicularis retaining ligament. (Modified from Ghavami A, Pessa JE, Janis J, et al. The orbicularis retaining ligament of the medial orbit: closing the circle. Plast Reconstr Surg. 2008;121:994– 1001.)

The trigeminal nerve along with its branches provides sensory innervations to the periorbital region (Fig. 13.15). The ophthalmic division enters the orbit and divides into the frontal, nasociliary, and lacrimal nerves. The terminal branch of the nasociliary nerve, the infratrochlear nerve, supplies the medial conjunctiva, and lacrimal sac. The lacrimal nerve supplies the lateral conjunctiva and skin of the lateral upper eyelid. The frontal nerve, the largest branch, divides into the supraorbital and supratrochlear branches. The supraorbital nerve exits through either a notch or a foramen and provides sensory innervations to the skin and conjunctiva of the upper eyelid and the scalp. The supratrochlear nerve innervates the skin of the glabella, forehead, medial upper eyelid, and

460

SECTION II

CHAPTER 13  • Blepharoplasty

Lacrimal nerve

Supraorbital nerve Supratrochlear nerve

3–5X

Zygomaticotemporal nerve

Infratrochlear nerve

Zygomaticofacial nerve

X

Infraorbital nerve

Figure 13.15  Sensory nerves of the eyelids. Temporal branches (facial nerve VIII)

Figure 13.17  On relaxed forward gaze, the ideal upper lid should rest approximately 2 mm below the upper limbus. The lower lid ideally covers 0.5 mm of the lower limbus. The ratio of distance from the lower edge of the eyebrow to the open lid margin to the pretarsal skin ratio should be greater than 3.

∗∗∗ ∗∗∗ ∗∗∗∗

Zygomatic branches (facial nerve VIII)

Figure 13.16  Anatomy of the brow and temporal region. The light green opaque area denotes the deep temporal fascia and the periosteum where sutures may be used to suspend soft tissue. Wide undermining, soft-tissue suspension, and canthopexy are safely performed here.

medial conjunctiva. A well-placed supraorbital block will anesthetize most of the upper lid and the central precoronal scalp.6,14,23 The maxillary division exits the orbit through one to three infraorbital foramina. It provides sensation to the skin of the nose, the lower eyelids, and the upper lid. Dissection is necessary lateral to the infraorbital nerve for successful midfacelifting and around the nerve for placement of tear trough implants. The facial nerve exits the stylomastoid foramen and divides in the substance of the parotid gland into the superior temporofacial and inferior cervicofacial branches (Fig. 13.16). The temporofacial nerve divides into the frontal, zygomatic, and buccal nerves; the cervicofacial nerve divides into the buccal, mandibular, and cervical nerves. There are significant variations in the branching of the facial nerve, which is responsible for facial expression. Innervation of facial muscles occurs on their deep surfaces. Interruption of the branches to the orbicularis muscle from periorbital surgery or facial surgery may result in atonicity due to partial denervation of the orbicularis with loss of lid tone or anomalous reinnervation and possibly undesirable eyelid twitching.15

The frontal branch of the facial nerve courses immediately above and attached to the periosteum of the zygomatic bone. It then courses medially approximately 2 cm above the superior orbital rim to innervate the frontalis, corrugators, and procerus muscles from their deep surface. A separate branch travels along the inferior border of the zygoma to innervate the inferior component of orbicularis oculi.24 The surgeon should take great care when operating in this area to avoid damaging this nerve during endoscopic and open browlifts.

Youthful, beautiful eyes The characteristics of youthful, beautiful eyes differ from one population to another but generalizations are possible and provide a needed reference to judge the success of various surgical maneuvers. Attractive, youthful eyes are bright eyes. Bright eyes have globes framed in generously sized horizontal apertures (from medial and lateral), often accentuated by a slight upward tilt of the intercanthal axis (Fig. 13.17). The aperture length should span most of the distance between the orbital rims. In a relaxed forward gaze, the vertical height of the aperture should expose at least three-quarters of the cornea with the upper lid extending down at least 1.5 mm below the upper limbus (the upper margin of the cornea) but no more than 3 mm. The lower lid ideally covers 0.5 mm of the lower limbus but no more than 1.5 mm.4,15 In the upper lid, there should be a well-defined lid crease lying above the lid margin with lid skin under slight stretch, slightly wider laterally. Ideally, the actual pretarsal skin visualized on relaxed forward gaze ranges from 3 to 6 mm in European ethnicities. The Asian lid crease is generally 2–3 mm lower, with the distance from lid margin diminishing as the crease moves toward the inner canthus. Patients of Indo-European and African descent show 1–2 mm lower than European ethnicities. The ratio of distance from the lower edge of the eyebrow (at the center of the globe) to the open lid

Diagnosis/patient presentation

margin to the visualized pretarsal skin should never be less than 3 : 1 (see Fig. 13.1), preferably more. Scleral show is the appearance of white sclera below the lower border of the cornea and above the lower eyelid margin. In general, scleral show is contradictory to optimal aesthetics and may be perceived as a sign of aging, previous blepharoplasty, or orbital disease (e.g., thyroid disease). More than 0.5 mm of scleral show beneath the cornea on direct forward gaze begins to confer a sad or melancholy aura to one’s appearance. However, in some youthful persons, the largeness of these apertures gives dramatic emphasis to the eyes and may be considered a strong and positive feature. The intercanthal axis is normally tilted slightly upward (from medial to lateral) in most populations. Exaggerated tilts are encountered in some Asian, Indo-European and AfricanAmerican populations. Such upward tilt of the lateral canthal axis may give the eye a youthful appearance, which is aesthetically pleasing in any ethnic group. The lower lid that droops in its lateral aspect and the eye with a downward tilt generally convey to the viewer an aging, ill-health distortion, or unattractiveness.25

Etiology of aging In the upper lid, excessive skin due to loss of elasticity and sun damage is one of the major causes of an aged appearance in the periorbital area. If there is an excess of skin that hangs over the lid or the upper eyelid appears to have multiple folds, it is difficult to have a rejuvenated appearance with cosmetics alone. In addition to relaxed skin changes, excessive fat herniation can cause bulging, resulting in a heavy appearance to the upper lid area. Although this fat is normal orbital fat, it appears to be protruding outward because of the laxity of the orbital septum, which holds the fat in place. Theoretically, replacement of the fat into a position that maintains a normal level of fat in the orbital area seems an optimal solution. However, this is not easily accomplished and may result in complications that are difficult to correct. Therefore, the skin and fat that seem to be in apparent excess should be treated accordingly. The etiology of aging changes in the lower lids is similar in some ways but quite different in others. Aging changes include relaxation of the tarsal margin with scleral show, rhytides of the lower lid, herniated fat pads resulting in bulging in one or all of the three fat pocket areas, and hollowing of the nasojugal groove and lateral orbital rim areas. Hollowing of the nasojugal groove area appears as dark circles under the eyes, mostly because of lighting and the shadowing that results from this defect (Fig. 13.18).26 It is clear that evaluation of all aspects of aging changes in the lids is important so the surgeon can plan the most effective operative procedure.

Diagnosis/patient presentation Evaluation basics The first essential step is to look at the patient carefully, thoroughly, and critically. The surgeon should be seated directly in front of the prospective patient with the patient’s eyes at his or her eye level. Note the general impression and feeling generated from looking at this person (Fig. 13.19).

461

Figure 13.18  Morphed digital photography (split right half = current preoperative photograph; split left half = photograph 20 years ago), demonstrating descent of periorbital fat and skin during the aging process. (From Odunze MO, Reid RR, Yu M, et al. Periorbital rejuvenation and the African-American patient: a survey approach. Plast Reconstr Surg. 2006;118:1011–1018.)

One should also look for areas of symmetry or asymmetry. Notice the shape of the eye; the prominence or asymmetry of the globes; and evidence of exposure, dryness, or injection of vessels. Look for evidence of decreased tone and dropped posture of the lower lids. What is the posture of the upper lid? Are the upper lids symmetric? Is there lid ptosis? At what level does the upper lid traverse the globe? What levels do the upper and lower lids sit in relation to the limbus? Next, have the patient relax the brow and close the eyes. Do the lids close? Then ask the patient to open the eyes. Is it necessary to raise the brows to effect comfortable forward vision? Does the corrugator frown increase in prominence with the eyes closed and the forehead relaxed? Is there transverse brow wrinkling? Is one brow lower? Which one and how much? Is there a prominent frown? Assess the lower lid tone by pulling the lid away from the globe and releasing, making sure the patient does not blink (modified snap test). Does each lid spring back immediately, reluctantly, or not at all? Is it held against the globe by only the tear seal? Most people presenting for blepharoplasty have a significant decrease in their lower lid tone, often asymmetric. What, if anything, would improve the aesthetic appearance of the eyes and periorbital region? Are there festoons or deep grooves (i.e., nasojugal grooves or tear trough deformities)? Is there excess skin, muscle, or fat? Quantitate any excess soft tissue on a simple eye diagram. Does restoration of lateral canthal posture correct the illusion of excess skin on the lower eyelid? Does it diminish it? Does the orbital septum appear to be excessively relaxed? Note the tilt of the intercanthal axis or lack thereof. The “four-finger lift” is performed by encircling the outer orbit with the tips of the index, middle, ring, and little fingers on one hand. With the index and middle fingers above the lateral brow, place the ring finger lateral to the canthus and little finger beneath the lateral canthus just lateral to the malar prominence. Gently move the four fingers posteriorly and

462

SECTION II

CHAPTER 13  • Blepharoplasty

Laxity of the orbital septum

Laxity and descent of the orbicularis oculi

Descent of the lid-cheek junction

Descent of the check fat pad with laxity of the orbitomalar ligament Laxity of the SMAS covering zygomaticus muscles and other elevators of the upper lip Deepening of the nasolabial fold

Jowl formation

Figure 13.19  Midcheek deflation due to loss of superficial and deep fat. SMAS, Superficial musculoaponeurotic system. (Modified from Rohrich RJ, Pessa JE. The fat compartments of the face: anatomy and clinical implications for cosmetic surgery. Plast Reconstr Surg. 2007;119:2219–2227.)

superiorly to lift the lateral brow, canthus, and cheek. If this test restores youthfulness and attractiveness, a canthopexy, browlift, and midfacelift may be beneficial.

Medical and ophthalmic history A thorough history and physical examination should be performed before surgery (Box 13.2). In addition, an adequate eye history encourages positive outcomes and reduces eye complications. Contact lens wear poses particular risks when eyelid surgery is performed. The natural progression of aging dries the eyes out, and long-term contact lens wearing hastens this process considerably. Traditional blepharoplasty techniques consistently produce vertical dystopia with increased scleral exposure, making the lens wear difficult if not dangerous. Ptosis and canthopexy surgery may alter the corneal curvature and require that contacts be refitted. The patient should discontinue contact lens wear in the perioperative period to allow healing without the need to manipulate the eyelids. Levator dehiscence or attenuation commonly accompanies

BOX 13.2  Important information to obtain during history and physical examination • Medication use: particularly anticoagulants, anti-inflammatory and cardiovascular drugs, and vitamins (especially vitamin E). • Herbal supplement use: herbs represent risks to anesthesia and surgery, particularly those affecting blood pressure, blood coagulation, the cardiovascular system, and healing. • Allergies: medication and type. • Past medical history: especially hypertension, diabetes, cardiovascular and cerebrovascular disease, hepatitis, liver disease, heart disease or arrhythmias, cancer, thyroid disease, and endocrine disease. • Bleeding disorders or blood clots. • Psychiatric disease. • Alcohol and smoking history. • Recreational drug use, which may interact with anesthesia. • Exposure to human immunodeficiency virus and hepatitis virus. • Any history of facial herpes zoster or simplex.

Diagnosis/patient presentation

long-term hard contact lens wear, caused by the mechanical stresses posteriorly from the rigid lens rubbing against the posterior lamella of the lid.27 The same population that seeks aesthetic surgery also gravitates toward refractive surgery, such as LASIK (laser-assisted in situ keratomileusis). A history of such surgery is necessary information because periorbital surgery, particularly canthopexies and levator surgery, can affect the refractive characteristics, cause mechanical irritation of the conjunctiva and cornea, or affect the corneal flap.28 Ptosis repair or debulking of heavy upper lids can change the corneal curvature, resulting in the need for a new prescription for eyeglasses. Canthopexy normally raises the contact point of the lid with the globe and can increase the tension of the lid with the globe and can increase the tension of the lid against the cornea, affecting corneal curvature. It can cause conjunctival chemosis or produce corneal erosion early postoperatively. Dry eye exposure problems are most prevalent in patients who have undergone LASIK surgery because the flap disrupts corneal innervations, forming an anesthetic effect that suppresses tear production. When in doubt, such patients should be reviewed by their refractive surgeon before undergoing blepharoplasty. One should check for a history of other eye procedures, including glaucoma surgery (forms a bleb of conjunctival tissue on the superior limbus), retinal, strabismus, and cataract surgery. Evaluate carefully for a history as well as physical evidence of facial muscle weakness, extraocular muscle imbalance, Bell palsy, or trauma, in addition to orbicularis hyperactivity such as blepharospasm or hemifacial spasm. Any ocular condition may affect the type or result of eyelid surgery.29 Superior or lateral visual field loss suggests functional ptosis or pseudoptosis. A 12–20° or a 30% improvement of the superior visual field, between a taped and untaped upper lid, may qualify for medical necessity. Chronic eye irritation, such as tearing, dryness, excessive blinking, discharge, eyelid margin inflammation, crusting, burning, or itching, must be brought under control before any surgery. Dry eyes should be aggressively sought out and treated before surgery. Dry irritated eyes before surgery will lead to irritated eyes after surgery, and the surgeon may be blamed. On questioning, most patients will rarely admit to dry eyes, although it is known that the eyes dry out considerably throughout our lifetime. Treatment options include artificial tears, ointment, anti-inflammatory drops, and punctal plugs or punctal closure.29,30 Exophthalmos, unilaterally or bilaterally, associated with a thyroid disorder should be completely stabilized for approximately 6 months before elective aesthetic surgery. However, there may be an urgent requirement in active Graves’ disease to perform procedures to protect the globe or the vision.13

Ocular examination An ocular examination before elective periorbital aesthetic surgery should include all of the elements covered in the following sections (Fig. 13.20).

Visual acuity The most essential preoperative test is assessment of visual acuity, by the surgeon or ophthalmic colleague. Document the vision with the patient wearing glasses or contact lenses if they

463

are needed. Note any vision deficits and have them evaluated before surgery. The most common cause of unrecognized loss of vision is amblyopia (lazy eye), which is present in 2% of the general population. A patient may often be unaware of the unilateral amblyopia (or any loss of vision) until the eyes are tested individually.

External examination The periorbital skin and tissues are examined for benign or malignant lesions, including xanthelasma, syringoma, basal cell carcinoma, benign moles, skin tags, and chalazia. Marked anesthetic improvement results from removal of benign lesions about the eyes, especially those that rise above the lid margin. Any cancerous (or precancerous) lesions must be removed before any aesthetic procedure is performed to preserve eyelid skin for reconstruction, if needed. Eyelid measurements are documented for use during ptosis surgery and, if necessary, for insurance purposes. In the eyelid of the white individual, the aperture (distance between the upper and lower eyelids) averages 10–12 mm. The margin–reflex distance (MRD), measured from the light reflex on the center of the cornea to the upper eyelid margin, ranges from 3 to 5 mm. True blepharoptosis is defined by the degree of upper lid infringement upon the iris and pupil. As the MRD decreases towards zero, the severity of blepharoptosis increases. Before method selection, the levator function must be determined by measuring the upper eyelid excursion from extreme downward gaze to extreme upward gaze; it generally ranges from 10 to 12 mm. If ptosis exists, the type of repair depends upon the severity of the ptosis and the reliability of the levator to recreate smooth, upper lid elevation. Moderate or severe levator dysfunction corresponds to eyelid excursion of 7–9 mm and 4–6 mm, respectively. A deep upper lid sulcus with a high lid fold in the presence of a droopy eyelid usually indicates a levator dehiscence, which is often unilateral or asymmetric.31,32 Pseudoptosis occurs when excess upper lid skin covers the eyelid, depressing the eyelashes, forming hooding and simulating ptosis. It is easily differentiated from true ptosis by simply elevating the brow or the hooded skin itself to determine the true resting lid level.33 Photographic evidence of this is often necessary for insurance purposes when a levator aponeurosis repair or a excisional blepharoplasty is planned. When the hooded skin hangs over the lashes, the lashes turn downward and sometimes interfere with vision or rub against the cornea. True trichiasis (misdirected lashes) may also exist, but inward-turning lashes can be trained to return to their natural posture after eyelid repair with lash rotation. Brow ptosis is a common aspect of facial aging. It adds weight and volume to the upper eyelid, to develop, or exacerbate, eyelid ptosis. The more ptotic brow is often selectively elevated or over-elevated by frontalis muscle contraction, which may confuse the surgeon as to whether eyelid ptosis or retraction exists. The ability to differentiate the causes of droopy eyelids – brow ptosis (brow weight resting on the eyelids), dermatochalasis (excess skin), and blepharoptosis (levator attenuation or dehiscence) – will enable the surgeon to select the proper correction. Unilateral as well as bilateral upper eyelid retraction is commonly associated with prominent globes, which are often asymmetrically proptotic. Most commonly, it is the result of Graves’ ophthalmopathy, which can lift the lid above the

464

SECTION II

CHAPTER 13  • Blepharoplasty

Positive vector

Negative vector

D Malar support

A Visual acuity via Snellen chart

B Schirmer’s test

E Tear film breakup time

C Snap back lost

Figure 13.20 (A–E) Evaluation of the patient should include an appreciation of visual acuity (with and without correction), baseline tear production, intrinsic lid tone, lower eyelid support, and tear film quality. The tests performed and their interpretation should be tailored by the clinician within the context of each patient and applied on an individual basis. (Modified from Spinelli HM. Atlas of Aesthetic Eyelid and Periocular Surgery. Philadelphia, PA: Saunders; 2004:31.)  

Diagnosis/patient presentation

superior limbus. A thyroid evaluation is appropriate before any surgery to correct retraction. If it is stable for more than 6 months, levator recession surgery can be combined with fat reduction blepharoplasty, but lid skin should rarely, if ever, be removed. Long-term soft contact lens wear is also a common cause of lid retraction that raises the lid to the superior limbus or above. Congenitally shallow or traumatically small orbits are also a cause of lid retraction, as is idiopathic retraction.27 If the retraction persists in spite of taping the brow or lid tissue out of the way of vision, the surgery to correct the retraction must either precede or accompany the eyelid or brow surgery. Retraction can also be accompanied by contralateral blepharoptosis according to Hering’s law.

Orbicularis oculi

Tear trough Levator labii superioris alaeque nasi

Orbits and malar eminence The relative position of the globe to orbital anatomy greatly influences appropriate surgical technique. There is a normal 10–12 mm projection of the globe seen in a profile photograph, as measured from the lateral orbital rim at the level of the canthal tendon to the pupil. Proptosis and enophthalmos are relative anterior and posterior displacement of the globe, respectively. Hertel exophthalmometry can be used to quantitate the degree of relative projection for documentation purposes.15,24 The tear trough is at the inferior orbital rim most medially, triangulated by the orbicularis, levator labii superioris alaeque nasi, and levator labii superioris muscles (Fig. 13.21). The indentation is at the junction of the thin eyelid skin above and the thicker and different nasal and cheek skin below, with attenuated subcutaneous tissue overlying the maxillary bone. It is the deepening of this groove that leads to true indentation and significantly impacts facial appearance. The relative lack of subcutaneous tissue in this area is subject to worsening concavity with aging. The cause of the deformity is due to a combination of orbital fat herniation, skin laxity and malar volume loss, and ptosis of skin and subcutaneous tissue.26 The ability to place the side of the finger into the bony furrow under the nasojugal groove suggests a potential benefit from a tear trough implant or the addition of soft-tissue augmentation (Fig. 13.22).34

465

Levator labii superioris

Figure 13.21  The anatomy of the tear trough deformity demonstrates the muscular triangle formed by the orbicularis oculi, levator labii superioris, and levator labii superioris alaeque nasi. (Modified from Hirmand H. Anatomy and nonsurgical correction of tear trough deformity. Plast Reconstr Surg. 2010;125:699–708.)

Tear trough

Pupils The pupils are evaluated for direct and consensual response to light. An abnormal result indicates a problem behind the globe (i.e., the optic nerve or brain). Refractive errors, amblyopia, and corneal or retinal problems will not present with an abnormal papillary response.

Extraocular muscles The extraocular muscles are tested for deviations, motility problems, or restrictions. Eye deviations often present with amblyopia unilaterally and corresponding reduced vision. One should examine the patient for the presence of an intact Bell phenomenon, an upward and outward rotation of the cornea with lid closure. This can be accomplished by gently forcing the upper eyelids open during closure. The presence of an intact Bell reflex affords protection for the eye and cornea in the event of incomplete eyelid closure. If the eyelid fails to close during sleep, the cornea may remain uncovered and dry out. Thus, the absence of Bell phenomenon raises the risk for postoperative problems, especially in those with pre-existing problems or dry eyes.29

Figure 13.22  Tear trough test. The ability to place the side of a finger into the bony furrow under the nasojugal groove suggests a potential benefit from tear trough augmentation.

Globe The globe is examined for clarity of the cornea, iris, and lens. The corneal light reflex should be sharp and no lesions noted anywhere on the globe. If there is any question of a corneal

466

SECTION II

CHAPTER 13  • Blepharoplasty

defect, a slit-lamp examination is needed, either by a surgeon or by an ophthalmologist on referral. Any whitening of the cornea is possibly an infectious infiltrate and should be treated aggressively with antibiotics.

Tear film Assessment of tear production is a necessary but unreliable task. Schirmer testing consists of placing filter paper strips in the lateral third of the lower eyelid. The irritation of any foreign object against the globe stimulates reflex tearing, possibly yielding a deceptively good test result. A topical anesthetic (tetracaine or proparacaine) eases discomfort and reflex tearing, giving a better assessment of basal tear secretion. After 5 minutes, normal tear production should be greater than 15 mm; 5–10 mm indicates borderline tear secretion, and less than 5 mm is hyposecretion. Basal tear production diminishes with age in all persons to a degree that usually becomes symptomatic by 50 years of age. In contact lens wearers, allergy sufferers, people with arthritis, and those with autoimmune diseases, this process accelerates and they often become symptomatic in their 30 s. It is important for patients to be aware of this age-related decrease in tear production preoperatively.

Photographic documentation No other area of cosmetic surgery is more dependent on accurate photography than the periorbital region (Box 13.3). It is essential in documenting existing anatomy and pathologic changes. Accurate photography assists in surgical planning, intraoperative decision-making, and documentation of results, and it may be necessary for legal protection.35

Unintentional deception in eye appearance There is a natural phenomenon that prevents surgeons from fully appreciating the potential adverse effects of the surgery. Women, and some men to whom appearance is important, subconsciously and automatically modify their appearance when they are confronted with a mirror, a camera, or someone carefully examining their appearance. They lift the chin, tilt the head backwards, elevate the eyebrows, and smile slightly. This gives the illusion of elevated lower eyelids (although it alters the intercanthal axis, turning it downward), and it cleans the upper lids. These unintentional changes simulate a browlift, although the medial brow is typically disproportionately elevated. This disguises from the surgeon, both on direct inspection and in photographs, the accurate preoperative appearance and true outcome of the surgery. When the mirror and camera disappear, the brow drops, the corrugators contract, and the lower lids drop to their natural posture. This then, is the face the real world is seeing. BOX 13.3  Recommended photographic views • Full face, upright (at rest) frontal, oblique, and lateral views. • Full face, upright and smiling. • Direct periorbital views in upward gaze and downward gaze and with eyes gently closed. • A view with a finger slightly elevating the brows with the eyes open and another with the eyes closed.

Patient selection Operative planning Before surgical planning, one must have a meaningful conceptualization of the desired result. Only then can the surgical maneuvers required be organized in a meaningful way (Box 13.4).35 Preoperative planning should take place with the patient upright under good lighting and with complete facial relaxation. It is also important to document the brow, canthus, and upper and lower eyelid posture and position, and all other desired alterations preoperatively. The preoperative photographs and surgical plan should be easily visible to the surgeon during the entire surgery. Skin and muscle are quantified for excision in millimeters or any standardized system comfortable to the surgeon. Fat excision is measured in terms of cubic centimeters (cc) or milliliters (mL). A pea-sized amount is roughly equivalent to 0.5 cc or 0.5 mL. Determination of fat excision should be approximated in multiples of this standard measure. Measurements should be consistent with the patient in a vertical position to avoid lid hollowness or concave depressions. In proptotic patients, more aggressive fat excision offers the possibility of reduction of globe projection, but skin removal, of any quantity, is most likely contraindicated.

Anatomic-directed therapy Upper eyelid position In the typical person with the brow in an aesthetically pleasing position, 20 mm of upper lid skin must remain between the bottom of the central eyebrow and the upper lid margin to allow adequate lid closure during sleep, a well-defined lid crease, and an effective and complete blink.

Lower eyelid tonicity The presence of atonic lower lids and lateral canthal laxity may give the impression that there is excess skin requiring removal. However, lower lid posture and optimal lateral canthal position should be restored manually before determining the amount of skin and other tissues to be removed. Lid and canthal restoration frequently eliminates skin excess. When skin removal is indicated, the surgeon will often need to remove skin more centrally than laterally.9,36

BOX 13.4  Preoperative periorbital plan The preoperative periorbital plan should include the following: • • • • • • • •

The patient’s specific concerns and desires for improvement. Brow position. Lower eyelid tonicity. Eyelid ptosis, retraction, or levator dehiscence. Exophthalmos or enophthalmos. Supraorbital rim prominence or hypoplasia. Suborbital malar and tear trough deformities. Excision of necessary skin, muscle, and fat – only if necessary.

Patient selection

Eyelid ptosis or retraction A patient’s response to phenylephrine testing can also guide therapy. Müller’s muscle receives its innervation from sympathetic fibers within the oculomotor nerve and can be directly activated with α-adrenergic eye drops. In general, the patient receives three drops of 2.5% phenylephrine over the course of 1 minute and a final drop applied 1 minute later. After several minutes, the patient’s eyelid position is remeasured. Posterior approaches to ptosis correction are typically reserved for patients with mild ptosis (1–3 mm) and a positive response. In patients with unilateral eyelid ptosis, one may be tempted to operate on the normal eye, which may appear to be retracted, instead of the “disguised” ptotic eye. As a consequence of Hering’s law, both levators are energized equally in an attempt to clear the visual axis of the ptotic lid, thereby making the normal lid appear retracted. Covering each eye separately and observing the lid position often leads to the discovery of the ptotic eye as the pathologic source. The retracted eye will drop to its normal position once the ptotic eye is covered, only to have the ptotic eye rise when it is uncovered. Symmetric elevation of the brow is similarly helpful in patients in whom asymmetric brow pseudoptosis obstructs peripheral vision. It is easy to correct existing true ptosis, or true retraction, at the time of blepharoplasty surgery. Even when ptosis is mild, correction avoids the probable worsening of the ptosis by the additional insults of a weakened levator due to surgical trauma, an edematous or bruised lid, a hematoma in the levator muscle, a cicatrix associated with even the smallest amount of orbital bleeding, or a simple asymmetric surgical rendering.37,38

Globe position and malar prominence The position of the globe greatly affects the procedural choices and quality of outcome in periorbital surgery. The high frequency of asymmetry in globe prominence is often not appreciated in aesthetic periorbital surgery. Unless it is recognized and treated appropriately, unfortunate outcomes are almost inevitable. In patients with infraorbital malar hypoplasia or tear trough deformity, it is not possible to achieve optimal aesthetic results without some contour correction. If the globe extends anteriorly past the inferior orbital rim, lower lid surgery will increase scleral show and lid deformity unless the lid and canthal posture are raised, the orbital rim–malar complex is enhanced, or the prominent globe is retropositioned. This bone deficit of the lower orbit, which occurs most commonly in men, creates an exophthalmos of the lower half of the globe. These patients can be described as vector-negative or having hemiexophthalmos. A youthful, vector-positive profile consists of an inferior orbital rim and malar soft tissue that are in the same plane of the globe (see Fig. 13.20).39 When a vector-negative profile exists, there is a relative scarcity of lower eyelid skin. Lids must not be shortened either by excessive skin or fat pad excision. To do so causes the lid margins to ride down the globe surface, resulting in more scleral show and pathologic exposure. Similar to proptotic patients, suspension canthopexy must be placed more superiorly and anteriorly to prevent scleral show. This relative lack

467

of lower lid skin can also be increased with lower lid spacers, canthal tendon elongation, or orbital fat reduction. In exophthalmos, tightening the lower lid, even when it is repositioned with a canthopexy or a lid shortening, may cause some severe potential problems. When it is horizontally tightened, the lid takes the course of least resistance and migrates under the proptotic globe, especially when the canthal attachment is not lifted. To overcome this, the canthopexy attachment commonly needs to be placed higher than is aesthetically most desirable. In addition, the canthal fixation must be placed more anteriorly to accommodate the proptotic globe, and occasionally the canthus needs an extension to reach the bone or augmentation of the orbital rim.

Tear trough deformities The tear trough deformity is a type of relative infraorbital malar hypoplasia where there is an asymmetric bony depression along the medial infraorbital rim. Tear trough implants (see Fig. 13.19) are reserved for severe deformities where the volume of surgical fat repositioning is inadequate and cost of filler exceptional.34,40 If the surgeon can place the side of his or her finger into this diagonally recessed bone, augmentation of the concavity should be considered. Factors such as age, skin quality, and severity of the hollowing dictate the appropriate procedure. Young patients with good skin quality will benefit from hyaluronic acid fillers placed between the deep dermis and orbicularis oculi fascia. This outpatient procedure can be performed concomitantly or weeks after blepharoplasty once perioperative swelling subsides (Fig. 13.23). Older patients require orbital fat repositioning from the medial and central compartments during a transconjunctival blepharoplasty. Alternative soft-tissue injectables include autogenous fat, hydroxyapatite, and micronized acellular dermis.

Optimal brow positioning Aesthetic surgery of the forehead is thoroughly reviewed in Chapter 11. Brow positioning is a cornerstone of blepharoplasty surgery. Most of the aesthetic improvement of the upper orbital region comes from proper brow positioning and canthopexy. When advocating periorbital rejuvenation, it is therefore appropriate to consider repositioning the resting brow position when considering blepharoplasty.41 A low resting brow is extremely common and occurs in people of all ages. The lateral overhang of the eyebrow, upper eyelid, and juxtabrow skin can cause visual field obstruction. These tissues progress downward from degenerative changes resulting in stretching of the forehead and brow tissues. The recurring pull of the orbicularis, corrugator, and procerus muscles contributes to descent of the brow. Many adults presenting for aesthetic surgery have significant – but often undetected – “resting” brow ptosis. This phenomenon has been termed “compensated brow ptosis”, where brow ptosis remains undetected because of the compensatory activation of the frontalis muscles to clear the obstructing lid overhang.42 If the brow is simply elevated to its proper position, the seemingly elevated upper lid tissue either disappears or

468

SECTION II

CHAPTER 13  • Blepharoplasty

Figure 13.23  (A) Preoperative and (B) postoperative photographs demonstrating tear trough augmentation with fillers.

A

B

Figure 13.24  Compensated brow ptosis – continuous obligatory frontalis muscle contraction to clear the periorbital tissues (and to affect comfortable and unobstructed forward vision).

diminishes dramatically, leaving most if not all of the irreplaceable eyelid skin. Furthermore, any scars resulting from skin excision, when it is required, remain short and need not extend beyond the orbital rim. If a blepharoplasty alone is performed in these patients, the visual incentive to elevate the brow disappears. The frontalis relaxes and the brow drops – exaggerating the aged, tired look that the blepharoplasty was supposed to correct (Fig. 13.24). In addition, the weakened frontalis now fails to oppose the corrugators and relaxes its pull on the glabellar and interbrow skin, thereby accentuating the glabellar crease and frown – a heavy price to pay for an aesthetic procedure designed to rejuvenate the face. These features can be prevented by a concomitant or preceding temporal browlift that restores the eyebrows to their proper position and checks against a profound drop in the resting posture of the brow after blepharoplasty.

Treatment/technique (Video 13.1 Video Lecture 13.1 )

&

Continuum of aesthetic enhancement The goal of the eyelid surgeon when evaluating patients is to develop an individualized treatment plan for the classic symptoms of periorbital aging. While surgical techniques deliver the most dramatic and lasting results, these procedures are not without inherent risks and postoperative recovery. Surgery is not always the first and immediate response. Patients in their 30s and 40s will frequently benefit from office-based, non-surgical care. Chemodenervation can minimize the early appearance of brow ptosis and fine-line rhytides along the lateral orbital rim. Fillers, which range in cost and resorption rates, can augment the

Treatment/technique

infraorbital rim in negative vector patients. Photodynamic and laser therapy are alternatives to treat minor skin excess. It is prudent to develop lasting relationships with patients and provide the least invasive, targeted procedure needed for rejuvenation.

Upper eyelid surgery The most common approach to upper blepharoplasty has been the en bloc excision of skin, muscle, and fat in an attempt to debulk the eyelid. However, traditional blepharoplasty may not always fulfill the promise of producing youthful, aesthetically pleasing eyelids. In particular, aggressive upper lid skin excision performed as standard procedure is both a functionally and aesthetically harmful form of upper eyelid blepharoplasty.

Simple skin blepharoplasty Preserving orbicularis muscle and preaponeurotic fat has been shown to enhance aesthetic outcomes for a variety of presentations. Many who present for upper blepharoplasty hope for a result that is aesthetically enhancing yet avoids a “surgical appearance” or hollowed upper periorbital. Volume-maintaining methods by preserving the orbicularis muscle can be used to preserve or restore a youthful convexity of the upper eyelid–brow junction. Excessive skin and facial soft-tissue descent may rest more on the deflationary effects of regional volume loss rather than true, gravitational descent. A youthful appearance is gained with maintenance or enhancement of volume and a shorter pretarsal fold. Closure of the skin ellipse after skin resection and orbicularis preservation can improve supratarsal and infrabrow volume. The effects of muscle preservation can be similar to results achieved by soft-tissue filler. Muscle resection should be reserved for patients with orbicularis redundancy or relative hypertrophy. The primary indication for selective myectomy is upper eyelid fold disparities and mild lid ptosis. When skin-only excision is elected, it should occur above the supratarsal fold or crease, leaving that structure intact. This retains most of the definition of an existing lid fold. If eyelid skin containing the crease is part of the excision, the lid fold becomes ill-defined, indistinct, and irregular. The supratarsal fold is located approximately 7–8 mm above the ciliary margin in women and 6–7 mm in men. The upper marking must be at least 10 mm from the lower edge of the brow and should not include any thick brow skin. The use of a pinch test for redraping the skin is helpful. The shape of the skin resection is lenticular in younger patients and more trapezoid-shaped laterally in older patients. The incision may need to be extended laterally with a larger extension, but extension lateral to the orbital rim should be avoided if possible, to prevent a prominent scar (Fig. 13.25). Similarly, the medial markings should not be extended medial to the medial canthus because extensions onto the nasal side wall result in webbing. At the conclusion of the case, the patient should have approximately 1–2 mm of lagophthalmos bilaterally. Fig. 13.26 displays the predictable, restorative outcomes that can be achieved with skin excision alone.

469

Anchor (or invagination) blepharoplasty Anchor blepharoplasty involves the creation of an upper eyelid crease by attaching pretarsal skin to the underlying aponeurosis. The advantage of an anchor blepharoplasty is a crisp, precise, and well-defined eyelid crease that persists indefinitely. Such lids are more desirable in women than in men because they tend to glamorize the orbital region. The disadvantage is that it is more time-consuming, requires greater surgical skills and expertise, and encourages greater frontalis relaxation as a result of more effective correction of the overhanging pseudoptotic skin. It accomplishes that task while minimizing upper lid skin removal.43 Key components of the anchor blepharoplasty include minimal skin excision (2–3 mm) extending cephalad from the tarsus. A 1–2 mm sliver of orbicularis must be removed in proportion to the amount of skin removed. A small pretarsal skin and muscle flap are dissected from the aponeurosis and septum adhesion. After sharply disinserting the aponeurosis from the tarsus, pretarsal fatty tissue can be removed to debulk the pretarsal skin. Key components of the anchor blepharoplasty include minimal skin excision (2–3  mm) extending cephalad from the tarsus. A 1–2 mm sliver of orbicularis must be removed in proportion to the amount of skin removed. A small pretarsal skin and muscle flap are dissected from the aponeurosis and septum adhesion. After sharply detaching the septal extension from the tarsus, pretarsal fatty tissue can be removed to debulk the pretarsal skin. Mattressed anchor sutures are placed connecting the tarsus to the aponeurosis and pretarsal skin (Fig. 13.27). Finally, a running suture approximates the preseptal skin incision.

Orbital fat excision A relative excess of retroseptal fat may be safely excised through an upper eyelid blepharoplasty incision. A small septotomy is made at the superior aspect of the skin excision into each fat compartment in which conservative resection of redundant fat has been planned. The fat is teased out bluntly and resected using pinpoint cautery. This fat usually includes the medial or nasal compartment, which contains white fat. Yellow fat in the central compartment is usually more superficial and lateral. Gentle pressure on the patient’s globe can reproduce the degree of excess while the patient lies recumbent on the operating room table (Fig. 13.28). Overall, undercorrection is preferred to prevent hollowing, which can be dramatic and recognized as an A-frame abnormality. The attenuated orbital septum may be addressed by using selective diathermy along the exposed caudal septum. Inflammation-mediated tightening can enhance septal integrity. Septal plication aid is unnecessary and may induce a brisk, restrictive inflammatory response.

Blepharoptosis During upper blepharoplasty, with the septum open and the aponeurosis and superior tarsus exposed, there is an ideal opportunity to adjust the level of the aperture. Inappropriate aperture opening can be due to upper lid ptosis or upper lid retraction. It is not uncommon for there to be ptosis of only the medial portion or retraction of only the lateral portion. A surgeon should not hesitate to take advantage of this opportunity

470

SECTION II

CHAPTER 13  • Blepharoplasty

Incision

Central fat pad (preaponeurotic) on levator aponeurosis

A

Levator aponeurosis

Pressure on globe causes medial fat pad bulge

Orbital septum

C

B

Skin and orbicularis muscle resection

Figure 13.25  Simple skin excision blepharoplasty. (A) Digital traction and light pressure by the surgeon allow smooth quick incisions. (B) The skin may be elevated with the orbicularis muscle in one maneuver, proceeding from lateral to medial. (C) The orbital septum is then opened, exposing the preaponeurotic space. The underlying levator aponeurosis is protected by opening the septum as cephalad as possible. (Modified from Spinelli HM. Atlas of Aesthetic Eyelid and Periocular Surgery. Philadelphia, PA: Saunders; 2004:64.)

A

B

Figure 13.26 (A) Preoperative and (B) postoperative photographs depicting predictable results with simple skin excision blepharoplasty anchor technique in addition to levator advancement with reinsertion into tarsus.  

Treatment/technique

471

for repair. True ptosis repair involves reattachment of the levator aponeurosis to the tarsus, with or without shortening of applicable structures (e.g., aponeurosis, Müller’s muscle, and tarsus).32,33 Approximately half of all patients presenting for periorbital aesthetic surgery have one brow that is several millimeters lower than the other. Half of those have significant unilateral ptosis on the side of the lower brow from the “mechanical weight” of the excess skin. Half of those patients’ ptosis will be corrected by manually raising the brow on the affected side. The other half have true ptosis, which most likely has gone undiagnosed because of overhanging tissue.

Surgical technique

Figure 13.27  Anchor blepharoplasty technique. Attaching the dermis of the pretarsal skin flap to the superior aspect of the tarsus and to the free edge of the aponeurosis. (Modified from Spinelli HM. Atlas of Aesthetic Eyelid and Periocular Surgery. Philadelphia, PA: Saunders; 2004:69.)

Whitnall’s ligament

There are a variety of techniques to address blepharoptosis but they are outside the scope of this chapter. Oculoplastic surgeons advocate posterior approaches to ptosis correction that rely on resecting Müller’s muscle and shortening the posterior lamella.44 We will thus present our preferred technique for uncomplicated involutional ptosis. A ptosis repair may be undertaken in combination with a skin excision upper blepharoplasty. The difference is adjusting (or advancing) the point of attachment of the levator aponeurosis to the tarsus. There is a significant learning curve to performing a ptosis repair, and even then, the ability to get perfect symmetry is elusive. In the setting of mild upper eyelid ptosis (approximately 1 mm), where the decision has been made to avoid a formal lid ptosis procedure, selective myectomy of the upper eyelid orbicularis can be performed to widen the lid aperture. The amount of muscle to be resected depends on a host of factors, including the severity of relative lid ptosis, brow position, and fold disparity (Fig. 13.29). The orbicularis muscle is then resected selectively using cautery that strips orbicularis muscle from the underlying orbital septum. The amount of resection is titrated depending on the amount of effect desired. For

Levator aponeurosis Intracuticular running suture

Interrupted sutures

A

Medial fat pad removed

B

Closure

Figure 13.28 Simple skin excision blepharoplasty. (A) The medial fat pad may require digital pressure to expose and grasp; however, care should be taken not to overly resect fat when using digital pressure techniques. (B) Closure may then be performed with a combination of interrupted and running intracuticular sutures. (Modified from Spinelli HM. Atlas of Aesthetic Eyelid and Periocular Surgery. Philadelphia, PA: Saunders; 2004:65.)  

472

SECTION II

CHAPTER 13  • Blepharoplasty

Orbital septum and underlying (preaponeurotic) fat

Levator aponeurosis

A

Levator plication

Figure 13.29  (A,B) Once the upper lid is incised, the levator may be modified (shortened/lengthened) in a number of ways, including simple plication. A suborbicularis skin flap can also be developed allowing access to preaponeurotic fat. (Modified from Spinelli HM. Atlas of Aesthetic Eyelid and Periocular Surgery. Philadelphia, PA: Saunders; 2004:69.)

1 mm or less of relative upper lid ptosis, resection of at least 3–4 mm of orbicularis is required. The effects are more powerful the closer the resection is to the inferior edge of the elliptical wound. No attempt is made to close orbicularis muscle in this resection, which could increase the risk of lagophthalmos. On the opposite side, which is likely retracted, a slight ptosis can be induced by resecting a larger degree of orbicularis

B

and/or lowering the upper eyelid margin. Placing the upper eyelid incision and crease 2 mm or higher on the relatively retracted side can also reduce the need for formal lid retraction surgery.38 The key components of formal lid ptosis correction include correct identification of the distal extensions of the aponeurosis and the orbital septal extension.12 The superior edge of

Treatment/technique

the tarsus is freed from any dermal or tendinous extensions. Leaving a small cuff of filmy connective tissue (approximately 1 mm) on the tarsus will minimize bleeding from the richly vascularized area. Ensure that there is complete hemostasis by using a fine forceps cautery, lifting all lid tissues away from the cornea and globe before cauterizing. Anchor the upper third of the tarsus to the remaining levator with 5-0 silk suture, placed as a horizontal mattress. The lid should be flipped to ensure that the suture is not exposed posteriorly on the tarsus, which could cause a troublesome corneal abrasion. The level of correction should be checked by having the patient open his/her eye. Some coaxing helps the patient open the eye gently rather than maximally, which the patient has been used to doing consistently to compensate for ptosis. The patient should blink frequently and look superiorly to ensure that the lid never rises above the superior limbus. For cases under general anesthetic, one should attempt to create one to two times the amount of lagophthalmos relative to the preoperative ptosis. If there is any medial or lateral retraction or ptosis, the central suture should be repositioned medially or laterally as many times as needed, with adjustment to a pleasing lid height and contour. Both sides should be completed before the suture is permanently tied. Once the desired lid height and contour of both eyes are achieved, the patient should be asked to open and close the eyes to ensure symmetry. Anchoring the tarsus, dermis, and aponeurosis at the right level keeps the pretarsal skin taut and flat, prevents lash eversion, and forms a neat, crisp lid crease that will persevere for many years.

Lower lid blepharoplasty Lower blepharoplasty has evolved substantially. There are two trends in blepharoplasty, one towards more aggressive techniques to maximize the aesthetic outcome and the other towards more conservative techniques to minimize the risk of complications. Although excellent aesthetic results can be achieved with transcutaneous lower blepharoplasty, lid retraction and ectropion are concerning complications. Conservative excisional techniques center on the concept of fat preservation. Transconjunctival lower blepharoplasty, although more conservative, does not eliminate the risk of lid malposition. An effective, lasting procedure should address the extrinsic and intrinsic support of the eye, which is weakened during the aging process. In the classic concept of lower lid blepharoplasty, the concern of the surgeon who resects lid fat is the difficulty of estimating the correct amount of fat to remove.45 If this is not done correctly, this miscalculation may lead to asymmetry, hollowing, or a sunken lid appearance. Relative enophthalmos is an obvious sign of aging because the volume of fat decreases due to involution and herniation within the bony orbit. By extension, rejuvenation proceeds by maintaining the fatty volume and strengthening the globe’s extrinsic support by canthopexy and orbicularis and midface suspension.

Transconjunctival blepharoplasty Transconjunctival blepharoplasty is the preferred procedure for fat reduction in patients without excess skin and with good canthal position. A transconjunctival approach is less likely to lead to lower lid malposition than is a transcutaneous

473

approach. It minimizes but does not eliminate postoperative lower lid retraction; transection of the lower lid retractors can cause a temporary rise in the lid margin, especially if they are suspended during the healing period. Previously suspected septal scarring through transconjunctival fat excision has not been shown to significantly alter lid posture or tonicity.46 The lower lid retractors (capsulopalpebral fascia and inferior tarsal muscle) and overlying conjunctiva lie directly posterior to the three fat pads of the lower lid. A broad and deep transconjunctival incision severs both conjunctiva and retractors but typically should not incise the orbital septum, orbicularis, or skin. The conjunctival incision is made with a monopolar cautery needle tip at least 4 mm below the inferior border of the tarsus – never through the tarsus (Fig. 13.30). A preseptal approach is obtained by entering the conjunctiva above the level of septal attachment to the capsulopalpebral fascia. A retroseptal approach involves a 1.5–2 cm incision lower down in the fornix, and is typically used to excise fat. There are differences of opinion about whether to leave the transconjunctival incision open or to close it; however, it is preferable to leave it open. Suturing the wound may trap bacteria or cause corneal irritation. Conjunctival closure, when it is elected, is simplified by a monofilament pull-out suture that enters the eye externally, closes the conjunctiva, and exits through the skin and is taped. The incision through the conjunctiva and retractors gives excellent access to the orbital fat. A 6-0 silk traction suture passed through the inferior conjunctival wound and retracted over the globe gives wide access to the orbital fat, even helping to prolapse the fat into the wound. The thin film of synoviumappearing capsule encasing the orbital fat is opened, releasing the fat to bulge into the operative field (Fig. 13.31). Once fat is removed or repositioned through a transconjunctival incision, excess skin can be removed through a subciliary position. Fat reduction may leave skin excess, leading to wrinkling. A conservative “skin pinch” can be done to estimate skin removal, or alternatively, skin can be tightened by skin resurfacing with chemical or laser peels (Fig. 13.32). One should be careful not to incise the orbital septum, which leads to increased postoperative retraction. This procedure works particularly well when there is an isolated fat pad, especially medially, accessed through a single stab incision through the conjunctiva.

Transcutaneous blepharoplasty A subciliary incision can be used to develop a skin flap or a skin–muscle flap. With either method, pretarsal orbicularis fibers should remain intact. For the skin–muscle flap, skin and preseptal orbicularis are elevated as one flap, while with a skin flap, the muscle and its innervation can be preserved.14 Periorbital fat, muscle, and skin can be addressed with either approach. Once the plane deep to the orbicularis is entered, dissection continues between the muscle and the orbital septum down to the level of the orbital rim. Periorbital fat can be excised through small incisions in the septum. The fat can also be retropositioned using capsulopalpebral fascia placation, or it can be transferred into the nasojugular fold. Orbicularis muscle fibers and skin can be excised at closure. However, care must be taken with muscle excision, which can lead to orbicularis denervation and lid malposition.

474

SECTION II

CHAPTER 13  • Blepharoplasty

Retroseptal approach Preseptal (suborbicularis) approach Non-conductive retractor

A Conjunctiva is tented and secured with a stay suture

Orbital septum B

C Inferior tarsal plate Conjunctiva is divided longitudinally just below the tarsal plate

Figure 13.30  (A) The transconjunctival approach to the retroseptal space may be in one of two ways: preseptal or retroseptal. The preseptal route requires entry into the suborbicularis preseptal space above the fusion of the lower lid retractors and the orbital septum. This will allow direct visualization of the septum, and each fat pad can be addressed separately in a controlled fashion. (B) A conjunctival stay suture is placed deep in the fornix and traction is applied superiorly while the lid margin is everted. This causes the inferior edge of the tarsal plate to rise toward the surgeon. (C) The conjunctiva and lower lid retractors are incised just below the tarsal plate entering the suborbicularis preseptal space. This plane is developed to the orbital rim with the assistance of the traction suture and a nonconductive instrument. (Modified from Spinelli HM. Atlas of Aesthetic Eyelid and Periocular Surgery. Philadelphia, PA: Saunders; 2004:86.)

Orbital fat

Orbital fat transposition

The relative excess of orbital fat may be handled in several ways. Most commonly, surgeons choose to excise the herniated fat with meticulous attention to hemostasis. Additional techniques exist to reposition the fat to create periorbital harmony.

An alternative to excising prominent orbital fat is to redrape the pedicled fat onto the arcus marginalis. Patients with tear trough deformities who have prominent medial fat pads are excellent candidates.47 Access to the medial and central fat pads is by the subciliary or transconjunctival incision.48 The

Treatment/technique

475

Inferior oblique muscle

Conjunctiva retracted superiorly Orbital septum opened

Lateral, central and medial fat pads (left to right)

A

Remove fat pads if they bulge

B Reposition fat pads transconjunctivally

Figure 13.31  (A) The orbital septum may then be punctured and the inferior oblique muscle identified and preserved. (B) The fat pads may be addressed individually in keeping with preoperative plans with either resection, repositioning, conservation, or any combination of the these techniques. (Modified from Spinelli HM. Atlas of Aesthetic Eyelid and Periocular Surgery. Philadelphia, PA: Saunders; 2004:87.)

minor degree of lateral fat pad prominence is generally insufficient to affect any change with repositioning. A supraperiosteal or a subperiosteal dissection for 8–10 mm caudal to the inferior orbital rim permits tension-free placement. The fat can be secured in place with interrupted absorbable sutures. This technique can be used as an alternative to fat grafting or filler injection. Patients must be warned that various degrees of fat loss and hardening are possible. There is also a rare

but described possibility of restrictive strabismus related to aggressive fat mobilization and fixation.

Plication techniques The fundamental agreement among surgeons who practice plication is that bulging of orbital fat is the major component in most cases of eyelid aging deformity. The conclusion is that most cases of baggy eyelids occur from a true herniation

476

SECTION II

CHAPTER 13  • Blepharoplasty

A

B

Figure 13.32  (A) Simple skin excision lower eyelid blepharoplasty. (B) Typical removal of redraped skin or skin–muscle from the lower lid, which can be the shape of an obtuse triangle, with the largest amount sacrificed laterally.

of the orbital fat out of the bony orbit. Consequently, rejuvenation centers on re-establishing the normal position of the globe orbital fat. Plication offers the advantages of prevention of depletion of the extraconal fat, achievement of a homogeneous and natural eyelid, avoiding local hollowing and sunken lid appearance, and no risk of infraorbital hematomas. Access is through a transcutaneous approach, which gives superior exposure.

Orbital septum plication In this procedure, the herniated septum is plicated and repositioned to its normal anatomic site within the orbit. The fat is replaced in the retroseptal position to regain its original anatomic integrity (Fig. 13.33). Three to four 5-0 polyglycolic acid sutures are placed in a vertical fashion from medial to lateral. The protruding fat pads are invaginated and the integrity of the thin, flaccid septum is restored. Additional support may be gained with septo-orbitoperiostoplasty variation.49 This technique plicates the flaccid septum and secures it to the periosteum of the inferior orbital rim. Because no disruption of the eyelid anatomy occurs, complications related to lid malposition such as lid retraction, scleral show, and ectropion are reduced.50

Capsulopalpebral fascia plication Anatomical dissection suggests that the Lockwood suspensory ligament descends with aging that leads to relative enophthalmos and fat herniation. Moreover, simply plicating the orbital septum, which is an acellular membrane with little tensile strength, will not restore the globe’s position. The capsulopalpebral fascia can be plicated to the orbital rim either through a transcutaneous or a transconjunctival approach. In the transcutaneous method, dissection is carried out between the orbicularis and the septum down to the orbital rim; the capsulopalpebral fascia is then sutured to the orbital rim. In the transconjunctival method, the capsulopalpebral fascia is divided from the tarsus, and orbital fat is retroplaced, its position maintained by suturing the capsulopalpebral fascia to the periosteum of the orbital rim using a continuous running 6-0 non-absorbable suture. The conjunctival gap of a few millimeters is allowed to re-epithelialize (Fig. 13.34).51–53 One advantage of the transconjunctival approach is the division of lower

eyelid depressors, which helps maintain the lower eyelid at an elevated level due to the unopposed action of the pretarsal orbicularis. Several series have shown this disruption does not interfere with lower eyelid or globe function.49,51

Orbicularis suspension Orbicularis repositioning can be used to eliminate hypotonic and herniated orbicularis muscle, soften palpebral depressions, and shorten the lower lid-to-cheek distance. The main steps include elevation of a skin–muscle flap, release of the orbicularis retaining ligament and resuspension of the orbicularis – frequently after lateral canthopexy. Along the entire infraorbital rim, the orbicularis retaining ligament is divided. Additional medial dissection is performed to release the levator labii when a tear trough deformity is present. The skin–muscle flap is draped in a superior lateral vector rather than a pure vertical vector. Excision of skin and muscle are performed by removing a triangle of tissue lateral to the canthus, thereby minimizing the amount of tissue removed along the actual lid margin. The lateral suspension of the orbicularis is to the orbital periosteum. Lower lid support is gained by resuspension of the anterior (skin and muscle) and posterior lamellae (tarsus by canthopexy). This technique is best suited for patients with scleral show, lid laxity, and a negative vector, which put them at risk for lid malposition in the postoperative period. Its drawback is that it inherently disrupts the orbicularis, which may lead to denervation. Mobilization of the levator labii muscles also may put the buccal branch of the facial nerve at risk.

Canthopexy As the lateral canthal tendon lengthens, it shortens the aperture and allows the lid posture to drop to give the illusion of excess lower lid skin as the tissues accordion inferiorly. With restoration of the normal intercanthal axis tilt, lid tone, and septal integrity, the appearance of excess skin and herniated fat disappears with minimal tissue excision and, in many patients, without the need for any muscle, skin, or fat excision (Fig. 13.35).37,54

Treatment/technique

Capsulopalpebral fascia

Capsulopalpebral fascia

Protruding inferior orbital fat Inferior orbital septum

Inferior orbital septum

Inferior orbital rim A

477

Inferior orbital rim B

Figure 13.33  (A,B) Schematic representation of procedure for lower eyelid. Note that only the inferior orbital septum is plicated and sutured to the inferior orbital rim. (Modified from Sensöz O, Unlu RE, Percin A, et al. Septoorbitoperiostoplasty for the treatment of palpebral bags: a 10-year experience. Plast Reconstr Surg. 1998;101:1657– 1663.)

Upper (ciliary) flap Inferior orbital septum Fascioseptal triangular space

A

Lower (ocular) flap made up of conjunctiva inferior tarsal muscle capsulopalpebral fascia B

Figure 13.34  (A,B) Suturing the lower capsulopalpebral flap to the arcus marginalis to reduce and contain the herniated fat. (Modified from Camirand A, Doucet J, Harris J. Anatomy, pathophysiology, and prevention of senile enophthalmia and associated herniated lower eyelid pads. Plast Reconstr Surg. 1997;100:1535–1538.)

A lateral canthopexy can establish an aesthetically and functionally youthful eyelid and reduce the incidence of lower lid malposition and scleral show (Fig. 13.36). It has become an integral part of a lower lid blepharoplasty and midfacelifting.36 It is increasingly appreciated that good and long-lasting surgical results in lower lid surgery are rarely possible without an effective canthopexy. A lasting canthopexy involves more than a simple stitch into the periosteum. A properly executed canthopexy restores the tone, posture, and tilt to the lower lid and serves as the fulcrum point for rejuvenation of the entire midface. In addition, it raises the Lockwood suspensory ligament (and the entire retinacular complex), lifting orbital structures upward, reducing lower lid fat herniation, and reducing upper lid hollowing – all an essential part of a youthful periorbital restoration. The degree of laxity predetermines the type of lateral canthal support. A lateral canthopexy is recommended for moderate lid laxity, which is considered 6 mm away from the globe. Lateral canthotomy, cantholysis of the inferior limb of the lateral canthal tendon, and release of the tarsal

strap are performed. This dissection is followed by a 2–3 mm full-thickness lid margin resection, depending on the degree of tarsoligamentous laxity. The lateral commissure is carefully reconstructed by aligning the anatomical gray line with 6-0 plain gut. Final fixation to the lateral orbital periosteum can be as described above.

Midfacelifting Patients will frequently complain that they would like the lower skin to be smoother and tighter, the fatty pads to be eliminated, and the tissues of the malar eminence to be fuller. Midface descent occurs in the spectrum of periorbital aging, clinically apparent in the fourth decade (Fig. 13.39). The orbicularis muscle and suborbicularis oculi fat (SOOF) descend in an inferonasal direction and, in conjunction with descent of the malar fat pad, results in the fullness of the nasolabial

Postoperative care

479

B

A

C

Figure 13.37  (A–C) Periosteal canthopexy. The inferior ramus of the lateral canthal tendon is secured and elevated to a raised position inside the orbital rim. Tension-free suspension occurs with release of the tarsal strap and lateral orbital thickening.

fold frequently seen with the aging face. This inferonasal vector of aging also creates a visual lengthening of the lower lids beyond the orbital margin. Lastly, relative loss of soft tissue secondarily skeletonizes the inferior orbital rim and zygoma, deepening the tear trough and diminishing the malar prominence.55,56 The middle third of the face, or midface, lies between the lateral canthal angle and the top of the nasolabial fold. It includes the lateral canthal tendon, the medial canthal tendon, the skin, fat, and orbicularis oculi muscle of the lower eyelids, the suborbicularis oculi fat pad, the malar fat pad, the orbitomalar ligament (orbicularis ligament), the orbital septum, and origins of the zygomaticus major and minor muscles and levator labii superioris. When evaluating the midface for aesthetic surgery, all the structures listed above must be considered. The authors’ preferred technique includes approaching the midface through a transconjunctival incision. After repositioning or resection of orbital fat, the midface is elevated in a supraperiosteal plane. The attachment of the orbicularis oculi muscle to the orbital septum is preserved. Adequate release of the remaining, lax orbitomalar ligament then permits malar fat

pad suspension in a superolateral vector to the lateral orbital rim and temporoparietal fascia (Fig. 13.40). Canthopexy is then performed to redrape lower eyelid skin and recreate a youthful intercanthal angle. Finally, a skin-only resection of the lower lid may be necessary to address any redundancy.

Postoperative care All patients are advised to expect swelling, bruising, some degree of ptosis, and tugging sensation on gazing upward. Although complete recovery takes months, patients generally look presentable approximately 2–3 weeks after surgery. Surgical literature has not advocated compression bandaging of the eyes after surgery. The concern is an undetected retrobulbar hemorrhage that results in vision loss. However, the reality is that the risk for hemorrhage, chemosis, and other problems is more likely in an eye that has no compression. Retrobulbar hemorrhage is likely to induce orbital pain, which should never be ignored, alerting the surgeon to the potential vision-threatening complication. If one chooses not

480

SECTION II

CHAPTER 13  • Blepharoplasty

A

B

D

C

E

Figure 13.38  The canthopexy suture series for a two-layered canthopexy. (A) The canthopexy suture fixating the tarsal tail into the drilled hole. (B) The second-layer orbicularis suture. (C) Lateral sutures fix the lateral orbicularis to the deep temporal fascia. (D) If a midfacelift is elected, an inferior drill hole can be made to fixate the midface tissues. (E) Burying the knot into the drill hole.

A

B

Figure 13.39  (A) Preoperative and (B) postoperative photographs demonstrating the benefit of midfacelift in the setting of blepharoplasty.

to use gently compressive bandages, postoperative edema can be reduced with cool compresses for up to 20 minutes intermittently during the initial 36 hours postoperatively. Patients are advised against using frozen compresses directly over their face in the setting of previous anesthetic use and pain medication.29 Additional recommendations include having the patient lie in a semi-recumbent position while resting and to avoid bedrest. Prescriptions for rewetting drops, Lacri-Lube, and

antibiotic ophthalmic ointment can be given to reduce the incidence of exposure keratoconjunctivitis and dry eye symptoms in the immediate postoperative period. Patients are permitted to shower the next day and use antibiotic ointments as needed, for routine incisional care. Avoiding direct sun exposure with sunglasses may reduce the severity of sunburn and the formation of irregular, darkened pigmentation. It is also suggested that patients refrain from using contact lenses and minimize the use of prescription eyeglasses.30

Postoperative care

481

Access via upper or lower blepharoplasty incision

Orbital fat Orbital septum Orbicularis oculi Malar bag Orbitomalar ligament SOOF Malar fat pad Zygomaticus SMAS Buccal fat pad

Extent of sub-orbicularis muscle/ malar fat pad/SMAS undermining

B

A

Single mattress suture repair

C

Cheek flap is elevated and sutured to deep temporal fascia or periosteum of lateral orbital rim

Figure 13.40  Midfacelift. (A) The red arrow depicts the plane of dissection to the midfacial structures in the cheek in a supraperiosteal approach. (B) Wide undermining of the periorbital ligamentous structures and lateral retinaculum may be transconjunctival or through the upper blepharoplasty incision. (C) Canthopexy and cheek suspension then proceed sequentially. SMAS, Superficial musculo-aponeurotic system; SOOF, suborbicularis oculi fat. (Modified from Spinelli HM. Atlas of Aesthetic Eyelid and Periocular Surgery. Philadelphia, PA: Saunders; 2004:129.)

When no canthopexy is performed, half-inch Steri-Strips, retracted superiorly, are applied as a “cast” (with benzoin or Mastisol for security). This treatment tends to reduce lid retraction. Alternatively, a Frost suture placed in the lower lid margin and fixed to the brow suspends the lid during

early healing. Temporary medial or lateral limbus tarsorrhaphies were previously popular after aggressive skin excision blepharoplasty techniques. These sutures were primarily used to minimize chemosis during the first 48 hours. Discomfort, restricted vision, and secondary office visits for

482

SECTION II

CHAPTER 13  • Blepharoplasty

suture removal have led to their limited use today. However, the best support during healing is a secure extended canthopexy.46

Complications Even the most carefully planned procedures will have a small percentage of complications. The possibility of such complications and a realistic appraisal of likely outcome should be discussed with the patient before surgery. Asymmetry is common postoperatively and can be caused by edema, bruising, and asymmetric sleep posture, but it also predictably follows undiagnosed preoperative asymmetry, including mild ptosis, made worse by the weight of postoperative edema. Patients should be advised that no reoperations are indicated before 8 weeks, and then only if the lids have stabilized and no edema or bruising is seen. The need for reoperations is infrequent, but when ptosis or exophthalmos is involved, incidence increases significantly to 10–30%.46 Retrobulbar hemorrhage is the most feared complication of eyelid surgery. Any complaint of severe orbital pain needs to be examined immediately, especially that of sudden onset. Acute management involves immediate evaluation, urgent ophthalmologic consultation, and a return to the operation for evacuation of the hematoma. Medical treatments, in addition to operative exploration, include administration of high-flow oxygen, topical and systemic corticosteroids and mannitol. Acute loss of vision mandates bedside suture removal and decompressive lateral canthotomy. Hospitalization with head elevation and close observation may be necessary to supplement the described measures.29 Peribulbar hematoma, in contrast, does not threaten vision. It usually results from bleeding of an orbicularis muscle vessel. Small hematomas may resolve spontaneously, though larger hematomas can be evacuated in the office. Visual changes, including diplopia, are generally temporary and can be attributed to wound reaction, edema and hematoma. Any damage to the superficial-lying oblique muscles can be permanent and lead to postoperative strabismus. Conservative management is recommended; refractory cases should be referred to an ophthalmologist. The most common complication after blepharoplasty is chemosis. Disruption of ocular and eyelid lymphatic drainage leads to development of milky, conjunctival, and corneal edema. Chemosis can be limited by atraumatic dissection, cold compresses, elevation, and massage. It is usually self-limited and resolves spontaneously, though prolonged chemosis can be treated with topical steroids. Dry eye symptoms are also frequently cited in the postoperative phase. Patients may complain of foreign body sensation, burning, secretions, and frequent blinking. Pre-existing dry eyes may be aggravated by postoperative lagophthalmos. Ocular protection can be achieved medically with liberal use of corneal lubricants. Additional complications such as lower lid malposition, lagophthalmos, undercorrection, asymmetry, and iatrogenic ptosis all require careful observation and photographic documentation. Reoperation should be performed no earlier than 3 months later. Secondary blepharoplasty can range from simple office-based procedures to extremely challenging interventions.

Special considerations Non-surgical enhancement The ability to surgically enhance the eye is a powerful tool that is amenable to expedited healing and future enhancement to the eye by using the growing armamentarium of non-surgical technology, including the ability to perform composite blending or stacking of surgery with fillers, lasers, and energy-based tissue tightening.57 If we consider the previously mentioned cosmetically desired youthful, appealing eye, we must look at smooth eyelid skin, adequate volume around the eye, and enhanced lower lid tone. The use of off-label hyaluronic filler injection to the tear trough and nasojugal area can significantly enhance a post-lower blepharoplasty result.58,59 Furthermore, the use of Juvederm Voluma for midfacial volume restoration has been shown to enhance the appearance of 52% of tear troughs with isolated filler injection to the midface.60 In addition, we have utilized hyaluronic acid filler to the infrabrow in those recovering upper blepharoplasty patients who have relative fat atrophy to the region. We have advocated waiting at least 3 months in the postoperative period and giving detailed informed consent to the off-label nature of this filler injection in the upper and lower eyelid. We also prefer the use of blunt cannula around the eye, as has been advocated in the literature.58 The ability to resurface the upper and lower lid skin with laser resurfacing post-surgery can reduce a surgeon’s tendency to over-resect eyelid skin that is atrophic. Ablative laser resurfacing to the upper and lower eyelid can be done at the time of surgery or years later to enhance surgical results, adding a third dimension to the eye. We find that the laser-based solutions help to prolong the life of the result and are useful to soften existing scars around the eyes. There are also expanded roles of micro-focused ultrasound or radiofrequency to tighten the lower lids. This application to boost tone to a lax lower lid and enhance blending of the lower lid cheek junction as well as adding tone to the lateral aspect of the upper eyelid post surgery. At The Few Institute, we advised the application of radiofrequency to the lower lids postoperatively in patients with significant edema and/or preoperatively in more involved surgical cases. In these cases, radiofrequency is started at 1–2 weeks after surgery. In cases that are more than 3 months post-surgery, with persistent fat protrusion or relative laxity, the ability to apply micro-focused ultrasound or radiofrequency can lead to reduction/elimination of postoperative fat protrusion. Our approach has been to apply radiofrequency-based energy over the course of 4–6 sessions, applied weekly, with sessions lasting 10–15 minutes per time.

Male blepharoplasty In the United States, 14% of blepharoplasties are performed on men, and blepharoplasty is the second most common cosmetic surgery performed on male patients.61 Men tend to seek out blepharoplasty more for functional reasons than women, but this difference has become less and less distinct in recent years. A more natural look is preferred, and the “operated look” will not be tolerated well by most male patients. Men

Special considerations

typically do not use cosmetics, so all scars must be carefully concealed. This also makes male patients suboptimal candidates for laser resurfacing. The lateral incision should rarely be extended beyond the later orbital rim. In men with heavy brows, resection of upper eyelid skin only will result in profoundly ptotic brows. Therefore, one should consider combined brow surgery with upper blepharoplasty. Many men are reluctant to have cosmetic surgery to correct brow ptosis, so careful preoperative counseling is needed to prevent a dissatisfied patient with worse brow ptosis postoperatively.30,62 Often, conservative eyelid resection is all that is required.

Blepharoplasty in people of color Patients who identify themselves as of other than European ethnicity account for 34% of all cosmetic procedures. Hispanics, African Americans, and Asian Americans have seen a steady rise in their market share over the past 20 years.63 The awareness of the benefits of cosmetic plastic surgery is becoming ever-present to a patient population that transcends cultural and racial boundaries. African American patients pursuing eyelid rejuvenation have preconceived notions and concerns distinct from their

Access the reference list online at   Elsevier eBooks+

483

non-European counterparts, thereby demanding a different surgical strategy. African Americans are twice as likely to be afraid of losing their ethnic identity and 10 times as likely to choose a surgeon with special interests in ethnic plastic surgery. There are several features that make the African American eye ethnically unique. The lateral canthus is cephalad to the medial canthus in great frequency. In addition, there is a tendency for a more oval, Asian-like palpebral aperture, as opposed to the more rounded palpebral fissure in those of European ethnicity. The supratarsal fold distance tends to be shorter than in the European eyelid but longer than the Asian eyelid. The lateral orbit and cheek skin is more sebaceous, and there is a decreased tendency toward rhytid formation. Finally, African Americans tend to be poor candidates for lower eyelid resurfacing because of pigmentation risk. The preferred surgical approach includes canthopexy to restore lateral canthal position, preservation of the majority of orbicularis to restore supratarsal contour, and avoidance of cephalad malposition of the upper eyelid incision to preserve limited pretarsal show. These subtleties are discussed preoperatively, often with the aid of youthful photographs, to appropriately plan surgery.25,64 The unique characteristics of the Asian blepharoplasty will be thoroughly discussed in Chapter 15.

References

References 1. Dupuis C, Rees TD. Historical notes on blepharoplasty. Plast Reconstr Surg. 1971;47:246–251. 2. Flowers RS. The art of eyelid and orbital aesthetics. Clin Plast Surg. 1987;14:709–721. 3. Nesi FA, Levine MR, Lisman RD. Smith's Ophthalmic Plastic and Reconstructive Surgery. 2nd ed. St. Louis, MO: Mosby; 1997. 4. Putterman AM. Cosmetic Oculoplastic Surgery: Eyelid, Forehead, and Facial Techniques. 3rd ed. Philadelphia, PA: WB Saunders; 1999. 5. Flowers RS. Advanced blepharoplasty: principles of precision. In: Zaoli G, Meyer R, Gonzales-Ulloa M, eds. Aesthetic Plastic Surgery. Vol. II. Padua: Piccin Press; 1987. 6. Wolff E. The Anatomy of the Eye and Orbit. Philadelphia: WB Saunders; 1976. 7. Doxanas MT, Anderson RL. Clinical Orbital Anatomy. Baltimore, MD: Williams & Wilkins; 1984. 8. Stewart TD. The points of attachment of the palpebral ligaments: their use in facial reconstructions of the skull. J Forensic Sci. 1983;28:858–863. 9. Jelks GW, Jelks EB. The influence of orbital and eyelid anatomy of the palpebral aperture. Clin Plast Surg. 1991;18:183–195. 10. Couly G, Hureau J, Tessier P. The anatomy of the external palpebral ligament in man. J Maxillofac Surg. 1976;4:195–197. 11. Whitnall SE. Anatomy of the Human Orbit and Accessory Organs of Vision. New York, NY: Oxford University Press; 1932. 12. Flowers RS, Nassif JM, Rubin PA, et al. A key to canthopexy: the tarsal strap. A fresh cadaveric study. Plast Reconstr Surg. 2005;116:1752–1758. 13. Ghavami A, Pessa JE, Janis J, et al. The orbicularis retaining ligament of the medial orbit: closing the circle. Plast Reconstr Surg. 2008;121:994–1001. 14. Spinelli HM. Atlas of Aesthetic Eyelid and Periocular Surgery. Philadelphia, PA: Saunders; 2004. 15. Zide BM. Surgical Anatomy Around the Orbit: The System of Zones. 2nd ed. Philadelphia, PA: Lippincott, Williams & Wilkins; 2006. 16. Fralick FB. Anatomy and physiology of the eyelid. Ophthalmology. 1962;66:575–581. 17. Reid RR, Said HK, Yu M, et al. Revisiting upper eyelid anatomy: introduction of the septal extension. Plast Reconstr Surg. 2006;117:65–70. 18. Jones LT. The anatomy of the lower eyelid and its relation to the cause and cure of entropion. Am J Ophthalmol. 1960;49:29–36. 19. Hawes MJ, Dortzbach RK. The microscopic anatomy of the lower eyelid retractors. Arch Ophthalmol. 1982;100:1313–1318. 20. Gioia VM, Linberg JV, McCormick S. The anatomy of the lateral canthal tendon. Arch Ophthalmol. 1987;105:529–532. 21. Muzaffar AR, Mendelson BC, Adams Jr. WP. Surgical anatomy of the ligamentous attachments of the lower lid and lateral canthus. Plast Reconstr Surg. 2002;110:873–884. 22. Jones LT, Mustardé JC, Callahan A. Ophthalmic Plastic Surgery. New York, NY: Aesculapius; 1970. 23. Dutton JJ. Atlas of Clinical and Surgical Orbital Anatomy. Philadelphia, PA: WB Saunders; 1994. 24. Beard C, Quickert MH. Anatomy of the Orbit. New York, NY: Aesculapius; 1969. 25. Odunze MO, Reid RR, Yu M, et al. Periorbital rejuvenation and the African American patient: a survey approach. Plast Reconstr Surg. 2006;118:1011–1018. 26. Hirmand H. Anatomy and nonsurgical correction of tear trough deformity. Plast Reconstr Surg. 2010;125:699–708. 27. Zinkernagel MS, Ebneter A, Ammann-Rauch D. Effect of upper eyelid surgery on corneal topography. Arch Ophthalmol. 2007;125:1610–1612. 28. Lee WB, McCord CD Jr, Somia N, et al. Optimizing blepharoplasty outcomes in patients with previous laser vision correction. Plast Reconstr Surg. 2008;122:587–594.

483.e1

29. Trussler AP, Rohrich RJ, MOC-PSSM CME article: Blepharoplasty. Plast Reconstr Surg. 2008;1:1–10. 30. Rohrich RJ, Coberly DM, Fagien S, et al. Current concepts in aesthetic upper blepharoplasty. Plast Reconstr Surg. 2004;3:32e–42e. 31. McCord CD, Tanenbaum M. Oculoplastic Surgery. New York, NY: Raven Press; 1987. 32. Beard C. Ptosis. St. Louis, MO: Mosby; 1976. 33. Anderson RL, Dixon RS. Aponeurotic ptosis surgery. Arch Ophthalmol. 1979;97:1123–1128. 34. Flowers RS. Tear trough implants for correction of tear trough deformity. Clin Plast Surg. 1993;20:403–415. 35. Flowers RS. Precision planning in blepharoplasty: the importance of preoperative mapping. Clin Plast Surg. 1993;20:303–310. 36. Flowers RS. Canthopexy as a routine blepharoplasty component. Clin Plast Surg. 1993;20:351–365. 37. Ortiz-Monasterio F, Rodriguez A. Lateral canthoplasty to change the eye slant. Clin Plast Surg. 1985;75:1–10. 38. Fagien S. The role of the orbicularis oculi muscle and the eyelid crease in optimizing results in aesthetic upper blepharoplasty: a new look at the surgical treatment of mild upper eyelid fissure and fold asymmetries. Plast Reconstr Surg. 2010;125:653–656. 39. Flowers RS. Orbital rim contouring. In: Ousterhout D, ed. Aesthetic Contouring of the Craniofacial Skeleton. Boston, MA: Little, Brown; 1991. 40. Yaremchuk MJ. Secondary malar implant surgery. Plast Reconstr Surg. 2008;121:620–628. 41. Flowers RS. Blepharoplasty and brow lifting. In: Roenigk RK, Roenigk HH, eds. Principles of Dermatologic Surgery. New York, NY: Marcel Dekker; 1989. 42. Flowers RS. The biomechanics of brow and frontalis function and its effect on blepharoplasty. Clin Plast Surg. 1993;20:255–268. 43. Flowers RS. Upper blepharoplasty by eyelid invagination: anchor blepharoplasty. Clin Plast Surg. 1993;20:303–307. 44. Allen RC, Saylor MA, Nerad JA. The current state of ptosis repair: a comparison of internal and external approaches. Curr Opin Ophthalmol. 2011;22(5):394–399. 45. Mendelson BC. Fat preservation technique of lower-lid blepharoplasty. Aesthet Surg J. 2001;21:450–459. 46. Codner MA, Wolfi J, Anzarut A. Primary transcutaneous lower blepharoplasty with routine lateral canthal support: a comprehensive 10-year review. Plast Reconstr Surg. 2008;121: 241–250. 47. Loeb R. Naso-jugal groove leveling with fat tissue. Clin Plast Surg. 1993;20:393–400. 48. Goldberg RA. Transconjunctival orbital fat repositioning: transposition of orbital fat pedicles into a subperiosteal pocket. Plast Reconstr Surg. 2000;105:743–748. 49. Sensöz O, Unlu RE, Percin A, et al. Septo-orbitoperiostoplasty for the treatment of palpebral bags: a 10-year experience. Plast Reconstr Surg. 1998;101:1657–1663. 50. Huang T. Reduction of lower palpebral bulge by plicating attenuated orbital septa: a technical modification in cosmetic blepharoplasty. Plast Reconstr Surg. 2000;105:2552–2558. 51. Camirand A, Doucet J, Harris J. Anatomy, pathophysiology, and prevention of senile enophthalmia and associated herniated lower eyelid pads. Plast Reconstr Surg. 1997;100:1535–1538. 52. de la Plaza R, Arroyo JM. A new technique for the treatment of palpebral bags. Plast Reconstr Surg. 1998;81:677–687. 53. Parsa AA, Lye KD, Radcliffe N, et al. Lower blepharoplasty with capsulopalpebral fascia hernia repair for palpebral bags: a long-term prospective study. Plast Reconstr Surg. 2008;121: 1387–1397. 54. Jelks GW, Glat PM, Jelks EB, et al. The inferior retinacular lateral canthoplasty: a new technique. Plast Reconstr Surg. 1997;100: 1262–1266. 55. Patipa M. Transblepharoplasty lower eyelid and midface rejuvenation: Part I. Avoiding complications by utilizing lessons learned from the treatment of complications. Plast Reconstr Surg. 2004;113:1459–1468.

483.e2

SECTION II

CHAPTER 13  • Blepharoplasty

56. Paul MP, Calvert JW, Evans GR. The evolution of the midface lift in aesthetic plastic surgery. Plast Reconstr Surg. 2006;117:1809–1827. 57. Few JW. Continuum of beauty: blending of surgical and nonsurgical cosmetic medicine. Treatment strategies. Dermatol. 2012;2:29–31. 58. Few JW, Kwan D. Fine rhytids: fillers. In: Marsh JL, Perlyn CA, eds. Decision Making in Plastic Surgery. Boca Raton, FL: CRC Press; 2010. 59. Hirmand H. Anatomy and nonsurgical correction of the tear trough deformity. Plast Reconstr Surg. 2010;125:699–708. 60. Jones D, Murphy DK. Volumizing hyaluronic acid filler for midface volume deficit: 2-year results from a pivotal single-blind randomized controlled study. Dermatol Surg. 2013;39:1602–1612. 61. American Society of Plastic Surgeons Gender Distribution: Cosmetic Surgery 2020. Arlington Heights, IL: American Society of Plastic

Surgeons; 2020. https://www.plasticsurgery.org/documents/ News/Statistics/2020/cosmetic-procedures-men-2020.pdf. 62. Flowers RS. Periorbital aesthetic surgery for men: eyelids and related structures. Clin Plast Surg. 1991;18:689–729. 6 3. American Society of Plastic Surgeons Cosmetic Demographics 2020. Arlington Heights, IL: American Society of Plastic Surgeons; 2020. https://www.plasticsurgery.org/documents/News/ Statistics/2020/plastic-surgery-statistics-full-report-2020.pdf. 64. Few JW. Rejuvenation of the African American periorbital area: dynamic considerations. Semin Plast Surg. 2009;23:198–206.

SECTION II  •  Aesthetic Surgery of the Face

14 Secondary blepharoplasty Seth Z. Aschen and Henry M. Spinelli

Access video lecture content for this chapter online at Elsevier eBooks+

Introduction

Anatomy

The eyelids are one of the first areas on the face to show signs of aging. They undergo a predictable pattern of anatomical changes, typically producing a tired appearance, and may also develop functional issues such as eyelid malposition. Optimal periocular rejuvenation with blepharoplasty necessitates not only addressing aesthetic and functional concerns of the eyelids, but also those of the eyebrow and midface. In 2020 there were 325,112 blepharoplasties performed in the US, making blepharoplasty one of the most commonly performed aesthetic procedures in the United States. Eighty five percent (85%) of these procedures were performed in women and were mostly performed in patients 40 years and older (91%).1 Given the commonality of this procedure and the global tendency for younger and younger patients to be undergoing plastic surgery, secondary blepharoplasties are being performed with increasing frequency and present a unique challenge for the plastic surgeon with the most common indication for secondary blepharoplasty being lid malposition of the upper eyelid. Most lid malpositioning resolves within 4–6 weeks; when malposition does not affect the cornea, correction should not occur until this window of time has passed as spontaneous resolution is common. During the interim period before operative repair or spontaneous resolution it is critical to instruct patients on corneal protection. This should include lubricating eyedrops, protective eyeglasses, and eyelid taping at night. Lid malposition that does compromise the cornea, however, should be treated as soon as possible. Overall, better results with secondary blepharoplasty are achieved when surgery is performed at 6 months to 1 year following the initial surgery. This fact alone can create consternation for the unhappy patient and the eager-to-please plastic surgeon. In most cases the senior author underscores the value in the adage “never put off to tomorrow what may be done day after tomorrow just as well”.2 This chapter discusses considerations specific to secondary blepharoplasty.

Skin The skin of the eyelid is the thinnest in the body and has minimal subcutaneous fat. Tissue outside the eyelids but in and outside the periocular region (zones III, IV, V) is histologically, structurally, and mechanically thicker and less pliable and must be considered as contributory to eyelid functional and aesthetic disorders3 (Fig. 14.1). As patients age, the periorbital skin has decreased type I collagen synthesis and increased dermal collagenase activity. With time, these metabolic shifts lead to thinning, folding, and wrinkling of the eyelid skin.

Orbicularis oculi The orbicularis oculi is the sphincter of the eyelid (Fig. 14.2). This muscle is adherent to the overlying skin and comprises three parts: orbital, palpebral, and lacrimal. The outer orbital portion attaches medially to the medial canthal tendon, the nasal part of the frontal bone, and along the inferomedial orbital margin. Laterally, the orbital portion continues around the orbit and attaches to the lateral canthus. The palpebral portion of the orbicularis oculi, the middle segment, has pretarsal and preseptal segments. Medially, the preseptal segment of the palpebral portion of the orbicularis oculi has the anterior head, which becomes the anterior crus of the medial canthal tendon and inserts into the frontal process of the maxilla, and the posterior head, which inserts into the posterior lacrimal crest (Horner’s muscle). Laterally, the preseptal fibers of the palpebral portion of the orbicularis oculi coalesce with the lateral palpebral ligament to form the lateral palpebral raphe. The small, inner portion of the orbicularis oculi, the lacrimal segment, interdigitates with the medial palpebral ligament. This portion of the orbicularis oculi arises from the orbital surface of the lacrimal bone, passes behind the lacrimal sac,

Anatomy

485

The critical point to evaluate in the patient preoperative period is the pressure or absence of lid face ptosis. In corrective secondary procedures, zone II (lower eyelid) should not be used to support zone V (cheek) in order to achieve an optimal functional and cosmetic result (Fig. 14.6).

V I

Tarsal plates IV III

II V Figure 14.1  Anatomical zones of the eyelids and periocular structures. Zone I, upper eyelid; zone II, lower eyelid; zone III, medial canthal structures including the lacrimal drainage system; zone IV, lateral canthal area; zone V, periocular contiguous area – glabella, eyebrow, forehead, temple, malar, nasojugal and nasal areas. Tissue in the periocular region outside of the eyelids (zones III–V) is thicker and less pliable. Examination of position and pliability of this tissue must be performed to understand its contribution to eyelid deformities. (From Spinelli HM. Periocular reconstruction: a systematic approach. Plast Reconstr Surg. 1993;91:1017–1024; discussion 1025–1026.)

and divides into upper and lower slips. These slips insert into the superior and inferior tarsi, medial to the puncta lacrimalia. The three segments of the orbicularis oculi have distinct functions. The orbital portion of the orbicularis oculi tightly closes the eye. Contraction of the pretarsal and preseptal portions of the palpebral orbicularis oculi primarily closes the eyelid. The lacrimal portion transposes the lacrimal canals medially to receive tears and compresses the lacrimal sac3–5 (Fig. 14.3). The orbicularis oculi is anchored by well-defined ligamentous attachments. Medially, the orbicularis occuli attaches directly to the inferior orbital rim. Laterally, the orbital retaining ligament bridges the fascia of the orbicularis oculi to the periosteum of the orbital rim. At the lateral canthus, the orbital retaining ligament merges with the lateral orbital thickening, a triangular condensation of the superficial and deep orbicularis oculi that extends across the frontal process of the zygoma onto the deep temporalis fascia. Release of the orbital retaining ligament and lateral orbital thickening allows untethered re-draping of the eyelid4,6 (Fig. 14.4). With age, the orbicularis oculi muscles relax, and the ligamentous attachments attenuate. This transformation results in progressive upper and lower eyelid ptosis. Malar ptosis compounds this eyelid ptosis, forming a malar crescent or festoon over the malar eminence with an aged appearance. In addition, the pigment of the orbicularis oculi becomes more apparent over the thinning skin.3 In effect, progressive senescent attenuation combined with Newtonian gravitational forces contributes to intercanthal narrowing, lateral canthal declination, lateral fat pad herniation due to septal laxity, eyelid malposition, and other pathology (Fig. 14.5).

The tarsal plates, composed of dense fibrous tissue, are located directly above the lid margins and contribute to the integrity and support of each eyelid. Each tarsus measures approximately 29 mm long and 1 mm thick. The semilunar, superior tarsus measures 10 mm centrally and narrows medially and laterally. Conversely, the rectangular, inferior tarsus measures 3.5–5 mm centrally. The medial and lateral ends of the tarsus are attached to the orbital rims by the medial and lateral palpebral ligaments. Each tarsus contains approximately two sebaceous meibomian glands. These glands secrete meibum which is an oily substance that prevents evaporation of the tear film.4

Septum The orbital septum has dense fibroelastic tissue and forms the anterior boundary of the orbital contents. On the upper eyelid, the orbital septum inserts 10–15 mm above the superior tarsal border and joins the levator aponeurosis. On the lower eyelid, the orbital septum joins the capsulopalpebral fascia 5 mm below the tarsal border. In addition, inferiorly, the orbital septum fixates to the rim of the orbital periosteum and forms the arcus marginalis.4

Postseptal (intraorbital) fat The upper eyelid has two distinct intraorbital fat compartments, medial and central, divided by the superior oblique. The medial fat pad is lighter and firmer than the central fat pad. In addition, the medial fat pad encompasses the infratrochlear nerve and the terminal branch of the ophthalmic artery. Of note, the lacrimal gland occupies the lateral compartment.4 The lower eyelid has three distinct fat compartments: the medial, central, and lateral fat pads. The inferior oblique separates the medial and central fat pads. The central and lateral fat pads are separated by the arcuate expansion, a fascial band extending from the capsulopalpebral fascia to the inferolateral orbital rim.4 The interconnecting septae of the intraorbital fat link the extraconal (outside the muscle cone) and intraconal (within the muscle cone) spaces. Traction on fat just posterior to the orbital septum can produce forces in any of these spaces and accounts for the small but definite risk of orbital hemorrhage or even blindness when addressing anterior orbital fat during a surgical procedure.4 The blepharoplasty surgeon should be well versed in the acute treatment of orbital hemorrhage.4,7

Preseptal (extraorbital) fat The preseptal, or extraorbital, fat represents retro-orbicularis oculi fat (ROOF), which may accumulate outside the orbital rim on the inferior lateral brow and upper malar areas.4

486

SECTION II

CHAPTER 14  • Secondary blepharoplasty

Orbicularis muscle Whitnall's ligament

Orbital septum

Levator aponeurosis Lower crus, lateral canthal ligament Lockwood's ligament

Arcuate expansion

Capsulopalpebral fascia Skin

Orbicularis muscle

Levator palpabrae muscle

Orbital septum

Sup. rectus muscle

Müller's muscle Levator aponeurosis Tarsal plate Conjunctiva

Inferior tarsal muscle

Inferior rectus muscle

Capsulopalpebral fascia Orbital septum Inf. oblique muscle

Upper eyelid retractors The levator palpebrae muscle is the upper eyelid retractor and originates from the lesser wing of the sphenoid, extending anteriorly along the superior orbit. The levator condenses approximately 14–20 mm above the superior border of the tarsus into Whitnall’s ligament. Anterior to Whitnall’s ligament, the levator forms a bilamellar aponeurosis that joins with the septum to insert into the tarsus. A lateral horn divides the lacrimal gland into the palpebral and orbital lobes and contributes to the lateral retinaculum.

Figure 14.2  The orbicularis oculi muscle is a broad muscular sphincter of the eyelid. It is adherent to the overlying eyelid skin. Crucial anchors for the muscle include the frontal bone, medial canthal tendon and inferior orbital medially as well as the lateral canthus laterally. Sup., superior; Inf., inferior. (From Spinelli HM. Atlas of Aesthetic Eyelid and Periocular Surgery. Philadephia: Saunders/Elsevier; 2004.)

A medial horn inserts into the lacrimal crest. The posterior lamella of the levator aponeurosis contains Müller’s muscle.4

Lower eyelid retractors The capsulopalpebral fascia forms the lower eyelid retractors. This fibroelastic tissue originates from the inferior rectus and oblique muscles, fuses into Lockwood’s ligament, and inserts approximately 5 mm below the inferior tarsus.4,8

Anatomy

487

Lacrimal gland Upper and lower canaliculi Tear film

Lacrimal sac

Lacrimal duct

Inferior turbinate

Superficial portion of orbicularis muscle

Figure 14.3  Activation of the preseptal, pretarsal, and orbital portions of the orbicularis oculi muscle close the eyelid. Contraction of the lacrimal portion of the orbicularis moves the lacrimal canals into position to drain the tear film. (From Spinelli HM. Atlas of Aesthetic Eyelid and Periocular Surgery. Philadelphia: Saunders/Elsevier; 2004.)

Orbital septum

Deep portion of orbicularis muscle Whitnall's ligament Tarsal plates

Lateral canthal tendon divided and inserting into Whitnall's tubercle

Orbicularis muscle (superficial portion) and orbital septum contributing to the lateral retinaculum

Figure 14.4  Pretarsal portion of orbicularis muscle joins with the lateral canthal tendon behind the orbital septum and ultimately inserts on Whitnall’s tubercle. Note the orbital septum dividing the orbicularis muscle into an anterior and posterior leaflet. (From Spinelli HM. Atlas of Aesthetic Eyelid and Periocular Surgery. Philadelphia: Saunders/Elsevier; 2004.)

488

SECTION II

CHAPTER 14  • Secondary blepharoplasty

LATERAL CANTHAL CHANGES WITH AGE

+10–15° 0°

0°

0°

0° -10–15°

Lateral canthus The lateral canthus partitions into an anterior and posterior leaflet. The anterior leaflet inserts onto the orbital rim periosteum, and the posterior leaflet inserts onto the lateral orbital tubercle (Whitnall’s), approximately 3 mm behind the orbital rim. The lateral canthus lies approximately 6 mm below the lacrimal gland fossa and is the culmination of the lateral canthal retinaculum, which consists of the lateral horn of the levator palpebrae superioris, preseptal and pretarsal orbicularis oculi, Lockwood’s ligament, and the check ligament of the lateral rectus muscle. The ideal position of the lateral canthal tendon is 10–15° above the medial canthal tendon.4 All key elements of the lateral retinaculum must be addressed before mobilizing the lateral canthus for any repositioning or tightening procedures. Fig. 14.7A shows a patient with lateral canthal effacement and displacement after three blepharoplasties; she also had levator dehiscence, upper lid ptosis, and ectropion of the lower lid. Fig. 14.7B demonstrates correction of the lateral canthus, lid ptosis, and ectropion with levator advancement and canthoplasty.

Figure 14.5  Attenuation and gravitational forces can lead to lateral canthal declination and, as this figure demonstrates, expected sequalae include septal laxity and eyelid malposition. (A–C) The lateral canthus is normally inclined cephalad by 10–15° compared with the medial canthus. Attenuation with aging produces a descent of the lateral canthus which rotates (clockwise on the left and counterclockwise on the right) around the medial canthus. The end result is a lateral canthus that is coplanar or declined compared with the medial canthus. As the lateral canthus sags inferiorly, the intercommisure distance shortens (distance between medial and lateral canthus) and the lower lid and inferior lateral septum become lax. This produces scleral show, ectropion or entropion, orbital fat prominence especially laterally, and tear film distribution and drainage problems. (From Spinelli HM. Atlas of Aesthetic Eyelid and Periocular Surgery. Philadelphia: Saunders/Elsevier; 2004.)

The treating surgeon should also note the position of the lateral canthus as a three-dimensional construct. The structure is supporting the eyelids laterally hanging in space. The lateral commissure (angle) lies within millimeters of the orbital rim and disruption of this anatomy can be noted in the repeat blepharoplasty patient. This disruption is especially notable after failed lateral canthopexy or canthoplasty procedures (Fig. 14.8).

Medial canthus The medial canthal tendon inserts into the bony orbit with three leaflets: anterior and posterior horizontal leaflets and a vertical leaflet. The medial canthal tendon is the culmination of the medial canthal retinaculum, the confluence of the deep head of the pretarsal orbicularis, the orbital septum, the medial end of Lockwood’s ligament, the medial horn of the levator aponeurosis, the check ligaments of the medial rectus muscle, and Whitnall’s ligament. The upper, lower, and common lacrimal canaliculi are closely approximated to the medial canthal retinaculum and care must be taken to ensure their integrity when altering its position4 (Fig. 14.9).

Corneal protection

489

CANTHOPEXY vs MIDFACE SUSPENSION w/CANTHOPEXY

Good cheek support

Cheek support is lacking

A

A

B

B

Corneal protection In any surgery involving the eyelids, corneal protection is necessary. Protective lenses are a routine part of any blepharoplasty procedure as these lenses function to prevent desiccation and injury to the cornea which can result in

Figure 14.6  A critical examination distinction is the degree of cheek support a patient has. The patient depicted in (A) has lower lid laxity and scleral show with only modest descent of malar soft tissues, which is confirmed by noting the relatively short distance between the lower lid margin and the cheek. This patient’s lower lid ptosis could be treated with a canthopexy alone. In contrast, the patient depicted in (B) has significant scleral show with a large difference between the lower eyelid and cheek soft tissues even with the lower eyelid having descended. Using a canthal procedure alone will not be sufficient and should not be attempted to support the malar soft tissue alone. Instead, this patient would require midface suspension as well as a canthal procedure. (From Spinelli HM. Atlas of Aesthetic Eyelid and Periocular Surgery. Philadelphia: Saunders/Elsevier; 2004.)

Figure 14.7  (A) Patient with lateral canthal effacement with displacement laterally and inferiorly. (B) Patient after correction with lateral canthal tendon resuspended helping to correct lower eyelid ptosis. (From Small K, Spinelli HM. Blepharoplasty. In: Cohen MN, Thaller SR. The Unfavorable Result in Plastic Surgery: Avoidance and Treatment. 4th ed. New York: Thieme; 2018: 266–283.)

devastating consequences. Additionally, care must be taken to avoid corneal abrasions which may be incurred with any internal sutures; all knots should be buried or placed externally as to avoid inadvertently scratching the cornea as the sensitive corneal tissue will only tolerate opposition with conjunctival or mucosal tissues.

490

SECTION II

Orbital lobe of lacrimal gland

CHAPTER 14  • Secondary blepharoplasty

Levator palpebrae superioris muscle

Whitnall's ligament

Orbital septum (partially removed)

Palpebral lobe of lacrimal gland

Levator aponeurosis

Superior crura Upper tarsal plate

Whitnall's tubercle Lateral canthal tendon

Medial canthal tendon

Inferior crura

Recess of Eisler

Lower tarsal plate

Capsulopalpebral fascia

Orbital septum (partially removed)

Figure 14.8  The upper and lower eyelids are suspended in space and can be thought of as completing a sling between the medial and lateral canthal tendons. Even millimeters of displacement of the position of the point where the lateral canthal tendon joins with the tarsal plates and orbicularis muscle can disrupt the position and function of the upper and lower eyelids. Note the three-dimensional construct of the eyelids’ supportive structures and orbital bony confines. The eyelids are effectively hanging in space, suspended medially and laterally. (From Spinelli HM. Atlas of Aesthetic Eyelid and Periocular Surgery. Philadelphia: Saunders/Elsevier; 2004.)

Posterior limb, medial canthal tendon

Superior limb, medial canthal tendon

Anterior limb, medial canthal tendon

Lacrimal fossa

Anterior and posterior lacrimal crests A

B

Figure 14.9  In (A) note the medial canthal tendon is the culmination of the medial canthal retinaculum, the confluence of the deep head of the pretarsal orbicularis, the orbital septum, the medial end of Lockwood’s ligament, the medial horn of the levator aponeurosis, the check ligaments of the medial rectus muscle, and Whitnall’s ligament. As seen in (B), care must be taken when repositioning the medial canthal tendon to preserve this confluence and reposition the entire structure as a whole. The medial canthus’ three bony attachments, upper and lower canaliculi, and lacrimal fossa are all in close proximity. (From Spinelli HM. Atlas of Aesthetic Eyelid and Periocular Surgery. Philadelphia: Saunders/Elsevier; 2004.)

Pathophysiology and anatomical changes of the aging eyelid In performing blepharoplasty, it is essential to have a full understanding of how normal periocular anatomy changes with aging to select the right procedure for each patient.

Especially important to understand is the fact that eyelids are a functional component of the larger face and their function is directly affected by anatomical neighbors. Specifically, as the upper lid is connected to the eyebrow and the lower lid to the cheek, as we age all of these tissues simultaneously undergo a predictable pattern of anatomical change related to loss of intrinsic support and gravitational forces.9

Patient evaluation

Intrinsic Support Forces (ISF)

Extrinsic Distraction Forces (EDF)

IS

491

ED

IS

With aging, the eyebrow, which is composed of skin, muscles (procerus, corrugator supercilii, depressor supercilii, frontalis, and orbicularis oculi), galea, and the brow fat pad (ROOF) undergoes attenuation of its ligamentous attachments which leads to eyebrow ptosis and descent onto the upper eyelid. This condition is termed dermatochalasis.9 Additionally, with aging the orbital septum develops laxity and the orbital fat pads protrude anteriorly (steatoblepharon), which lowers the upper eyelid fold position. The ligamentous attachments to the lacrimal gland (Soemmering’s ligaments) may also become attenuated leading to gland ptosis. While a low or absent upper eyelid fold is a component of age-related pathophysiology in occidentals, it is anatomically physiologic in Asian individuals wherein the levator fibers insert into the pretarsal skin more caudally, if at all. Furthermore, with aging the levator aponeurosis may attenuate or dehisce from its insertion site in the skin, leading to upper eyelid drooping, termed blepharoptosis, associated with elevation or loss of the upper eyelid fold. The levator muscle has tethering attachments to the overlying orbital fat pads and thus dehiscence of the levator aponeurosis can result in fat pad retraction and a superior sulcus deformity. In the lower eyelid, the thin skin is prone to developing dermatochalasis with aging due to decreasing levels of collagen and elastin. With aging, the orbital septum develops laxity and the inferior orbital fat pads protrude anteriorly; the suborbicularis oculi fat (SOOF) may also contribute to lower eyelid fullness above the orbitomalar ligament and tear trough deformity in the nasojugal groove. In addition, the medial canthal tendon can become attenuated with age, which leads to inferior and lateral displacement of the lacrimal puncta resulting in inferior and medial descent of the tendon, which results in a further decrease in lateral canthal inclination. Descent of the lateral canthal tendon also shortens the intercommissure distance leading to horizontal lower eyelid laxity. Over time, this is exacerbated by downward distraction forces from the

ED

Figure 14.10  The lower eyelid is held against the globe by intrinsic support provided by the tarsal plate, canthal tendons, and orbicularis muscle sling. In normal function the net vector of these forces is posterior and superior. Any forces that increase extrinsic distraction forces such as senescence, surgery, lasers, or trauma can disrupt the normal apposition of the lower eyelid to the globe. The lower lid position is determined by a balance of two opposing forces which may be affected by senescence and/or procedures. (From Spinelli HM. Atlas of Aesthetic Eyelid and Periocular Surgery. Philadelphia: Saunders/Elsevier; 2004.)

cheek and may result in malposition, causing conditions such as increased scleral show, ectropion, or entropion (Fig. 14.10). Midface aging also results in descent of the malar fat pads causing prominence of the orbital rims and bulging of the prezygomatic space from edema (malar mounds) or orbicularis oculi muscle redundancy (festoons). These two conditions can be very difficult to treat and may cause significant patient distress and consternation for the surgeon.

Patient evaluation A thorough patient history and physical examination can assist in identifying the ideal surgical approach in addition to elucidating the patient’s desires. The preoperative consultation should educate the patient on the appropriate surgical steps based on their aesthetic aspirations, clinical history, and eyelid anatomy. Together, the surgeon and patient should select the approach that maximizes the patient’s goals in addition to addressing their unique tissue characteristics. The patient must thoroughly understand the limitations of their eyelid topography; this can be addressed by reviewing patient images and physical attributes with the patient. This educational approach and informed consent have proven to enhance patient satisfaction and overall aesthetic outcomes.4

Medical history A detailed general medical history and ocular history should be performed and must include a description of dry eyes or use of ophthalmic lubricants, use of corrective lenses, thyroid disease, history of refractive surgery, recent acute or chronic blepharitis, and any other ocular and periocular conditions. Knowledge of these conditions should help to tailor the surgical procedure performed to the individual patient in order to minimize risks and maximize cosmetic and therapeutic aspects

492

SECTION II

CHAPTER 14  • Secondary blepharoplasty

Figure 14.11  A patient with bilateral Graves’ disease. A detailed medical and surgical history is critical to identify potential complicating factors when planning eyelid surgery. The patient has proptosis and has had numerous failed decompressions. He is presenting with missing lateral ocular rims and describes dry eyes and corneal exposure. A secondary procedure must be thoughtfully planned and executed. (From HM Spinelli, Talk: “Positioning the upper and lower eyelids in the blepharoplasty patient”, 8 May 2017.)

of the procedure. For example, patients with dry eyes and corrective lenses will require greater tear production, and these patients will tolerate less evaporative loss than patients without these pre-existing conditions. Similarly, chronic blepharitis or recurrent herpes zoster can be exaggerated by eyelid surgery and in these cases prophylactic antibiotic and/or antiviral therapy may be needed prior to surgical intervention4 (Fig. 14.11). In the case of secondary blepharoplasty, a thorough history of prior blepharoplasty and other ophthalmologic procedures must be described and documented. Date of procedure, immediate postoperative results, complications, evolution of anatomy, and current concerns must be elucidated fully to establish the best approach to repeat surgery in this area. This can be performed by having the patient describe their concerns while looking in a mirror and by reviewing static and dynamic eyelid and facial photographs from multiple viewpoints to identify abnormalities.4 It is extremely helpful to amalgamate and dovetail patient desires and expectations with those of the surgeon, while keeping in mind that sometimes, a divergence between aesthetic desires and patient functional physiology exists. This must be identified and conveyed to the prospective patient before embarking on a surgical procedure. For example, it is, in general, a mistake for a surgeon to significantly increase corneal exposure in patients with pre-existing tendencies to dry eye syndrome, no matter how much the patient prefers the appearance.

Physical examination Physical examination is essential to establishing the ideal surgical approach and the initial exam should note gross abnormalities in addition to the presence or absence of normal structures. The proper anatomic position and relationship of the upper and lower eyelids should be identified and documented. The upper lid should divide the width of the iris in half and the lower lid should lie above or abut the corneoscleral junction limbus. Both the upper and lower lids should have a smooth sweeping arch or contour and the maximal arch of the upper lid should lie at the medial-most aspect of the pupillary aperture.

Inflammatory changes and eyelid crusting should be documented as this indicates blepharitis. A clear glistening corneal surface, sclera, and conjunctiva without injection or chemosis (edema) are evidence of adequate coverage, lid excursion, and appropriate wetting of the ocular surface. Eyelid folds should be symmetrical although the fold height varies by race and gender. The patient’s superior sulcus should be examined appreciating the level of concavity or convexity in addition to its relationship to eyelid movement4 (Fig. 14.12). Eyelid margin rotational abnormalities (ectropion or entropion) and whether they change with the blinking cycle should be evaluated. For instance, patients with involutional entropion usually present with lax lower eyelids, scleral show, and occasionally a tendency towards ectropion until they are asked to forcibly close their eyes. Almost immediately upon closing, their lower eyelids will briskly roll inwards against the globe with forced blinking4,10 (Fig. 14.13). Patients who present with one or more previous surgical procedures present more complex problems and require more elaborate planning and solutions. Fig. 14.14A shows a patient with lower and upper eyelid and canthal dystopia after four prior blepharoplasties. Correction of these symptomatic and aesthetic problems requires canthal repositioning, ptosis correction, and spacer grafts. Fig. 14.14C demonstrates correction of the deformity by canthoplasty and a palatal graft. Baseline visual acuity must be documented with a Snellen chart exam and both eyes should be assessed with and without corrective lenses. Patients commonly complain about changes in their visual acuity postoperatively and thus their baseline vision must be documented pre-surgically. Of specific note, astigmatism in a selective meridian can be alleviated or induced by surgery, and in these patients, ophthalmological referral may be warranted prior to any surgical intervention.4 The repositioning and re-tensioning of eyelids that occurs during blepharoplasty surgery can change the pressure vectors on the cornea leading to variable corneal curvature. If the blepharoplasty is being performed to restore more normal tension vectors in the setting of senescence or previous blepharoplasty a previously induced astigmatism may be improved. Extraocular motion and pupillary function should be assessed with specific care to document any asymmetries. Normal facial animation and a pupillary light and accommodation response should localize an abnormality and identify possible interventions.4 Additionally, tonicity of the lower eyelid should be measured. This is performed by gently pulling down the lower eyelid and distracting it away from the globe, which allows the lid to retract back into its regular anatomic position. Any delays in snapback or asymmetries in the rate or position of the lower lid during this test should be recorded; an intact lower eyelid should position itself against the globe reverting to an appropriate height within 1 second of distraction. Snap back can be graded as weak, moderate, or brisk and anything but a brisk or normal snap back requires increased intrinsic support or minimization of extrinsic distraction forces.4,9 Periorbital anatomy should be evaluated, specifically the presence or absence of zygomatic or malar support. Patients with malar eminences that lie posterior to their cornea have poor lower lid support and are prone to malposition. In patients with lower eyelid malposition (scleral show), the surgeon should digitally tighten and elevate the lower eyelid

Patient evaluation

493

A

20/20

< Va < 20/40 20/40 Va 20/20 sc

2. Schirmer's test

cc

1. Visual acuity via Snellen chart

4. Malar support

3. Snap-back test Good

Poor

5. Tear film break-up time B

Figure 14.12  (A) Photograph of a patient with asymmetric upper eyelid fold heights. As part of the patient examination it should be noted that there is right ptosis, canthal displacement laterally, and asymmetric light reflex. History should include dry eyes, thyroid disease, contact lens wear, and other potentially inciting factors. (B) Physical examination should include visual acuity, Schirmer’s tear test, snap-back test, malar support, and tear film break-up time. (A, From HM Spinelli, Talk: “Blepharoplasty: unifying aesthetics and function”, 15 May 2015. B, From Spinelli HM. Atlas of Aesthetic Eyelid and Periocular Surgery. Philadelphia: Saunders/Elsevier; 2004.)

494

SECTION II

CHAPTER 14  • Secondary blepharoplasty

Tarsus Suborbicularis fascia

Septal orbicularis overriding

Inferior tarsal muscle Capsulopalpebral fascia

Dehisced lower retractor lid

Septum Inferior rectus muscle Inferior oblique muscle A

C

Orbicularis muscle

Fat

B

Figure 14.13  A patient should be examined with their eyelids relaxed as well as when they are blinking. These images depict the mechanism of involutional entropion with the septal orbicularis overriding the tarsus and dehiscence of the lower lid retractors. These sequalae of involutional entropion explain the tendency of the lower eyelids to roll inward against the globe when blinking. (A) Normal anatomy of the lower eyelid retractors. (B) The pathology of involutional entropion with overriding septal orbicularis and dehisced lower lid retractors. (C) Patient with lower lid laxity and involutional entropion leading to scleral show, chemosis, and lid retraction after blepharoplasty. Additionally, pseudoherniation of the lateral fat pad can be seen because of septal laxity. (From Spinelli HM, Tabatabai N, Nunn DR. Correction of involutional entropion with suborbicularis septal and lateral canthal tightening. Plast Reconstr Surg. 2006;117(5):1560–1567.)

Procedures/techniques

A

B

Figure 14.14  (A) Preoperative photograph of a more complex multiply operated patient who presents for correction. (B) Postoperative photograph demonstrating correction of the deformity by canthoplasty and a palatal graft. With tightening of the septum some of the herniation of the lateral fat pad has been reduced. (From Small K, Spinelli HM. Blepharoplasty. In: Cohen MN, Thaller SR. The Unfavorable Result in Plastic Surgery: Avoidance and Treatment. 4th ed. New York: Thieme; 2018: 266–283.)

A

B

Figure 14.15  (A) Patient with chemosis, scleral show, and lid retraction secondary to blepharoplasty. (B) The correction achieved after a canthoplasty, palatal graft, and nasal bone graft. (From Small K, Spinelli HM. Blepharoplasty. In: Cohen MN, Thaller SR. The Unfavorable Result in Plastic Surgery: Avoidance and Treatment. 4th ed. New York: Thieme; 2018: 266–283.)

while also visualizing the tension created on the suborbital soft tissues as this manual suspension may guide further surgical interventions. These sequential maneuvers mimic the forces engineered by canthal procedures alone by adding midface support or spacer grafts as needed to anatomically position the lower eyelid. Surgeons must try to assess which lamella (anterior, middle, or posterior) is deficient to adequately plan complementary procedures to canthopexy such as cheek or midface suspension, interposition grafts, skin grafts, or external flaps.4 Fig. 14.15A demonstrates a patient with chemosis, scleral show, and lid retraction after blepharoplasty. Fig. 14.15B

495

demonstrates correction with canthoplasty and palatal graft. From a practical perspective chemosis either preop or postop should be managed conservatively first. Wetting drops and avoiding mechanical irritation of the area can be helpful. If persistent, a temporary tarsorrhaphy or eyelid taping can be considered postop. All patients should be assessed for baseline tear production with a Schirmer’s test using topical anesthesia and standardized No. 41 filter paper strips. This assessment must occur in a dark room to prevent the effect of ambient light on tear production. Patients are subdivided into three categories: low tear producers (0–9 mm), moderate tear producers (10–20 mm), or high tear producers (21–30 mm). Very high tear producers may have obstruction of the nasolacrimal system and may present with complaints that include epiphora, recurrent medial canthal swelling, and or mucopurulent drainage.4,10 In addition to tear production, tear quality is an important contributory factor in maintenance of an adequate precorneal tear film. The ability of tears to withstand evaporation or break-up should be assessed via a fluorescein test. Fluorescein is introduced into a topically anesthetized eye and after the patient blinks to disperse the agent, the eyelids are held apart and uniform tear film is visualized over the corneal surface through a cobalt blue filter. The period of time between holding the patient’s eyes open and tear film break-up should be longer than 20 seconds.4 Finally, for any blepharoplasty surgeon, appreciation of a patient’s tarsoligamentous integrity is important prior to any lower eyelid procedure. Once established, the surgeon can determine a viable plan. This includes evaluation of lower lid laxity, medial canthal laxity, and lateral canthal laxity. The snap-back test is used as an evaluative tool for assessing horizontal laxity and involves displacement of the lower lid anteriorly. In a patient who has had a blepharoplasty, distraction of greater than 8 mm suggests lack of tarsoligamentous integrity. The test is performed by pulling the eyelid inferiorly to the level of the inferior orbital margin and then releasing it, timing the speed at which it returns to its normal position. Slow snap-back tests or persistent lower lid eversion may indicate eyelid and canthal laxity requiring correction. Further, more nuanced tests described previously can assist in obviating complications.

Procedures/techniques Upper eyelid blepharoplasty The morphology of the upper eyelid can be differentiated into four different categories: occidental, deep set, baggy, and Asian. The normal youthful appearing occidental eyelid has levator extensions inserting into the skin surface to define a lid fold about 6-8 mm above the lid margin and the orbital septum coalesces with the levator aponeurosis to create a fat containing aponeurotic space. Lid fold height and degree of sulcus concavity or convexity is determined by the position of the levator–skin linkage and the anterior–posterior relationship of the preaponeurotic fat. In the deep-set lid, or with levator dehiscence, the upper lid crease is displaced superiorly and measures 8–13 mm from the lid margin. The orbital septum and preaponeurotic fat linked to the levator are displaced superiorly and posteriorly

496

SECTION II

CHAPTER 14  • Secondary blepharoplasty

A

B

Figure 14.16  (A) Patient with levator dehiscence leading to effacement of the upper lid fold. Over-resection of fat and hollowing is also seen. (B) The levator dehiscence of the same patient intraoperatively. (From Small K, Spinelli HM. Blepharoplasty. In: Cohen MN, Thaller SR. The Unfavorable Result in Plastic Surgery: Avoidance and Treatment. 4th ed. New York: Thieme; 2018: 266–283.)

creating a high or absent lid crease, a deep superior sulcus and, in the case of levator dehiscence, eyelid ptosis. Fig. 14.16 shows a patient with levator dehiscence and over-resection of fat after previous blepharoplasty and identifies the levator dehiscence intraoperatively. Note the associated upper eyelid ptosis and a sulcus deformity. In the aging eyelid, the septum becomes attenuated and stretches, the preaponeurotic fat attachments loosen, and the orbital fat prolapses forward, sliding over the levator into an anterior and inferior position. These changes produce an inferior displacement of levator skin attachments and a low and posterior position of the preaponeurotic fat pad. Clinically, this may appear as a low hanging lid crease that is only a few millimeters from the lid margin which may not be visible due to the overhanging lid. The youthful Asian eyelid resembles the baggy or senescent upper lid with a low levator skin zone of adhesion and inferiorly and anteriorly located preaponeurotic fat producing the characteristic low eyelid crease and convex upper eye sulcus4,11 (Fig. 14.17). The four previously described morphologic differences of the upper eyelid (occidental, deep set, baggy, and Asian) all experience the same changes associated with aging which results in a convergence of anatomy; many of these ethnic differences are erased by aging or attenuation of structures. In planning and executing an upper lid blepharoplasty, the surgeon must first determine the endogenous lid crease or the height at which to create a new lid crease if this is different from the existing crease. The level of the lid crease serves as the lower limb of the blepharoplasty incision and the height of supratarsal fixation, if indicated. The width or extent of skin excision is determined by pinching the lid skin between forceps and using slight lash line eversion as the endpoint. Concurrently, the extent of lateral eyebrow ptosis and the

amount of lateral upper eyelid hooding should be determined and the degree of lateral hooding will dictate the lateral extent of the incision. Generally, incisions that extend beyond the orbital rim are not well tolerated. Upper and lower limbs of the incision usually have unequal lengths in an attempt to eliminate dog-ears and this must be exaggerated when widening the lateral skin excision. A fine balance exists between the extent of lateral hooding and maintaining the incision lines within the confines of the orbital rim. If the lateral extent of the incision becomes excessive, a lateral brow suspension should be entertained (Fig. 14.18). Of note, an enlarged or herniated lacrimal gland may produce fullness of the lateral portion of the upper eyelid; the gland can be resuspended or plicated to ameliorate this. Excision of the gland is discouraged as this may lead to dry eye syndrome.4,12 Fig. 14.19 demonstrates a herniated lacrimal gland in a patient after upper lid blepharoplasty. This usually occurs with violation of the superior structures in the lateral upper eyelid allowing the lacrimal gland to descend. Upper lid blepharoplasty incisions can be efficiently performed with digital traction and light pressure; slightly more pressure must be exerted on the scalpel laterally as the skin thickens. The skin can be elevated with the orbicularis muscle using a needle-tipped insulated cautery and resection can be optimized by transposing the myocutaneous flap superonasally while providing digital traction laterally. Alternatively, the same maneuvers as delineated above may be employed with the difference being the resection of the upper lid skin is performed independently of incising or removing a strip of the underlying orbicularis. The orbital septum may be stabbed or widely incised, exposing the preaponeurotic space. The underlying levator aponeurosis is protected by opening the septum as cephalad as possible as the levator and septum diverge superiorly.4 Fat will prolapse spontaneously or with

Procedures/techniques

A

Figure 14.17  In an Asian patient the zone where the levator has its zone of adhesion is characteristically low and there can be anteriorly located preaponeurotic fat. The combination of these factors can lead to a low eyelid crease and an appearance similar to a senescent upper eyelid. Note the similarity between the (A) aged face with occidental upper eyelid and the (B) youthful attractive Asian upper eyelid. (From HM Spinelli, Talk: “Eyelid and periocular surgery: Unifying aesthetics and function”, 16 May 2015.)

B

light digital pressure (medial fat is whiter and lies medial to the superior oblique muscle, central or preaponeurotic fat is darker and less fibrous), however care must be taken to not overly resect fat when using digital pressure techniques creating depressions or sulcus deformities which are aesthetically not well tolerated. Excessive traction and manipulation of orbital fat can lead to a deep orbital hemorrhage and should be avoided. Closure can then be performed with a 6-0 nylon interrupted suture laterally and 5-0 intracuticular sutures medially. Once the upper lid skin is incised or excised, the levator may be modified (shortened or lengthened) by various interventions such as plication of the levator muscle, removing a strip and opposing the cut ends, or plicating and removing excess levator above the suture line.4,13 Fig. 14.20 demonstrates intraoperative levator advancement sutures. Unrecognized ptosis can cause a perfectly well-executed upper blepharoplasty to result in an unhappy postoperative patient. Of note, the skin edges can be incorporated into these modifications to accentuate or move the lid crease (supratarsal fixation). The new crease is created with a definitive connection between the upper and lower limb of the skin excision edges and the underlying deeper tissues (tarsal plate, levator aponeurosis, etc.). Fig. 14.21 outlines the planning and execution of an upper eyelid blepharoplasty. The senior author (H.M.S.) underscores the old carpentry adage: “plan twice and cut once”.

Eyelid malposition Eyelid malposition can generally be grouped into upper and lower dystopias. The examining surgeon must first discriminate between eyelid malposition and globe dystopias. Retractions of the upper and lower lids may be as a result of exophthalmos or excessive projection of the globe as in

497

Graves’ disease. Ptosis of the upper eyelid and lower eyelid may result from volumetric discrepancies in which the orbit is too big for the enclosed soft tissue, as is often the case in a zygomatico-orbital fracture (see Fig. 14.22A,B).

Ptosis Ptosis is a common concern of patients seeking secondary blepharoplasty. Ptosis, or the abnormally low position of the upper eyelid can be a senescent change or caused by trauma to the levator complex, including during prior surgical dissection. Unrecognized ptosis may also manifest itself postoperatively after blepharoplasty and requires subsequent correction. Additional surgical causes of ptosis include levator fibrosis due to hematoma resorption, tractional ptosis in an attempt to position the lid too cephalically or via adhesions between the orbital septum and levator aponeurosis. It is common for patients undergoing blepharoplasty to experience some ptosis due to edema, however this should resolve in a timely fashion with time and massage; if the ptosis is persistent these other etiologies should be considered and it may be necessary to remove supratarsal fixation sutures. Ptosis is defined as mild (1–2 mm), moderate (2–3 mm), and severe (>4 mm). In cases of secondary blepharoplasty, the most common form of ptosis is disinsertion of the levator aponeurosis via inadvertent penetration or detachment of the levator aponeurosis during resection of retroseptal fat or pre-levator orbicularis oculi. The secondary blepharoplasty patient either had unidentified ptosis before the original procedure necessitating the patient and/or the referring physician to seek resolution and correction or has had an iatrogenic disruption of the levator complex by traction injury causing dehiscence or with too inferior or posterior dissection to the orbital septum where the levator, orbit, septum, and orbicularis oculi

498

SECTION II

CHAPTER 14  • Secondary blepharoplasty

Lid crease marks lower limb of incision

Lateral browlift

Figure 14.18  (A) Demonstration of the procedure for determining the vertical extent of upper eyelid skin excision. The identified lid crease serves as the lower limb of the blepharoplasty incision. The height of skin excision is determined by pinching the lid skin between forceps and using slight lash line eversion as the end point. (B) Note the upper eyelid incisions and their lateral extent are determined by lateral hooding and the consideration of brow ptosis. (From Spinelli HM. Atlas of Aesthetic Eyelid and Periocular Surgery. Philadelphia: Saunders/ Elsevier; 2004.)  

Upper limb of incision is defined when lashes evert

are in closest apposition. Superiorly, this anatomy diverges rendering a safer and easier dissection. Treatment is achieved by exploration of the levator complex and advancement and reattachment to the anterior tarsus.

Upper lid retraction All apparent (upper and/or lower) eyelid retractions should be discriminated from globe dystopias. Lamellar deficiencies can be confused with proptosis and ptosis with enophthalmos for example (Fig. 14.22). Upper lid retraction, defined as elevation of the upper eyelid margin above the superior corneal limbus, may result from excessive skin removal from the upper eyelid in primary blepharoplasty and may prevent closure of the eyelids in severe cases and various degrees of eyelid eversion.

Correction of this condition involves release of retraction with application of a full-thickness skin graft. Retraction may also be caused by adhesions, fibrosis, and shortening of the levator aponeurosis. Surgical correction of this pathology requires release of the adhesions often with lid traction sutures and interpositional fascial grafts. Ideal grafts may include autogenous deep temporal fascia and other similar pliable thin tissues.14 Simple recession alone except in the most minimal of executions will lead only to recurrent retraction, lending credence to the dictum horror vacui (“nature abhors a vacuum”). Occasionally lid retraction occurs as a result of contralateral ptosis due to excessive innervation to compensate for ptosis of the contralateral eyelid. This phenomenon is known as Hering’s law and must be evaluated via physical examination before surgery by covering each eye and performing independent evaluations. The surgeon should appreciate the concept

Procedures/techniques

499

the preoperative history and physical examination, the cosmetic goals of the patient, and the preferred surgical approach. Lower lid deformities can be addressed either by a transcutaneous or transconjunctival approach.

Transcutaneous lower lid blepharoplasty

Figure 14.19  Patient with herniation of the lacrimal gland after upper eyelid blepharoplasty. At the initial surgery re-suspension of the lacrimal gland should have been considered. Lacrimal gland herniation should be distinguished from subcutaneous fat, with the former requiring suspension and the latter allowing for resection. (From Small K, Spinelli HM. Blepharoplasty. In: Cohen MN, Thaller SR. The Unfavorable Result in Plastic Surgery: Avoidance and Treatment. 4th ed. New York: Thieme; 2018: 266–283.)

For a transcutaneous lower lid blepharoplasty, the primary incision should be in a desired fold or potential fold lateral to the lateral canthus; the incision should be limited but must provide access for small curved scissors. The plane is developed from lateral to medial by pushing and spreading with the scissors. Once this plane is developed, the myocutaneous flap can be mobilized with ease. Using the scissors, the second incision is completed lateral to medial ending just lateral to the lower lid punctum. Using an insulated retractor the flap is mobilized to the orbital rim without violating the septum.4 The septum can then be opened widely or with stab incisions; the inferior oblique muscle must be visualized and protected before resection or repositioning fat. The muscle is most anterior medially, adjacent to the medial fat pad. Care must be taken as over-resection of fat, especially in the lateral compartment, can lead to unacceptable cosmetic results. Orbital fat then may be repositioned and/or resected depending on the needs of the patient.15 Skin resection should be conservative with lateral and cephalic vectors kept in mind. Resection should transpose the most tension to under the canthus and the least tension in the mid-lower lid. Before closure, resection of a few millimeters of orbicularis muscle at the superior aspect of the flap may diminish any bulge or roll. This excised muscle can be used as a sling, fixed to the lateral canthus to reinforce repair. Hemostasis is achieved and closure is performed using a 6-0 silk medially and interrupted nylon sutures laterally.

Transconjunctival lower lid blepharoplasty

Figure 14.20  Intraoperative image of levator advancement sutures being placed with local anesthesia. Of note, the patient had a previous blepharoplasty with untreated ptosis by a referring plastic surgeon. The patient’s previous blepharoplasty did not address the levator dehiscence as a cause of ptosis. Additionally, the overlying skin can be incorporated into these sutures to further accentuate the created fold. (From Small K, Spinelli HM. Blepharoplasty. In: Cohen MN, Thaller SR. The Unfavorable Result in Plastic Surgery: Avoidance and Treatment. 4th ed. New York: Thieme; 2018: 266–283.)

of equal and opposite innervation to the upper eyelids in evaluating upper eyelid malpositions before embarking on lid repositioning procedures.

Lower eyelid blepharoplasty Lower eyelid blepharoplasty can successfully address redundant skin and muscle, laxity of the septum, excess fat, lower lid malposition, and prominence of the nasojugal groove. Operative approach is multifactorial and should be guided by

The ideal candidate for a transconjunctival lower lid blepharoplasty is a younger patient without midface ptosis. The transconjunctival approach to the retroseptal space may be preseptal or retroseptal; the most controlled and anatomically consistent approach is the preseptal route. The retroseptal route entails incising the conjunctiva and cutting through the lower lid retractors into the postseptal space. Alternately, the preseptal route requires entry into the postorbicularis preseptal space above the fusion of the lower lid retractors and the orbital septum; each fat pad can be addressed separately in a controlled fashion.4,16 A few surgical pearls serve to streamline this procedure. Firstly, a protective lens should routinely be used. A conjunctival stay suture can be placed deep in the fornix and the lid margin to apply traction superiorly (Fig. 14.23). This causes the inferior edge of the tarsal plate to rise to the surgeon. The conjunctiva and lower lid retractors are then incised just below the tarsal plate entering the postorbicularis preseptal space. A plane is then developed to the orbital rim with the assistance of the traction suture and a retractor. The orbital septum may then be widely incised or punctured while identifying and preserving the inferior oblique muscle. The fat pads can be addressed individually and resection, repositioning, and/or conservation are all viable options and this is aided by the development of a supraperiosteal tunnel with

500

SECTION II

CHAPTER 14  • Secondary blepharoplasty

A

B

Skin and muscle resected

Levator aponeurosis Orbital septum

C

D

Figure 14.21  (A–D) Highlights of pre-surgical markings and execution of skin excision portion of upper blepharoplasty. Endogenous lid crease identification is accomplished by tensing and relaxing upper eyelid skin. Once markings are completed the skin and orbicularis muscle can be resected in one maneuver. A needle-tipped insulated cautery is most advantageous, especially in avoiding any delayed hemostasis problems. The orbital septum is widely opened, exposing the preaponeurotic space. (From Spinelli HM, Weinstein AL, Janhofer DE. Blepharoplasty. In: Thaller SR, Panthaki ZJ, eds. Tips and Tricks in Plastic Surgery. Cham: Springer; 2022.)

a temporary transcutaneous stay suture to maintain proper location when repositioning the fat. A single absorbable conjunctival suture may be useful when closing to avoid Tenon’s capsule/membrane inclusion cysts; this suture should be placed laterally to prevent postoperative complaints of corneal irritation.4,16

Lateral canthal tendon anchoring procedures Lateral canthal tendon anchoring procedures such as canthoplasty or canthopexy can also be performed as indicated by patient history, physical exam, and the operative plan. We define canthopexy as tightening or suspension of the lateral canthal tendon without division of one or more of its elements. It is performed either by plication of the lateral aspect of the inferior crus of the lateral canthal tendon or the common canthal tendon or by fixation of the tendon directly to

the lateral orbital rim periosteum. The utility of canthopexy is limited to treating milder degrees of lower eyelid laxity and providing lower lid support to counteract distraction forces from edema17 (Fig. 14.24). For more severe lower eyelid laxity or in cases of failed prior canthopexy, a canthoplasty, which we define as division of part or all of the lateral canthal tendon with a canthotomy may be required. The lateral aspect of the divided supportive structures can then be fixed to the orbital rim with or without shortening the structures in a more lateral/cephalic position, thereby tightening the lax lower eyelid. Canthoplasty is a powerful procedure that can tighten the lower lid against the globe as well as alter the position of the lateral canthus in order to accommodate varying degrees of eye prominence and different fissure shapes. Release of the lateral retinaculum and proper canthoplasty execution allows the surgeon to position the lateral canthus and commissure wherever necessary.

Procedures/techniques

A

C1

501

B

C2

Figure 14.22  (A) Patient with lamellar deficiency after multiple previous blepharoplasties. The retraction of upper and lower lids can give the appearance of exophthalmos. (B) Patient with lid retractions caused by excessive projection of their globe secondary to Graves’ disease which is causing volumetric incongruity proptosis. (C) Apparent ptosis of the left upper eyelid in a patient with enophthalmos. The patient has a globe dystopia resulting from an expansion of the orbital volume which can commonly be seen after zygomatico-orbital fracture. (From HM Spinelli, Talk: “Eyelid and periocular surgery: Unifying aesthetics and function”, 16 May 2015.)

The modified lateral tarsal strip canthoplasty is a technique in which the lateral canthotomy is first performed and inferior crus of the lateral canthal tendon and other retinacular elements tethering the lower lid are divided. Once the lower lid is completely mobilized, a tarsal strip is created by circumferentially de-epithelializing the redundant segment of lateral lower lid, which is back-cut under the tarsal plate. This “neocanthal” tendon can be trimmed as needed for proper positioning of the lower lid margin and anchored to lateral orbital rim periosteum at Whitnall’s tubercle using a double-armed braided non-absorbable 4-0 suture on a spatulated semicircular needle or an appropriate other suture the surgeon

may prefer. Following lateral canthal tendon anchoring procedures, if applicable, a commissuroplasty is performed by reapproximating the upper and lower eyelid margins using a single 6-0 Vicryl interrupted suture4,18 (Fig. 14.25).

Secondary lower lid procedures Lower lid deformities can result from over-resection of excess skin and muscle during blepharoplasty. Lower lid malposition with scleral show can result from scarring of the pretarsal orbicularis oculi muscle to the middle lamella. The orbicularis muscle may also become denervated which leads to muscle

502

SECTION II

CHAPTER 14  • Secondary blepharoplasty

B

A

C

Incised orbital septum D

Orbital rim Pressure on upper lid causes lateral orbital fat pad to bulge anteriorly

Remove medial and central fat pads

Medial fat pad

Lateral fat pad

Orbital rim E

Central fat pad F

Figure 14.23 (A–F) Planning and execution of transcutaneous lower blepharoplasty. Incision at the desired fold height should be used to introduce scissors so that a suborbicularis preseptal plane can be developed. Second incision should end just lateral to the punctum. Care should be taken to avoid over-resection of fat in the lateral compartment. (From Small K, Spinelli HM. Blepharoplasty. In: Cohen MN, Thaller SR. The Unfavorable Result in Plastic Surgery: Avoidance and Treatment. 4th ed. New York: Thieme; 2018: 266–283.)  

Procedures/techniques

flattening, laxity of the lower lid and an incomplete blink mechanism. Surgical correction of lid retraction involves lysis of adhesions, possible interposition grafts, or larger flaps depending on the severity and extent of the retraction. In the correction of lower lid malposition, measurement of the soft tissue to bone distance (measured from orbital rim

503

to midface cheek fat pad) is essential to determining which procedure will best provide lower lid support. In the case of deep-set eyes (positive or neutral vector), the distance usually measures less than 1 cm and tarsal strip lateral canthoplasty and inferior retinacular lateral canthoplasty/canthopexy are most effective.4,19 In patients with prominent eyes (positive

CANTHAL SUSPENSION BY LATERAL TARSAL STRIP

Lateral canthotomy

Division of lower crus and wide lateral lysis

Denude lateral tarsal strip

Suture fixation of strip to internal periosteum of lateral orbital rim

Commissuroplasty Trim excess skin and/or orbicularis muscle A

Figure 14.24  (A–C) Demonstration of lateral suture canthopexy. Proper fixation should be to the periosteum of the lateral orbital rim.

504

SECTION II

CHAPTER 14  • Secondary blepharoplasty

B

C

Figure 14.24, cont’d (A, From Spinelli HM. Atlas of Aesthetic Eyelid and Periocular Surgery. Philadelphia: Saunders/Elsevier; 2004.)

A

B

Figure 14.25  (A,B) Alignment of the upper and lower eyelids in three-dimensional space can be assured with the commissuroplasty in a canthoplasty procedure. Commissuroplasty is a delicate but important step to reapproximate the upper and lower eyelid margins. The Grey lines of the upper and lower eyelids should align after this procedure. (From HM Spinelli, Talk: “Eyelid and periocular surgery: Unifying aesthetics and function”, 16 May 2015.)

vector), the distance measures greater than 1 cm and these patients are suitable candidates for inferior retinacular lateral canthoplasty, dermalorbicular pennant lateral canthoplasty, or midfacial advancement procedures. Keep in mind that for a given anatomic orbital rim position, midface soft-tissue location is the variable (Fig. 14.26). The fundamental contributors to lower eyelid malposition can be divided and addressed by understanding three integrated anatomic and physiologic concepts. The examiner can elevate the lateral canthus digitally and if malposition is corrected then a canthal procedure alone will usually suffice. If a second examiner’s digit is necessary to elevate the midface and reposition the eyelid correctly, then while still tightening the lateral eyelid with the first digit, a midface suspension (external lamella) support procedure is necessary. Should both these maneuvers fail to correct the eyelid malposition then a spacer graft should be utilized (Fig. 14.27).

Complications in blepharoplasty The continuous rise in demand for blepharoplasty in the US and possibly the diverse array of new practitioners has

predictably coincided with an increased number of early and late complications resulting from the procedure. These complications are often what causes a patient to seek secondary blepharoplasty and thus it is imperative that the surgeon be familiar not only with the undesirable cosmetic outcomes but also with any sight-threatening complications and their management (Algorithm 14.1).

Visual loss secondary to hemorrhage Retrobulbar hematoma is the most feared complication of blepharoplasty as the degree of impairment is profound should treatment be deferred or the condition unrecognized in a timely fashion. The overall incidence of retrobulbar hemorrhage after blepharoplasty is approximately 1 in 2000 cases with visual loss reported with an incidence of 1 in 22,000 cases. This serious complication can occur during the procedure or several days after the procedure.20 Bleeding is believed to result from inadequate control of hemostasis during removal of the superficial orbital fat pads or secondary to disruption of deep orbital vessels from manipulation of superficial fat pads as these fat pads are linked to the deep orbital fat by way of a continuous array of septae. Hemorrhage can also occur as

Complications in blepharoplasty

505

CANTHOPEXY vs MIDFACE SUSPENSION w/CANTHOPEXY

Cheek suppor t is lacking

A

B

a result of trauma to the vasculature during injection of local anesthetic. Patient-related factors such as hypertension and coagulopathies in addition to the use of medications such as aspirin or vitamin E may also contribute to bleeding. It is essential to recognize signs of retrobulbar hemorrhage as early as possible to avoid permanent visual compromise. On the operating table, these signs may include sudden pupillary changes, proptosis, visual loss, and/or loss of ocular motility. All patients discharged after blepharoplasty procedure should be instructed to contact their surgeon in the case of severe pain and/or visual loss; for this reason these patients should not receive an eye patch and their vision should be routinely checked after surgery and prior to discharge. First-line treatment in the event of orbital hemorrhage should be canthotomy and cantholysis with concomitant medical treatment using systemic corticosteroids, hyperosmolar agents, carbonic anhydrase inhibitors, and topical beta-blockers. Should retrobulbar hemorrhage occur during the procedure, the status of the globe (including intraocular pressure) and the optic nerve should be properly assessed, preferably by an ophthalmologist. All surgeons, however, should be familiar with tonometry and basic techniques for evaluating the globe. Mild hemorrhage can be controlled by head elevation and close observation; for more severe hemorrhage a stepwise approach must be taken to decompress the globe. This includes the lysis of one or both crura of the lateral canthal ligament which allows the globe to move forward and protects the globe and optic nerve from ischemic and/or compressive damage. Additionally, intraocular pressure can be reduced by means of topical medications (i.e., timolol 0.5%, dorzolamide 2%, or brimonidine) and/or systemic administration of hyperosmolar agents (mannitol).4

Figure 14.26  (A) Patients with a positive vector (prominent eyes) often lack midface support. If the distance from the orbital rim to the midface cheek fat pad is greater than 1 cm the patient will likely benefit from a midface advancement procedure. (B) The deep-set sulcus and preaponeurotic fat retraction associated with levator dehiscence. (From Spinelli HM. Atlas of Aesthetic Eyelid and Periocular Surgery. Philadelphia: Saunders/Elsevier; 2004.)

In cases of severe hemorrhage refractory to the previously described measures, the inferior orbital wall can be decompressed and/or the retro-orbital space explored to control the hemorrhage. Paracentesis of the anterior chamber may also be performed to decrease intraocular pressure, however this treatment is best performed by an ophthalmologist (Algorithm 14.2).

Globe perforation during anesthesia Perforation of the globe during local anesthesia injection is a rare but devastating complication. This is best avoided by protecting the globe with a corneal shield before injecting the anesthetic agent and by directing the needle away from the globe. Should this complication occur, it is essential to recognize it early and to intervene quickly with ophthalmic consultation and halting the procedure immediately. Some indicative signs are sudden change in vision or a change in the position and the usual circular symmetry of the pupil.

Damage to the extraocular muscles Extraocular muscles may be damaged during local anesthetic injection resulting in temporary or permanent strabismus. This complication occurs more commonly with unguided retrobulbar or peribulbar injections but more commonly occurs due to damage to extraocular muscles during surgical dissection. The inferior oblique muscle is the extraocular muscle most at risk of damage during blepharoplasty and damage often occurs due to failure to adequately identify the muscle during lower lid blepharoplasty. This muscle is the only muscle that originates anteriorly in the orbit with its insertion on the maxillary bone approximately one-third of the way from the junction of the medial and inferior wall. The muscle then

506

SECTION II

CHAPTER 14  • Secondary blepharoplasty

Facelift incision

Malar fat pad

SMAS

SMAS sutured to zygomatic periosteum

SOOF and malar fat pad sutured to deep temporal fascia A1

A2

Figure 14.27  (A1) Midface suspension diagrammatic and (A2) intraoperative photograph demonstrating adjustment to canthal height.

Complications in blepharoplasty

507

B

severe lid malposition with midface descent severe horizontal lid laxity & retraction horizontal lid laxity mild lid margin eversion

Increasing severity of defect

We already know the trends

Increasing technical complexity + er n pac sio + s pen sty us pla eek s l ch ica ert + v ft sty gra pla acer p stri sp sal tar

+/-

lon

ya

sty

pla

pex e

C

Figure 14.27, cont’d (B) Palate graft when cartilaginous and midface advancement are inadequate. (C) Etiology of the lower eyelid defect versus the optimal procedure to address the defect. (A, From Spinelli HM. Atlas of Aesthetic Eyelid and Periocular Surgery. Philadelphia: Saunders/Elsevier; 2004. B, Jelks GW, et al. Secondary blepharoplasty: techniques. In: Neligan PC, Rubin JP, eds. Plastic Surgery. Philadelphia: Elsevier Saunders; 2018. C, Jelks GW, Steinbrech DS, Jelks EB, et al. Secondary blepharoplasty. In: Neligan PC, Warren RJ, eds. Plastic Surgery: Volume Two: Aesthetic Surgery. 3rd ed. Elsevier; 2012.)

Algorithm 14.1 Most Common Complications After Blepharoplasty

Immediate to 1 week post op - Chemosis - Corneal abrasion - Hematoma - Dry eyes - Infection - Visual loss - central retinal artery occlusion - globe perforation - retrobulbar hemorrhage

1–8 weeks post op

8 weeks post op or later

- Malposition of upper or lower eyelids - ptosis - lagophthalmos - ectropion

- Upper or lower eyelid malposition - Over/under-resection of skin or orbital fat - Malar festoons - Scarring - Dry eye syndrome - Asymmetries of the palpebral fissures - Eyelash alopecia

- Dysfunction of lacrimal ducts - Corneal exposure - Strabismus

Algorithm for common complications after blepharoplasty based on time post operation.

508

SECTION II

CHAPTER 14  • Secondary blepharoplasty

Algorithm 14.2 Management of Retrobulbar Hemorrhage

Patient with vision loss or decreased acuity AND tense hard globe, loss of direct/ red light reflex, ophthalmoplegia, proptosis, or orbital pain

Yes

Ophthalmology consult and evaluation

No

Clinical concern for retrobulbar hemorrhage

Medical therapy (NOT to delay surgery)

Timolol eye drops

IV hyperosmotic agents (mannitol)

Acetazolamide

IV steroids

Emergent surgical management -Lateral canthotomy and inferior cantholysis -Removal of any sutures -Evacuation of hematoma

Algorithm for management of the emergent postoperative complication of retrobulbar hematoma. From HM Spinelli, Talk: “Correction of unsuccessful cosmetic eyelid surgery”, 27 April 2012.

courses posteriorly and laterally to insert on the globe near the corresponding region on the macula. It is best observed between the medial and central fat pads and has a pink/purple coloration, which is easily distinguishable from the surrounding tissues (Fig. 14.28). Superior oblique muscle palsy has also been described due to damage to the trochlea during upper lid blepharoplasty. This is best avoided by careful nasal dissection, avoidance of excessive cautery in the region of the trochlea, and proper identification of the superior medial palpebral artery inferonasal to the medial fat pad.

Damage to the cornea Trauma to the corneal epithelium is common during blepharoplasty. While the majority of these abrasions heal spontaneously within 24 hours, this may cause the patient significant discomfort and may be a potential source of infection. Extensive epithelial damage can lead to corneal ulceration and even frank perforation. The complication is most commonly caused by abrasive movements of instruments and sutures or traumatic insertion and removal of protective contact lenses. The best way to avoid this complication is to pay close attention to the various instruments used during the procedure in addition to filling the corneal protective shield with appropriate lubricants before insertion. Should a corneal abrasion occur, antibiotic ointment can be prescribed and the patient observed until healing occurs. Topical anesthetic solutions to alleviate pain should be avoided as this will significantly delay healing and put the patient at risk for neurotrophic corneal ulcer.

Wound dehiscence Wound dehiscence may occur immediately after surgery or subacutely within days to weeks postoperatively. The most common causes of dehiscence include inadequate closure, disruption of sutures, and hematoma. Hematoma may occur as the vessels recover from the effects of epinephrine used with anesthesia or from clot lysis. In general, small quantities of bleeding can be observed carefully in the recovery room. In the rare event of brisk bleeding, the patient may need to be taken back to the operating room for exploration. Lower lid fat excision may be associated with a “flash” hemorrhage from vessels deep in the orbit which may present as a retrobulbar hemorrhage or continuous serosanguineous discharge through the lower lid conjunctival incision. Sometimes it is best to remove the conjunctival suture to allow for freer expression of the fluid until hemostasis is obtained to avoid secondary pressure within the orbit.

Lower eyelid malposition Final positioning of the lower lid relies heavily on an adequate understanding of lower lid anatomy. Externally, the lower lid must be opposed to the globe along its entire length. An imaginary line drawn from the medial canthal angle should subtend an angle of 10–15° from the horizontal. The relation between the lower lid margin and the inferior corneal margin must be such that, on primary gaze, no sclera is visible. The general position of the lashes must be such that they are not in contact with the cornea (entropion) nor should the margin be rotated in a way that palpebral conjunctiva is exposed. Over-resection of

Complications in blepharoplasty

509

Most anterior portion of inferior oblique muscle

Inferior oblique muscle Check ligaments of medial rectus muscle Superior rectus muscle

Superior oblique muscle

Check ligaments of lateral rectus muscle

Inferior rectus muscle

Levator palpebrae superioris muscle

Superior rectus muscle

Central fat pad

Annulus of Zinn

Trochlea (pulley) Superior oblique muscle Medial fat pad

Lateral rectus muscle

Medial rectus muscle Medial fat pad

Inferior oblique muscle

Lateral fat pad

Inferior rectus muscle

Central fat pad

Figure 14.28  The extraocular muscles and respective positions anteriorly and positions susceptible to injury. The inferior oblique extraocular muscle is the muscle most commonly injured during blepharoplasty. This image demonstrates that the inferior oblique muscle originates extraocularly on the maxillary bone. A pink or purple hue can often be seen when approaching this muscle during dissection. (From Spinelli HM. Atlas of Aesthetic Eyelid and Periocular Surgery. Philadelphia: Elsevier/Saunders; 2004.)

skin or aggressive dissection and fat removal during transconjunctival blepharoplasty can lead to entropion or ectropion. This may be caused by lack of external skin (ectropion) or disinsertion of the lower lid retractions (entropion).21 Many patients with dermatochalasis have variable degrees of eyelid laxity, which must be addressed during surgical intervention (i.e., canthal tightening, lateral canthal strip). This malposition

often becomes more apparent postoperatively after the removal of skin and fatty tissue. It is therefore essential that the surgeon preoperatively examines the relative position of the eyelid margin and tarsal consistency before surgery utilizing a snap-back test and other tests as previously described.4 Conjunctival chemosis with prolapse may result from significant tightening of the lower eyelid with resultant edema, or it

510

SECTION II

CHAPTER 14  • Secondary blepharoplasty

B

A

C

Figure 14.29  Ptosis in the immediate postoperative period should be observed initially because these issues often spontaneously resolve without additionally intervention. (A) Patient presenting with bilateral ptosis, visual field destruction, and sulcus deformity after previous blepharoplasty. (B) Early result after ptosis/sulcus correction. (C) Late result without any additional intervention. (From HM Spinelli, Talk: “Positioning the upper and lower eyelids in the blepharoplasty patient”, 8 May 2017.)

may occur when repositioning severely and chronically malpositioned eyelids. This is caused by a stretching or expansion of the conjunctiva, which results in a redundancy when the eyelid is repositioned. Conjunctiva requires moisture and desiccation is not well tolerated. Conjunctival prolapse can be positive feedback in that exposure leads to desiccation and edema leading to further exposure. Proper wetting with topical drops and ointments is usually helpful in preventing or worsening of the cycle, however healing can also be encouraged by a temporary lateral tarsorrhaphy suture in more severe cases. In the most recalcitrant cases, removing a portion of the herniated redundant edematous prolapsed conjunctiva can be definitive.4

Upper eyelid malposition Upper lid malposition is less common than lower lid malposition. The majority of upper lid malpositioning occurs as a result of excessive skin excision or damage to the levator complex. During the preoperative examination, attention must be paid to eyelid closure and any evidence of lagophthalmos noted as this is likely to worsen postoperatively. In deciding on the amount of skin to remove, care must be taken not to confuse excessive upper eyelid skin with brow ptosis. After the brow is held in its desirable anatomic position, smooth forceps can be used to determine the amount of upper skin to be removed in such a way that the lashes are slightly everted. Inadequate preoperative assessment of eyelid movement and anatomy may result in postoperative lagophthalmos and corneal dryness or decompensation.22

Ptosis is a rare complication of blepharoplasty and may result from damage to the levator aponeurosis muscle during dissection or excessive stretching of an already rarified muscle during surgery. Alternately, it may result from lack of recognition of preoperative ptosis in a patient with significant dermatochalasis. The later etiology presumes unrecognized ptosis preoperatively and can lead to an unhappy postoperative patient despite a well-executed blepharoplasty. In evaluating patients with eyelid malposition after surgery, it is essential not to intervene too quickly, however. While the patient and surgeon may feel compelled to immediately correct the problem, many of these difficulties spontaneously disappear or improve significantly, rendering the initial corrective treatment adequate and additional interventions would be excessive or inappropriate in addressing the actual long-term problem (Fig. 14.29).

Loss of lashes Loss of lashes is most common in patients undergoing combined blepharoplasty and ptosis repair. In these cases the anterior tarsal surface is exposed and loss of lashes can occur with excessive inferior dissection (2–3 mm from the lid margin in the upper lid). Damage of the hair follicle results causing subsequent atrophy and loss of lashes in the postoperative period. Distal dissections can also cause iatrogenic alterations to the marginal pretarsal orbicularis muscle (muscle of Riolan) which can cause lid malposition, and/or meibomian gland dysfunction. For this reason, it is best to avoid distal lid dissections.23

Complications in blepharoplasty

Dry eyes Postoperative complaints of dry eye occur in patients with preoperative tear insufficiency and the volume and relative quality of the tear film are components of a sufficient wetting surface. By widening the palpebral fissure and increasing exposure to the environment, blepharoplasty can result in worsening of dry eyes in the predisposed patient. Keep in mind that the “happy” wet cornea is a result of a balance between production and evaporation. Dryness may also be caused by cicatricial changes in the skin (pulling the lids apart) or conjunctiva or by damage to the lacrimal gland itself in an upper lid blepharoplasty where it may be mistaken for upper lid fat. This complication is best avoided by careful dissection laterally, where the lacrimal gland is located.4 Often, symptoms of dry eyes can be addressed by the use of artificial tears and lubricants. If symptoms persist, patients should be referred to an ophthalmologist to evaluate the status of the corneal tear film. Possible treatment options include the use of temporary or permanent punctal plugs along with aggressive use of topical wetting agents.10

Infection Infection is an extremely rare complication due to the extensive vascularity of the eyelids and orbit. Once the orbital septum has been violated, however, pathogens can easily gain access to the deep orbital structures. A common source of infection is believed to be the nasolacrimal outflow system in patients with post-lacrimal sac stenosis in whom bacteria can multiply and reflux towards the conjunctiva. Signs of orbital cellulitis include pain, redness, decreased vision, restricted ocular motility, and proptosis. Systemic antibiotics are warranted in this situation and close management with appropriate specialists is encouraged. As a precautionary measure, proper assessment of the nasolacrimal apparatus before surgery may avoid this potentially devastating complication.4

Incisional scarring Postoperative scarring after blepharoplasty is relatively rare and can generally be managed with massage and topical

A

511

steroids. More severe scars can be managed by intralesional corticosteroid injection or excision with radiation therapy. The surgeon must resist the urge to intervene early when scarring is a problem as scarring often improves with time. Additionally, in cases in which tension is a contributing factor, resection alone rarely improves the final result and may even worsen it.

Excessive fat resection While the upper lid is relatively forgiving from excessive fat resection, orbital hollowing may occur. This is especially seen in patients with excessive skin in whom removal of redundant preaponeurotic fat is performed. Removal of excess fat from the upper lid, especially in the midportion of the lid, may result in an accentuated appearance of the superior orbital rim. Excessive fat resection of the lower eyelid most commonly leads to malposition. This is best corrected by fat grafting via fat injection in addition to lateral canthoplasty. The nasal fat pad is more forgiving and over-resection of this area rarely results in significant cosmetic abnormality. When excess fat is present in this location, the fat can be sculpted and repositioned to assess upper lid contour. This is easily achieved with use of electrocautery or ablative laser. Fat, superficial fascia, and thin dermal grafts may all serve as late fillers.24,25

Inappropriate lower lid fat resection Excessive fat resection from the lower lids can result in tear trough deformity. This can be avoided by careful study of the relationship between the globe and orbitomaxillary junction preoperatively. Excessive fat resection should be avoided and, when possible, the removed fat can be repositioned on the orbital margin to soften the superficial appearance of the inferior rim.26,27 The senior author (H.M.S.) has found fat repositioning alone, except in the mildest of cases, to be insufficient for correcting the lower lid sulcus deformity. Instead the senior author prefers to address significant inferior lid sulcus deformities with a combination of lateral canthal/septal tarsal strip, arcus marginalis release, and deep orbital fat grafting (Fig. 14.30). Under-resection of fat may also create superficial asymmetry and a globular appearance of the lower skin. This

B

Figure 14.30 Demonstration of how significant inferior lid sulcus deformities can be corrected with a combination of lateral canthal/septal tarsal strip, arcus marginalis release, and deep orbital fat grafting. (A) Preoperative photograph of patient presenting after two previous blepharoplasties with lower eyelid sulcus depression, canthal effacement, and scleral show. (B) Postoperative photograph after treatment (H.M.S) with “combination procedure” with canthoplasty, orbital fat repositioning, deep orbital fat grafting, and arcus marginalis release.  

512

SECTION II

CHAPTER 14  • Secondary blepharoplasty

compilation can be minimized by palpating and re-examining the superficial contour of the lower lid after the removal of each fat compartment. If an uneven appearance persists beyond the 3-month postoperative period, further resection should be considered to re-establish appropriate lower lid contour.

Access the reference list online at   Elsevier eBooks+

Conclusion Secondary blepharoplasty is inherently more complicated than the primary procedure due to prior scarring, altered anatomy, and patient concerns. All surgeons performing this procedure must be aware of the risks and difficulties with this secondary procedure.

References

References 1. Plastic Surgery Statistics Report, 2020. American Society of Plastic Surgery. Available at https://www.plasticsurgery.org/documents/ News/Statistics/2020/plastic-surgery-statistics-full-report-2020.pdf. 2. Twain M. Memoranda. Galaxy. New York; 1870. 3. Spinelli HM, Jelks GW. Periocular reconstruction – a systematic approach. In: Year Book of Plastic, Reconstructive, and Aesthetic Surgery. St Louis, MO: Mosby–Year Book; 1994:88–90. 4. Small KH, Spinelli HM. Blepharoplasty. In: Cohen MN, Thaller SR, eds. The Unfavorable Result in Plastic Surgery: Avoidance and Treatment. 4th ed. New York: Thieme; 2018:266–283. 5. Spinelli HM, Shapiro MD, Wei LL, Elahi E, Hirmand H. The role of lacrimal intubation in the management of facial trauma and tumor resection. Plast Reconstr Surg. 2005;115(7):1871–1876. 6. Codner MA, McCord Jr CD. Eyelid and Periorbital Surgery. 2nd ed. New York: Thieme; 2016. 7. Lisman RD, Hyde K, Smith B. Complications of blepharoplasty. Clin Plast Surg. 1988;15(2):309–335. 8. Yong Seok Nam, Seung-Ho Han, Sun Young Shin. Detailed anatomy of the capsulopalpebral fascia. Clin Anat. 2012;25(6):709–713. 9. Spinelli HM, Weinstein AL, Janhofer DE. Belpharoplasty. In: Thaller SR, Panthaki ZJ, eds. Tips and Tricks in Plastic Surgery. Cham: Spinger Nature; 2022:123–128. 10. Spinelli HM, Farris RL. The tear film. In: Smith BC, ed. Ophthalmic Plastic and Reconstructive Surgery. St Louis, MO: CV Mosby; 1987:535–545. 11. Mizuno T. Subciliary augmentation of the lower eyelid in Asians using a deep temporal fascia graft: a preliminary report. Aesthetic Plast Surg. 2014;38(2):303–308. 12. Gulyas G, Toth BA. Improving the lateral fullness of the upper eyelid. Aesthetic Plast Surg. 2006;30(6):641–648. 13. Thomas CB, Perez-Guisado J. A new approach: resection and suture of orbicularis oculi muscle to define the upper eyelid fold and correct asymmetries. Aesthetic Plast Surg. 2013;37(1):46–50. 14. Schwarz GS, Spinelli HM. Correction of upper eyelid retraction using deep temporal fascia spacer grafts. Plast Reconstr Surg. 2008;122(3):765–774.

512.e1

15. Chia CT, Swartz KA, Spinelli HM. Transcutaneous lower lid blepharoplasty. In: Aesthetic Head and Neck: An Operative Atlas. New York: McGraw-Hill; 2012. 16. Schwartz KA, Silich R, Spinelli HM. Transconjunctival lower lid blepharoplasty. In: Aesthetic Head and Neck: An Operative Atlas. New York: McGraw-Hill; 2012. 17. Carraway JH, Grant MP, Lisman RD, Spinelli HM. Correction of lower lid laxity. Aesthet Surg J. 2005;25(2):159–168. 18. Spinelli HM. Aesthetic surgery of the lower eyelid. J Cutan Laser Ther. 2000;2:106–107. 19. Pessa JE, Desvigne LD, Lambros VS, et al. Changes in ocular globe-to-orbital rim position with age: implications for aesthetic blepharoplasty of the lower eyelids. Aesthetic Plast Surg. 1999;23(5):337–342. 20. Hass AN, Penne RB, Stefanyszyn MA, Flanagan JC. Incidence of postblepharoplasty orbital hemorrhage and associated visual loss. Ophthalmic Plast Reconstr Surg. 2004;20(6):426–432. 21. Spinelli HM, Tabatabai N, Nunn DR. Correction of involutional entropion with suborbicularis septal and lateral canthal tightening. Plast Reconstr Surg. 2006;117(5):1560–1567. 22. Sackeyfio R, Silich R, Spinelli HM. Eye lid rejuvenation. In: Avram M, Avram M, Ratner D, eds. Procedural Dermatology. New York: McGraw-Hill; 2014. 23. Lipham WJ, Tawfik HA, Dutton JJ. A histologic analysis and three-dimensional reconstruction of the muscle of Riolan. Ophthalmic Plast Reconstr Surg. 2002;18(2):93–98. 24. Park DH. Treatment of sunken eyelid. In: Shiffman, M, ed. Autologous Fat Transfer. Berlin: Springer. 2009:155–164. 25. Hoffmann RJ. Restylane injections for the lower eyeliod tear trough. In: Hartstein ME, Holds JB, Massry GG, eds. Pearls and Pitfalls in Cosmetic Oculoplastic Surgery. New York: Springer; 2014:485. 26. Elahi E, Spinelli HM. Eyelid and orbit reconstruction. In: Plastic Surgery. London: Elsevier; 2009. 27. Zoumalan CI, Roostaeian J. Simplifying blepharoplasty. Plast Reconstr Surg. 2016;137(1):196e–213e.

 

SECTION II •  Aesthetic Surgery of the Face

15 Asian facial cosmetic surgery

Access video and video lecture content for this chapter online at Elsevier eBooks+

SYNOPSIS

ƒ Currently most Asian patients want aesthetic improvement with ethnic preservation. ƒ Asian blepharoplasty deals with widening of the eye from all quarters, not just creating a supratarsal fold. ƒ Asian rhinoplasty is revolutionized with various new concepts and techniques, such as quadripod theory, septum-based nasal tip plasty, and various extension graft techniques. ƒ Asian facial bone contouring is evolving from simple bony resection to relocation and balanced facial bone resection. Aesthetic orthognathic surgery aims to balance the facial proportion based on occlusal plane changes and maxillomandibular rotations. ƒ In Asian facelifts, the soft tissue and underlying skeleton should be considered to ensure successful facial rejuvenation. ƒ Everything is in the face.

Introduction The face, while only a single part of the body, is the icon of self-identity and easy recognition. Facial cosmetic surgery is becoming increasingly popular among Asians. Although many countries use the term “Asia” referring to land masses where more than half of the world’s population resides, the word actually refers to people of East, Southeast, and South Asia with a Mongoloid ancestry (e.g., Koreans, Japanese, Chinese, Vietnamese, Filipinos, Indonesians). Asian and Caucasian faces each have unique features. Asians generally have small and puffy eyes with an epicanthal fold, shallow orbits, low-profile nasal dorsum with thick skin, flat faces with large cheekbones, and broad widths. This is especially true for East Asians.1 However, as the largest continent, Asia has numerous ethnic groups.1,2 Southern Asians have darker, thicker skin, larger eyes with double folds, and smaller, narrower facial skeletons compared to northern Asians, whereas

 

Jong Woo Choi, Tae Suk Oh, Hong Lim Choi, and Clyde Ishii

Western Asians have unique features. Despite some constants, standards of beauty vary among countries. Anatomic characteristics and cultural differences, including ethnic trends, should be considered before performing facial cosmetic surgery. Populations of Asian and non-Asian ethnicity have both similarities and differences in facial skeletons and soft tissues. However, regardless of origin, the face, including the eye, nose, and facial contour, consists of three-dimensional structures, which should be familiar to all surgeons to get an ideal of facial aesthetics. Facial projection, width, and height are important considerations in all facial aesthetic procedures (Fig. 15.1) The understanding of this three-dimensional concept is essential for plastic surgeons. For example, the nose is also a three-dimensional structure. The rhinoplasty adds a significant dimension in the sagittal profile, but also gives a change in coronal and axial plane. Approaching Asian facial aesthetic surgery with an understanding of the three-dimensional concept and multiple contour planes allows for easier selection of the ideal treatment. 1. Facial projection may be enhanced by forehead augmentation with implant or fat grafting, augmentation rhinoplasty, orthognathic surgery, bimaxillary anterior segmental ostectomy (ASO), or advancing genioplasty. Given that most Asians tend to have brachycephalic features, aesthetic procedures often focus on enhancing anterior projection. 2. Malarplasty and mandibuloplasty are popular in Asian countries because these procedures help balance facial widths. While facial bone contouring is aimed at narrowing the facial width, blepharoplasty, including medial and lateral canthoplasty, widens the eye to create a balance between the eye and the face. 3. Forehead narrowing plasty, blepharoplasty, rhinoplasty, orthognathic surgery, and genioplasty are being performed in many Asian countries to improve facial vertical balance. Contemporary Asian blepharoplasty aims at four-directional widening, which includes

514

SECTION II

CHAPTER 15  • Asian facial cosmetic surgery

Figure 15.1  Multiple facial contours based on the facial depth level. The facial planes are changed according to the patient’s facial width, height, and projection.

Figure 15.2  Differences between Western and Asian facial skeletons. Generally, Western and Asian skulls are dolicocephalic and brachycephalic, respectively.

vertical widening based on subclinical ptosis correction and horizontal widening based on medial and lateral canthoplasty. It is incorrect to assume that Asians seek to “Westernize” their faces. Most Asian patients now want to preserve their ethnic background, aside from enhancing their appearance (Fig. 15.2).1–3 Based on cultural differences among races, the perception of attractiveness, or beauty, seemed to be different between Asian and Western subjects.4,5 Advances in facial anthropometry have clarified the ideals that Asian subjects seek from their facial cosmetic surgery. Certain studies using 3D photogrammetry have documented differences in facial

proportions between attractive Asian and Western women.6–11 Overall proportions of attractive women’s faces were found to be similar between the two ethnicities, but several differences were identified in terms of facial proportions. Attractive Asian women have a longer midface than the lower face, while attractive Western subjects tend to have thicker lips, longer chins, and relatively shorter midfaces. In general, Asians consider prominent appearance of zygomas and mandibles as unfavorable, leading to numerous techniques focusing on bony reduction and contouring. As the concept of attractiveness is constantly evolving, surgeons should be aware of recent trends and be familiar with anthropometric data regarding what is considered attractive and normal (Fig. 15.3 and Table 15.1).

Introduction

515

Figure 15.3  Ideal facial proportions in attractive Asian and Western women. CH, Chin height; ICW, intercanthal width; LFH, lower facial height; LH, labial height; LW, labial width; MFH, middle facial height; NH, nasal height; NW, nasal width; PW, palpebral width; UFH, upper facial height.

Figure 15.4 Ideal periorbital anthropometry in attractive Asian and Western women.  

516

SECTION II

CHAPTER 15  • Asian facial cosmetic surgery

Table 15.1  Facial proportion anthropometry in ordinary and attractive young female populations of diverse ethnicity

Facial height ratio (upper : middle : lower)

ICW (%)

PW (%)

LW (%)

NW (%)

NH (%)

LH (%)

CH (%)

Anthropometry in ordinary young females Farkas et al.9 North American

35.6 : 27.5 : 36.9

24.3

23.6

38.3

24.2

27.5

NA

NA

German

35.9 : 27 : 37.1

23.2

25.8

39.1

25.1

27

NA

NA

Thailand

34.7 : 29.1 : 36.2

26

20.9

32.8

29.1

29.1

NA

NA

Singaporean Chinese

34.8 : 27.5 : 37.7

26.5

20.9

34.7

27.3

27.5

NA

NA

37.8 : 27.9 : 34.3

24.8

20.7

32.9

26.3

27.9

NA

NA

53.6 : 70.8 : 62.6

28.4

20.5

34.8

31

27.8

8.8

22.2

Japanese Choi, Kim et al.

7

Korean

Anthropometry in attractive young females Rhee73 East Asian (Korean, Japanese, Chinese)

31.5 : 36.3 : 32.2

20.7

16.1

28.6

28.2

23.0

8.4

NA

Caucasian

31.5 : 35.6 : 32.8

17.3

15.7

27.4

26.1

21.5

8.5

NA

Thailand

33.4 : 33.3 : 33.4

21.7

20.2

NA

NA

NA

NA

NA

Diverse ethnicity

35.8 : 31.5 : 32.6

22.3

23.9

NA

NA

NA

NA

NA

36.4 : 28.7 : 34.9

23.2

21.1

34.7

24.0

28.7

10.3

NA

Korean

29.3 : 38.5 : 32.1

24.3

19.8

31.1

26.9

29

9.2

22.2

Paraguayan

27.9 : 37.4 : 34.7

23

21.4

33.6

28.5

28.2

10

23.5

Burusapat and Lekdaeng10

Galantucci et al.11 Caucasian Choi, Yi et al.

8

CH, Chin height; ICW, intercanthal width; LH, labial height; LW, labial width; NA, not available; NH, nasal height; NW, nasal width; PW, palpebral width.

Asian blepharoplasty Introduction Blepharoplasty does not appear to be the most commonly performed cosmetic operation in North American and European countries, whereas it is the most popular plastic surgery procedure in East Asian countries, with about 30%– 60% of Asian women from metropolitan areas undergoing this procedure.12 The patient demographics are also significantly different. In the West, older patients often desire to undergo rejuvenation surgery, while in the East, it is increasingly younger patients who are paying attention to aesthetic procedures. In general, Asian women tend to have relatively wide-set eyes, puffy upper eyelids, slanted canthal angles, and lowset or absent eyelid creases. Periorbital beauty standards in Asians have changed. It is affected by Western influences and

socio-cultural trends. Facial attractiveness depends on certain relationships between periorbital structures. Given that blepharoplasty is a common operation in Asian women, surgeons should be familiar with the spatial relationships between periorbital structures. Recent studies have examined the anthropometric differences in periorbital structures between attractive persons of different ethnicities.6,12–14 Attractive Asian women have certain proportions in periorbital structures, with 10%–20% greater intercanthal width ratios as palpebral width ratios and 2.4 times greater palpebral width-to-height ratios. Western women have a narrower intercanthal distance, with 5%–10% greater intercanthal width as palpebral widths, and 2.6 times greater palpebral width-to-height ratios (Fig. 15.4).

Access the Historical Perspective section online at Elsevier eBooks+

Historical perspective

Historical perspective Historically, plastic surgery literature from Western countries has described Asian individuals as having puffy creaseless eyelids and epicanthal folds, both of which obscure the visual field. This stereotypic generalization has received scrutiny in the past four decades, and we now understand that about half of East Asian women have clear supratarsal folds without strongly conspicuous epicanthal folds.1,2 The post-World War II surgeons from the US and Europe reported that Asian patients wanted to have Caucasian “round eyes”.15 However, this perception of “Western” norms has shifted or has been rejected in East Asian countries. Most contemporary Asian patients do not favor Caucasian eyelids.1,2,16 Large deep-set

A

B

516.e1

eyelids with high creases do not compliment the overall harmony of the Asian face. Therefore, blepharoplasty should reflect the ethnic identity (Fig. 15.5). Surgically created supratarsal fold or “double eyelid” was first described by Mikamo in 1896 for a patient who lacked an upper eyelid fold.12 Shirakabe et al.17 made a historical review of 32 surgical techniques reported in Japan. Sayoc also considered anatomic upper eyelid differences between Caucasian and East Asian populations in terms of blepharoplasties.18 Hawaii served as the first testing ground, with surgeons such as Fernandez and Flowers publishing a series of studies and essays on blepharoplasty in Asian patients.19,20 Subsequent developments in blepharoplasty include further aesthetic refinements and minimally invasive approaches.21

Figure 15.5  (A) The differences in skeleton and levator attachment make Oriental eyes look different (B). Multiple theories exist regarding the formation of the supratarsal crease or fold. First theory: expansions of the levator palpebrae superioris muscle penetrating through the septum and orbicularis oculi muscle to the overlying dermis were thought to be more present in Caucasian eyelids. Second theory: supratarsal crease formation is the level of fusion of the orbital septa and the levator aponeurosis. The level of adhesion defines the superior palpebral crease in most Caucasian eyelids, whereas lower fusions results in a low-lying or absent crease in the Asian eyelid. Third theory: the skeletal differences cause eyelid differences.

Asian blepharoplasty

Preoperative consideration and diagnosis Blepharoplasty should be performed while respecting the anatomical differences between Asian and Caucasian eyelids. Decades ago, Asian patients just wanted to form visible supratarsal creases. More recently, Asian blepharoplasty has evolved not just to create the supratarsal fold but also to reduce eyelid puffiness, and increase the palpebral fissure width.22 Reducing eyelid puffiness does not equate to sunken or deflated upper eyelids.3 Height, depth, adhesion, power, and volume should be considered in natural double eyelid formation (Fig. 15.6), with each factor contributing to making a “favorable fold”. A favorable fold cannot be created if one factor is inappropriate; therefore, these factors should be considered in detail. 1. Height: In Asian blepharoplasty vernacular, the lower border of the supratarsal fold is called the “double eyelid line”, and the distance between this line and the eyelid margin at primary gaze is termed “pretarsal exposure” or “show”. Asian plastic surgeons have previously created high double folds owing to the influence of Westernization. Nowadays, the height of the fold is reduced to create a natural double fold. 2. Depth: Depth is defined as the distance between the anterior and posterior lamellae at the primary gaze. Higher lower flaps indicate deeper-formed double fold. 3. Adhesion: Appropriate adhesion is required for double fold maintenance. During incisional double-eyelidplasty, any soft tissue interfering with the connection between the anterior and posterior lamellae should be adequately removed. However, if excess pretarsal tissue is removed, the fold line easily becomes unnatural, and a depressed scar may be formed. 4. Power: The levator function is the most fundamental factor for creating a natural double fold. Impaired levator function releases the double fold, thereby it looks unnatural. 5. Volume: Adequate upper eyelid volume helps create a natural double fold. If this volume is insufficient, the fold line may not form well. Conversely, high volumes may leave unnatural appearance of the line. The shape of the desired crease should also be considered. Typically, the Caucasian eyelid crease has a semilunar shape, as the central third is farthest from the lash line.23 This semilunar shape appears unnatural to Asian patients, who prefer a parallel crease to the lid margin. Laterally, the ideal crease has slightly less curvature such that the crease is farther from the lash line than the central third. This lateral flare gives an uplifted upper eyelid appearance, minimizing the bunching of skin flaps that commonly occurs over the lateral canthus. Medially, the crease may taper toward the medial canthus (i.e., “tapered fold”) or run outside the epicanthus (i.e., “parallel fold”) (Fig. 15.7).24 The desired double eyelid shape varies according to the individual. Preoperatively, the surgeon and patient should agree regarding the height and shape of the fold. The fold height and shape can be simulated using a bent paper clip or a similar instrument, or the patients may bring model images.

Double-eyelidplasty The surgery involves creating a supratarsal crease by forming a connection between the anterior (dermis, orbicularis oculi

517

muscle [OOM]) and posterior (levator complex, tarsal plate) lamellae of the upper eyelids. Double blepharoplasty techniques can generally be categorized as “non-incisional” or “incisional”.

Non-incisional method The advantages of the non-incisional method are minimal scarring and a short recovery time. However, the fixation may be looser than with the incisional method. Therefore, this method is not suitable for Asian individuals with conditions that may increase the risk of double fold loosening, such as thick eyelid skin or excess orbital fat (Fig. 15.8). The non-incisional method creates a mechanical connection between the anterior and posterior lamellae by introducing a suture through a pinpoint access incision formed by a needle or scalpel tip. Numerous non-incisional techniques have been previously described.25–30 Currently, the most common technique is the single-knot continuous buried method (Fig. 15.9), by using 5–6 pinpoint incisions to insert stitches. The stitches are then tied to create a single knot, resulting in a double-fold line. During this technique, local anesthetic is injected into the skin and conjunctiva, and 5–6 pinpoint incisions are made along the marked fold line. The stitch is then inserted through the incisions from the skin side to the conjunctival side and then back to the skin side. With this, a single stitch passes through the entire fold line, connecting the dermis and levator complex. The surgery is complete when a knot is created at the incision where the stitch is initially inserted. Surgeons should tie the knot well to avoid creating an excessively loose or deep double eyelid (Video 15.1 ).

Incisional method The incisional method is often preferred for Asian individuals because of the anatomical characteristics of their eyelids (Fig. 15.10). Traditionally, fixation using a simple tarsodermal suture is the most common method.31 Currently, double-eyelidplasty has evolved to enable careful manipulation of more diverse tissues to create more natural and dynamic double folds (Box 15.1).32 Because there is no gold standard for incisional Clinical tip: Indications for incisional method • • • •

Dermatochalasis Thick eyelid skin Excessive orbital fat Moderate-to-severe blepharoptosis

BOX 15.1  Dynamic double fold and static double fold (Fig. 15.11) In a naturally occurring double fold, the double fold line is either not visible or only a shallow crease is noted when the eyes are closed. As soon as the eyes are opened, the double fold line begins to crease and appear due to the connection between the levator complex and dermis. This is called a dynamic double fold, which is the surgical goal of double-eyelidplasty. However, depressed scars are likely after incisional double-eyelidplasty due to various causes. Consequently, this results in an unnatural double eyelid and a visible depressed double fold line upon eye opening and closing. This is called a static double fold and commonly causes secondary double-eyelidplasty.

518

SECTION II

CHAPTER 15  • Asian facial cosmetic surgery

c

a b

d

A

B

C

D

Figure 15.6 Five important factors that should be considered for making natural double fold. (A) Height: a, double eyelid line, lower border of fold; b, upper lid margin; c. pretarsal exposure; d, lower lid margin. (B) Depth: the black line represents the fixed anterior lamellar height. Higher heights indicate longer lines and deeper double folds. (C) Adhesion: depending on the degree of removal of the pretarsal soft tissue, a linear adhesion (left) and a planar adhesion (right) are formed. (D) Volume, which is proportional to the height.  

Asian blepharoplasty

519

Figure 15.7  Shape of double fold.

Figure 15.8  Preoperative and postoperative photos of non-incisional double fold operation.

1. 2. 3.

4.

Figure 15.9  Single-stitch continuous buried method. The stitch is simply inserted through the skin at the level of the preferred lid crease, traversing the full thickness of the lid tissues down to and including either the levator aponeurosis or the tarsal plate. Lat., Lateral; Med., medial.

double-eyelidplasty, surgeons select the best technique based on their experience while considering the previously mentioned five factors. In general, the following steps were performed during the incisional method.

5.

6.

Incision: A skin incision is made along the marked fold line after surgical preparation and injection of a local anesthetic agent. Dissection: An incision is made to the exposed layer of the OOM and the orbital septum. Fat removal: If a puffy eyelid is present, the septum is opened to remove an adequate septal fat. If additional debulking is required, the retro-orbicularis fat can also be removed. Exposure of tarsal plate: After making an incision to the pretarsal area, the upper border of the tarsal plate is dissected and exposed. For optimal fixation, some pretarsal tissues should be preserved. Pretarsal preparation: Pretarsal soft-tissue removal is the most important step in incisional double-eyelidplasty. An adequate amount of soft tissue should be removed to connect the anterior and posterior lamellae without tension. Conservative removal is critical here to avoid depressed scar formation. In most cases, removal of the pretarsal soft tissue is sufficient, but OOM removal can also be performed (Video 15.2 ). Fixation: The dermis, OOM, or musculocutaneous junction, is fixed to the posterior lamellar tissues to make a double

520

SECTION II

CHAPTER 15  • Asian facial cosmetic surgery

Figure 15.10  Preoperative and postoperative photos of incisional double blepharoplasty.

Figure 15.11  Dynamic and static double fold. (Above) Static double fold. When the eyes are closed, a deeply depressed scar is observed, and when the eyes are opened, a very unnatural double eyelid is observed. (Below) Dynamic double fold. The scar was almost invisible with the eyes closed, and a natural double eyelid was observed with the eyes opened.

A

B

C

D

Figure 15.12  Various double fold fixation methods. (A) Tarsodermal fixation. (B) Tarsus–dermis–aponeurosis fixation. (C) Dermis–aponeurosis fixation. (D) Septo-aponeurotic junctional thickening fixation.

fold. The posterior lamella tissue used may vary according to the surgeon’s preference. For example, tarsal plate, levator aponeurosis, tarsus-aponeurosis, or septo-aponeurotic junctional thickening (SAJT) can be used; alternatively, several tissues may be simultaneously used (Fig. 15.12). Usually, 5–8 fixation points are used (Video 15.3 ).

7.

8.

Check double fold: The depth of the fold is checked by lid eversion. It is generally appropriate to fix the double fold enough to induce a mild outward turn of the eyelash to prevent double fold loosening. Skin excision: The presence of remnant skin was estimated by spreading the upper flap to the incision site.

Asian blepharoplasty

521

The skin should be excised without tension to prevent scar widening on the double fold.

Ptosis correction In decreased levator function, double eyelids easily become loosened and will not fold well, creating an unnatural result. Therefore, Asian patients should be precisely evaluated to correct the blepharoptosis. Patients of both Asian and non-Asian origin share similarities in causes and related anatomy of blepharoptosis. However, Asian individuals desire to have larger and more attractive eyes. Therefore, subclinical ptosis is often corrected simultaneously with double blepharoplasty.33

Non-incisional method Non-incisional ptosis correction has become popular in East Asia since its introduction by Shimizu,34 as it is able to correct subclinical ptosis without incision or dissection. However, relapse can occur postoperatively. Furthermore, repeat procedures may cause scar contractures, complicating re-operations. The procedure can be performed anteriorly or posteriorly, and a Müller tucking suture is created on the conjunctival side (Fig. 15.13).

Figure 15.13  Anterior approach of non-incisional ptosis correction.

Incisional method The incisional method can correct any degree of ptosis with a lower recurrence rate. Levator complex advancement and shortening are the basic principles of ptosis surgery.35–38 In this procedure, the mass effect is proportional to the degree of advancement and shortening (Box 15.2) Therefore, the surgical approach varies according to the degree of ptosis. Levator plication, a relatively simple method, is commonly used. In conventional levator plication, only the levator aponeurosis is used; therefore, recurrence is common.39–43 Plication of the entire levator complex is often performed, greatly reducing the recurrence rate (Fig. 15.14A).44,45 The levator resection method is suitable for severe ptosis ­requiring a large amount of levator complex shortening (Fig. 15.14B).46–48

A

B

BOX 15.2  Mass effect of levator surgery The principle of levator complex plication surgery is to fold the levator complex to shorten its length. This method is performed without separation of the tarsus and levator complex. Therefore, as the amount of folding of the levator complex increases, the volume of the folded levator complex increases and the effect of shortening by folding gradually decreases. This is called the mass effect. Therefore, for ptosis of more than a moderate degree that requires significant levator complex shortening, surgical methods that reduce the mass effect are required. Levator resection produces the least mass effect. However, a lot of dissection is required. For moderate-degree ptosis requiring moderate correction, a proper combination of levator complex plication and levator resection can be used (Fig. 15.14C).

C

Figure 15.14 (A) Levator complex plication. The thread is passed between the Müller muscle and the conjunctiva with dissection between the levator aponeurosis and the tarsal plate but without dissection between the Müller muscle and the conjunctiva. The posterior levator complex is advanced, folded, and fixed to the tarsus. The adhesion established between the posterior part of the Müller muscle, the tarsal plate, and between the layers of Müller’s muscle itself is stronger. (B) Levator resection method: after dissection between the Müller muscle and the conjunctiva, the levator complex is pulled and fixed to the tarsal plate. Since the levator complex is advanced without folding, the mass effect is minimal. Therefore, use of the levator resection method is suitable in cases of severe ptosis requiring significant correction. (C) Combined levator complex plication and levator resection: the tarsus and levator complex are separated to slightly dissect between the Müller muscle and conjunctiva. Then, levator complex advancement is performed to reduce the mass effect.  

522

SECTION II

CHAPTER 15  • Asian facial cosmetic surgery

Secondary double-eyelidplasty With the increase in Asian blepharoplasties, the need for secondary double-eyelidplasty has also significantly increased. There are various causes for this, such as asymmetry, looseness, abnormal shape, or most commonly, a high and deep location of the double eyelids, giving an unnatural appearance. This section focuses on secondary double-eyelidplasty for unnatural double eyelids. The process involves identifying the problem among the factors for natural double eyelid formation, completely releasing the existing adhesion, and creating a new natural double eyelid. Since secondary double-eyelidplasty is indicated due to a combination of the problems, it releases all existing adhesions and corrects each of these problems.

Height problem The double eyelid height is determined through preoperative consultation with the patient. Asians generally prefer a double eyelid line height of 5–10 mm from the lid margin, but patient preferences may vary. Double eyelids were previously designed highly because it was expected to make the eyes look bigger. Nowadays, people prefer naturally appropriate double eyelids. Therefore, the double eyelid height is surgically reduced (Fig. 15.15). The surgical procedure is as follows: 1. A double eyelid line is designed lower than the existing line. 2. All preaponeurotic and preseptal plane adhesions are released after incision. 3. The lower flap is fixed at the appropriate height. 4. The scar is excised if there is sufficient skin (Fig. 15.16A). Otherwise, the scar tissue is used as part of the upper flap to reduce the pretarsal show (Fig. 15.16B).

Depth problem Double eyelids look deep and unnatural if the lower flap (anterior lamella) is fixed at a point that is significantly

higher than the incision line, even if the double eyelids are designed at an appropriate height (Fig. 15.17). The principle of deep double eyelid correction is to release all adhesions and lower the lower flap fixation (Fig. 15.18). Many patients with deep double eyelids also have coexisting high double eyelids. In such cases, the correction principle is the same as that for height reduction. However, fixation of the lower flap should be performed at a point lower than the previously fixed point.

Adhesion problem When excessive pretarsal soft tissue is removed during the first operation, it leads to the formation of static double eyelids. These patients present with depressed scars due to excessive adhesion formation, making the double eyelids look unnatural. This is especially noticeable when the eyes are closed (Fig. 15.19). Correction aims to completely release the adhesion between the anterior lamella of the lower flap and tarsus. The lower flap should be fixed without tension to prevent excessive adhesions.

Power problem Most patients who require secondary double-eyelidplasty are accompanied by ptosis for the following reasons: 1. Ptosis misdiagnosis or neglect: If only doubleeyelidplasty is performed without ptosis correction, the double eyelid is easily loosened and an unnatural double eyelid is created. In addition, ptosis may become more severe. 2. Adhesion on the levator gliding plane: If adhesions were previously made to the gliding plane of the levator, ptosis occurs. These unnatural double eyelids should be addressed with appropriate adhesiolysis and ptosis correction. Ptosis correction in secondary blepharoplasty does not differ from primary surgery, but the previous adhesion between the tarsal plate and levator complex should be released to prevent recurrence.

Figure 15.15  Photos before and after re-operation of a patient with a high double fold.

Asian blepharoplasty

523

A

B

Figure 15.16  Height problem. (A) Skin sufficient. If the skin is sufficient, the existing scar can be excised. (B) Skin insufficient. If the skin is insufficient, an incision is made under the existing scar to release the adhesions.

Figure 15.17  Photos before and after re-operation of a patient with double eyelid depth problem.

Volume problem

Four-directional extension

The unnatural double eyelid has a sunken upper eyelid, mostly because of an insufficient upper flap volume. If accompanied by ptosis, ptosis correction is performed, and the orbital fat is repositioned to the sunken area. In most cases, this problem is addressed without resorting to fat injections. Conversely, for puffy eyelids, despite an appropriate double eyelid height, they appear unnatural; therefore, the height should be reduced.

Asian blepharoplasty has a high demand for expansion of the palpebral fissure. Thus, surgery to expand the area of the white scleral triangle in all four directions of the eye has been developed. These can be performed alone or combined with double blepharoplasty to maximize the effect (Figs. 15.20 & 15.21).

524

SECTION II

CHAPTER 15  • Asian facial cosmetic surgery

Figure 15.18  Depth problem. If the height is low but the depth is deep, an incision is applied along the existing scar to release the adhesion.

Figure 15.19  Photos before (above) and after (below) re-operation of a patient with double eyelid adhesion problem.

Medial epicanthoplasty Asian eyelids have an epicanthal fold, which is a medial extension of the upper eyelid skin covering a portion of the lacrimal lake and shortening the eye length. In addition, it inhibits the formation of double eyelids. Therefore, numerous medial epicanthoplasty methods have been established.49–53 Most traditional methods leave a noticeable scar in the intercanthal area; hence, they are not commonly used. The skin redrape method, first introduced by Dr. Oh, is currently the most popular method,54 and results in barely visible scars because the incision follows the subciliary line of the lower lid, and the tension is sufficiently released (Fig. 15.22).

Lateral canthal lengthening

Figure 15.20  Four-directional extension of palpebral fissure.

The Caucasian upward canthal slant gives a youthful and attractive impression.55 On the other hand, Asians perceive the upward canthal slant to provide a sharp impression with smaller eyes56; therefore, they prefer otherwise. As Asian individuals commonly have elevated canthal slants, various canthal slant-lowering and length-increasing methods have been developed.57–60 Currently, lateral canthal lengthening is divided into two categories: (1) moving the lateral canthus

Asian blepharoplasty

525

Figure 15.21  Preoperative and postoperative photographs of four-directional extension (incisional double-eyelidplasty with ptosis correction, medial epicanthoplasty, lateral canthal lengthening with canthal slant lowering).

Figure 15.22  Modified skin-redraping medial epicanthoplaty.

526

SECTION II

CHAPTER 15  • Asian facial cosmetic surgery

after lateral canthotomy to control the canthal slant and the canthal length,59,60 and (2) elevating the rotation flap in the lateral canthus for lower lid extension57,58 (Fig. 15.23) (Video 15.4  ).

fascia, arcuate expansion, and arcus marginalis, via the transconjunctival approach (Fig. 15.24).

Lower lid lowering

The aging process does not differ between those of Asian and Caucasian ancestry; however, Asian lower blepharoplasties focus on three-dimensional shaping.62 It aims to create pretarsal fullness, a flat preseptal area, and a volumetric mid-cheek beyond creating a flat eyelid. Specifically, restoring pretarsal fullness is crucial. Anatomical and cultural differences play a significant role in pretarsal fullness.63,64 “Western” patients do not favor pretarsal

In reverse ptosis, in which the lower limbus is obscured by the lower lid, lowering the lower lid to expand the palpebral fissure enlarges the eyes.61 In addition, lowering of the lower lateral eyelid can have a similar effect as lowering the canthal slant. The surgery is performed by suturing the tarsus to various tissues of the lower lid, such as the capsulopalpebral

Asian lower blepharoplasty

A

B

Figure 15.23  Various cosmetic lateral canthal lengthening methods. (A) Rotation flap method. (B) Lateral canthotomy method.

Asian blepharoplasty

527

C

Figure 15.23, cont’d (C) Canthal angle-preserving lateral canthotomy method.  

1. 2.

3. 4.

5.

6.

Figure 15.24  Lower lid lowering procedure.

fullness,65 whereas Asian patients often undergo procedures to augment this area (Fig. 15.25).64,66 The following six factors are essential in shaping a threedimensional lower eyelid:

Pretarsal fullness: The pretarsal OOM tone is maintained and its volume reinforced using the preseptal muscle. Adequate fat treatment: Adequate fat removal, replacement, or reinforcement enhances pretarsal fullness, but avoids overtreatment because of the risk of a sunken eyelid. Orbital height shortening: The orbital height, which may have increased from aging, by lifting fat in the midface or using a fat graft, is reduced. Canthal restoration: The lower eyelid will never become three-dimensional in cases of lateral canthal distortion. Therefore, restoration of the normal canthal appearance is essential to shape the lower eyelid. Rejuvenation: The lower lid is lifted through a suborbicularis oculi fat (SOOF) lift and orbicularis muscle suspension, while fine wrinkles are improved by excision of the remnant skin. Volume replacement: Even if the lower blepharoplasty was properly performed, the area that was partially lacking in volume could be reinforced with a fat graft or filler injection to create a more three-dimensional shape.

A three-dimensional lower eyelid is created when all of the aforementioned elements are harmonized intraoperatively (Fig. 15.26). Surgically, the steps are as follows: 1. Incision: A subcilliary incision is made in the mobile skin further below the eyelash, not in the tight skin just below the eyelash, to prevent scar contracture.

528

SECTION II

CHAPTER 15  • Asian facial cosmetic surgery

Figure 15.25  Preoperative and postoperative photos of pretarsal augmentation operation using acellular dermal matrix.

4.

5. 6.

7.

Figure 15.26  Preoperative and postoperative photos of lower blepharoplasty.

2.

3.

the OOM and orbital retaining ligament from the inferior orbital rim. Continue the dissection into the prezygomatic and premaxillary spaces for a SOOF lift. Fat treatment: After SOOF dissection, fat treatment is performed using fat repositioning, septal reinforcement, or fat removal to correct the orbitomalar groove. At that time, excess removal or repositioning of orbital fat from the orbital cavity can result in a sunken lower eyelid. In contrast, excessive conservative treatment results in insufficient correction and recurrent fat bulging. An adequate amount of fat should be used based on the patient’s upper eyelid status, amount of orbital fat, midface volume, and maxillary protrusion. This process requires a learning curve. SOOF lift: The fully dissected SOOF is fixed to the inferior orbital rim to reduce orbital height and improve infraorbital hollowness. OOM suspension: The OOM suspension is a key shaping procedure, which aims to lift, shape, and provide lateral canthal support by lifting the preseptal OOM and suturing it to the lateral orbital rim at the canthal level. Skin excision: Skin remnants are conservatively excised because adequate skin coverage is important in three-dimensional eyelid shaping. The amount of skin to be excised is measured when the lower lid is tightest (during wide mouth opening while looking upward).

Aging upper blepharoplasty Musculocutaneous flap elevation: The skin flap is elevated to expose the pretarsal OOM. The incision should be made in the preseptal portion, not in the pretarsal portion.62 The facial nerve branch that innervates the OOM is usually located medially (Fig. 15.27A).67 Therefore, when making an incision in the OOM, the medial one-third should be preserved to avoid pretarsal flatness due to denervation (Fig. 15.27B). SOOF elevation: Dissect from the preseptal area to the level of the inferior orbital rim, and then release

Similar to non-Asian individuals, the following techniques are used to treat aging eyelids in Asian patients: 1. Brow lift 2. Suprabrow lift 3. Infrabrow lift 4. Upper blepharoplasty The brow–lid distance and eyelid thickness should be considered when selecting the surgical method (Algorithm 15.1).

Asian rhinoplasty

A

Figure 15.27  Preservation of medial orbicularis oculi muscle innervation. (A) Pathway of zygomatic nerve’s branch to medial OOM. AN, Angular nerve; LPB, lower palpebral branch; UmPB, upper medial palpebral branch. (B) Preservation of medial one-third of OOM during lower blepharoplasty.

B

blepharoplasty. It is noteworthy that the sagging skin should not be extremely excised, and fat removal should be performed conservatively. An infrabrow lift is appropriate for thick skin. In this chapter, only the infrabrow lift, which is commonly used as a method of Asian aging upper blepharoplasty, is described in detail.

Algorithm 15.1

Brow–lid distance

Short

Infrabrow lift

Long enough

Brow lift Suprabrow lift

Skin thickness

Thick

Infrabrow lift

529

Thin

Incisional double fold

Surgical algorithm for aging upper eyelid in A­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­s­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­i­­­­­­­­­­­­­a­­n­­s.

Rather than using any numerical value as a reference point in the evaluations, determining the appropriate surgical method for each patient through consultation is recommended. First, the brow–lid distance should be evaluated. Performing upper blepharoplasty in patients with short brow–lid distance results in a shorter brow–lid distance and thicker eyelids, creating strong and stuffy impressions. Therefore, in such cases, brow lift or suprabrow lift is considered first, regardless of eyelid thickness. If the brow–lid distance is within sufficient dimensions, the method of upper blepharoplasty is determined by evaluating the skin thickness. Incisional double-eyelidplasty can be performed if the skin is thin. The surgical principle of aging double-eyelidplasty is not different from that of general

The upper eyelid thickness varies, depending on the region,68 with thicker regions closer to the eyebrow. When performing upper blepharoplasty with skin excision, this difference must be considered. When skin excision is performed during double-­ eyelidplasty, the thin skin close to the eyelash is excised. Subsequently, the relatively thicker skin forms the upper flap of the double eyelid. In patients with thick upper eyelid skin, this creates a very unnatural and strong-looking double eyelid. Therefore, in patients with thick eyelid skin, skin excision inferior to the eyebrows is more ideal (Fig. 15.28).69 However, the infrabrow lift may reduce the brow–lid distance postoperatively, potentially decreasing the effectiveness of the procedure. 1. Patients with a lot of brow action: Brow action compensatory to saggy skin almost disappears after the surgery, causing brow ptosis. 2. With simple skin excision only, the upper flap could be pulled lower, causing postoperative brow ptosis. Thus, to minimize postoperative brow ptosis, techniques that sling the lower flap to the periosteum70 or frontalis muscles71 are performed after infrabrow excision (Fig. 15.29).

Asian rhinoplasty Introduction The goals of Asian rhinoplasty are usually quite different from those of “Western” rhinoplasty. Relative to its Caucasian counterpart, the Asian nose is smaller and shorter, has less tip projection, and a wider nasal base (Fig. 15.30) These differences

530

SECTION II

CHAPTER 15  • Asian facial cosmetic surgery

Figure 15.28  Preoperative and postoperative photos of infrabrow lift with frontalis sling fixation.

Figure 15.29  Picture of frontalis sling fixation. From the lower flap orbicularis oculi muscle stump margin, sutures were applied to the exposed frontalis muscle in several areas in a horizontal mattress fashion.

Figure 15.30  The common goals of Asian rhinoplasty include improving nasal tip projection, tip caudal rotation, and making more definite nasal dorsum lines while reducing not only the tip width, but also the alar width.

involving the nasal framework and soft tissue on the nose dictate a unique approach when performing rhinoplasty in most Asian patients. On the other hand, the principles of rhinoplasty apply to all ethnicities when dealing with entities such as the dorsal hump or crooked nose.

In general, the appearance of the nose is quite different between women of Asian and Caucasian origin. Asian nasal skeletons are generally smaller and more delicate72 (Fig. 15.31). As Asian women have a flat forehead and weak chin, the relationship of the nose with the chin and forehead forms

Asian rhinoplasty

531

Figure 15.31  The differences of nasal framework and skeleton are shown on CT scans. The shape of the nasal bone, malar bone look clearly different.

Figure 15.32  Ideal anthropometric angle and proportion reported in attractive Asian and Western women. LMA, Labiomental angle; NFA, nasofacial angle; NFrA, nasofrontal angle; NH, nasal height; NMA, nasomental angle.

a more obtuse angle. From an aesthetic standpoint, certain geometric characteristics of the nose appear to be present in attractive women. Anthropometric studies have reported the ideal value of the nose in women of different racial origin.6–8,10–12,14,73 Although the general nasal skeleton is bigger in those of Caucasian ancestry, they share certain angular and proportional relationships of the nose with other facial structures. The geometric features of an attractive face should be

considered to obtain an aesthetic nasal appearance in Asian patients (Fig. 15.32 and Table 15.2).

Access the Historical Perspective section online at Elsevier eBooks+

Historical perspective

Historical perspective Rhinoplasty in Asian patients was first reported in 1964 by Khoo Boo-Chai.74 Following this, Furukawa summarized the important aspects of Asian rhinoplasty in 1974.75 He reported anthropometric data for the Japanese population, identified the optimal nasal profile for Asian patients, and described unique Asian rhinoplasty techniques. Moreover, he introduced a morphologically diverse set of dorsal silicone implants. In 1986, McCurdy put a convincing argument for aesthetic goals of rhinoplasty that applied to both non-Caucasian and Caucasian noses.76 Parsa reported nasal augmentation with split calvarial grafts in Asian patients in 1991.77 Columella lengthening for

531.e1

nasal tip remodeling was reported by Shin and Lee in 1994,78 and Watanabe studied the alar anatomy of Asian patients in 1994.79 In 1996, Han and Kang reported prefabrication of nasal implants via curing of silicone adhesive, with satisfactory results in Asian patients.80 These advancements in our understanding of nasal anatomy and surgical techniques specific to Asian patients allowed for an ever-expanding list of rhinoplasty techniques in the ensuing decades. Many mainstream techniques have been fine-tuned to further improve aesthetic outcomes and decrease complication rates. The management of complicated and/or difficult rhinoplasty cases is now finding consensus among a larger group of rhinoplasty surgeons practicing in high-income East Asian countries.

532

SECTION II

CHAPTER 15  • Asian facial cosmetic surgery

Table 15.2  Nasal anthropometry in ordinary and attractive young female populations of diverse ethnicity

NFrA (%)

NFaA (%)

NMA (%)

NLA (%)

LMA (%)

145.6

29.1

135

88.3

143.6

East Asian (Korean, Japanese, Chinese)

141.5

NA

129.1

109.5

NA

Caucasian

137.9

NA

125.6

101.8

NA

Thailand

142.82

39.76

NA

104.57

NA

Diverse ethnicity

138.58

43.79

NA

112.46

NA

NA

NA

131.12

123.12

NA

Korean

147.2

28.8

134.7

108.4

147.2

Paraguayan

142.3

33.2

128.9

98.8

139.1

Anthropometry in ordinary young females Choi, Kim et al.7 Korean Anthropometry in attractive young females Rhee et al.73

Burusapat and Lekdaeng

10

Galantucci et al.

11

Caucasian Choi, Yi et al.

8

LMA, Labiomental angle; NFaA, nasofacial angle; NFrA, nasofrontal angle; NMA, nasomental angle.

Recent trends Surgeons should keep in mind some differences in the desired aesthetic purpose of the patient and surgeon to satisfy Asian patients undergoing rhinoplasty. 1. Patient’s perspective: Most Asian patients undergoing rhinoplasty desire an augmented dorsum and improved tip projection while controlling tip rotation. As discussed in the Introduction of this chapter, the brachycephalic facial skeletal shape requires anterior projection in terms of facial balance. For this purpose, forehead augmentation, augmentation rhinoplasty, anterior segmental setback ostectomy (ASO), and advancing genioplasty are popular in Asian countries. 2.

Surgeon’s perspective: The surgeon seeks to augment the nasal dorsum and improve tip projection while controlling the tip rotation. The surgeon is challenged by the relatively thick skin and weak nasal framework, which is often seen in Asian individuals. L-shaped silicone implants have often been used in the past but are associated with multiple complications in the long term. Therefore, contemporary Asian rhinoplasty has evolved into the use of autogenous cartilage for nasal tip work, while silicone implants still prevail for dorsal augmentation.

Current trends in nasal tip remodeling in Asian countries are at odds with the classical understanding of nasal tip biomechanics. The tripod theory was first suggested by Anderson in 1969 and is based on the three legs of the paired lateral crus on pyriform apertures and conjoined medial crus on the columella base (Fig. 15.33A).81 However, the use of a septal extension graft and/or derotation grafts suggests that a fourth tensor-stress vector might play a role in determining

the position and orientation of the nasal tip. This additional element was discussed in detail by Lamson, who reasoned that the caudal septum provides major mechanical support to the nasal tip. As rhinoplasty is currently practiced in Asian countries, an increasing number of rhinoplasty surgeons appear to be following the “quadripod” concept of the nasal tip, with the anterior caudal septum as the fourth leg, as suggested by JW Choi,82 who would rather call it “septum-based nasal tip plasty”. These would be the basic steps in Asian nasal tip plasty based on the quadripod theory, which are different from “Western” rhinoplasty (Fig. 15.33B).

Diagnosis The patient interview and physical examination of the nose should not vary across ethnicities. Nasal analysis is the same for all patients.

Nasal dorsum Most Asian patients who wish to undergo rhinoplasty have a relatively low nasal dorsum. In recent years, patients have been requesting augmentation of the dorsal contour with a simultaneous increase in tip projection. The height of the nasal dorsum in such patients must be assessed in the context of the entire lateral profile from the forehead to the lip and chin. The thickness of the nasal skin must also be considered, especially if the augmentation requires alloplastic material. The thick soft-tissue envelope offers a robust separation between the implant material and the outside world. However, the thickness of the skin envelope correlates with resistance to tissue expansion, and patients should be counseled on the limitation that thick skin places on implant size and, subsequently, on dorsal profile augmentation.

Asian rhinoplasty

A

B

533

Figure 15.33  (A) Traditional nasal tip tripod theory suggested by Anderson in the 1960s. (B) Contemporary Asian nasal tip quadripod concept based on the septum as a major supporting structure.

Nasal tip The cartilaginous framework is extremely delicate in most Asian patients. This is universal in patients with an underprojected nasal tip and can be assessed in a number of ways.83 The goal of examination should be to find a balancing point between patient wishes and anatomic constraints of both the nasal tip and its relationship to the remainder of the face. Dentoalveolar protrusion can be found at some frequency in Asian patients. If this contributes significantly to the perception of tip underprojection, rhinoplasty alone will not solve the patient’s problem.

Surgical techniques and treatment Prerequisites for Asian rhinoplasty (Figs. 15.34 & 15.35) 1.

2.

3.

Release of intercartilaginous ligaments for tip control: The amount of tip projection required for Asian rhinoplasty is relatively larger than usual, making complete release of the lower lateral cartilage from the nasal framework essential in Asian rhinoplasty.84 Without adequate release, the nasal tip tends to rotate cephalically, which leads to a very unfavorable upturned nose with excessive nostril. Release of the transverse nasal sling aponeurosis: Considering the amount of lengthening in Asian rhinoplasty, the release of the transverse nasal sling is crucial for redraping the skin envelope in Asian rhinoplasty.85 Without this procedure, the skin envelope will not redrape as planned. Restructuring the nasal framework: Ideally, nasal tip projection should be performed based on restructuring the lower lateral cartilages after releasing them from the upper lateral cartilage. The hinge complex in the pyriform aperture often needs to be released to achieve this.

Figure 15.34  Important nasal anatomic structures which are uniquely crucial for Asian rhinoplasty.

Generally, it is recommended that the nasal tip should be made not by the simple onlay graft, but by restructuring the nasal tip cartilages. If only a multilayered tip onlay graft were performed for the purpose of tip projection, the lobular tip ratio would be damaged.

How to control the nasal tip projection A. Mild projection i. Interdomal or transdomal suture. ii. Strut graft: free strut or fixed strut on anterior nasal spine (Fig. 15.36).

534

SECTION II

CHAPTER 15  • Asian facial cosmetic surgery

A

B

Figure 15.35  The modern Asian rhinoplasty often includes separation of the upper and lower lateral cartilages to allow lower lateral cartilage mobilization, and improves tip projection with various maneuvers while minimizing the risk of unwanted tip movement. (A) Pre- and postoperative photographs. (B) After complete release of lower lateral cartilage from upper lateral cartilage, maximal tip projection can be achieved.

Figure 15.36  Derotation graft and columellar strut graft harvested from cavum and cymba concha of the ear, respectively.

iii. Tip onlay graft: single (Fig. 15.37A,B). B. Moderate projection i. Tip onlay graft: multiple (Fig. 15.37C) ii. Tip extension suture (Fig. 15.38). iii. Derotation graft (Fig. 15.36). C. Severe projection i. Septal extension graft: larger sized (see Fig. 15.40). ii. L-strut rib cartilage graft (see Fig. 15.40). Achieving adequate nasal tip projection is one of the most important goals in Asian rhinoplasty. For mild tip projection, various suture techniques, such as interdomal or transdomal sutures, can be used. However, given the size and strength of the Asian lower lateral cartilage, a strut graft or tip onlay graft is often necessary for tip projection (see Figs. 15.36 & 15.37). Two types of strut grafts are possible. The floating type of strut grafts has been reported to yield 1–2 mm of tip projection in non-Asian noses.86 However, floating strut grafts do not seem to be effective in Asian patients with thicker nasal skin and more delicate alar cartilages. In view of this, strut grafts are usually fixed to the anterior nasal spine, while accepting the trade-off in stiffer nasal tips. Sources of strut grafts include the septum, concha, rib cartilage, and homologous rib cartilage. Care must be taken to avoid asymmetry from cartilage warping. Alloplastic materials should be avoided at all costs in this area. For moderate tip projection, multiple-layered tip onlay grafts, tip extension sutures, or derotation grafts are required (see Figs. 15.36–15.38). However, since the multiple-layered tip onlay graft may adversely affect the columella

Asian rhinoplasty

A

B

C

Figure 15.38  Tip extension suture for the tip rotation and projection

lobular ratio, repositioning of the lower lateral cartilages would be recommended based on the release of the intercartilaginous ligaments (Fig. 15.39). Finally, for severe tip projection, a septal extension graft or L-strut rib cartilage graft would be efficient (Fig. 15.40). We should note that the more projection, the more the deviation. To overcome skin tension, a stronger nasal tip framework should be established for decent outcomes in the long term (Fig. 15.41).

How to control nasal tip rotation A. Prerequisite (see Fig. 15.34). i. Release the transverse nasal sling. ii. Release the scroll ligament (intercartilaginous ligament). iii. Release the hinge complex. B. Restructuring nasal frameworks i. Mild: Interdomal suture, transdomal suture, tip extension suture (see Fig. 15.38).

535

Figure 15.37  Tip onlay graft. (A) Onlay graft with conchal cartilage. (B) Shield graft with conchal cartilage. (C) Multiple onlay graft for tip projection.

ii. Moderate: Derotation graft with conchal cartilage (see Fig. 15.36) or septal extension graft with septal cartilage (see Fig. 15.40). iii. Severe: L-strut rib cartilage graft (see Fig. 15.40C). Lower lateral cartilage relocation based on the release of the scroll ligament and hinge complex is important to rotate the nasal tip. A simple suture is often insufficient to maintain the tip rotation, considering the gap between the tip and upper lateral cartilages. 1. Tip extension sutures (see Fig. 15.38): Tip extension suture is a simple and effective approach for tip rotation and projection.87 However, the surgeon should keep an eye on not obstructing the internal valve. If a sizable gap between the upper and lower lateral cartilage exists, a derotation graft using the conchal cartilage may be used. 2. Derotation graft (see Fig 15.36): The derotation graft lengthens and projects the nasal tip complex at the same time.88,89 Prior to the introduction of the derotation graft by Paik, cephalic rotation was most commonly addressed by rigid fixation of the mobilized alar cartilage complex. The derotation graft technique was developed to allow a secure connection between the middle vault and lower cartilages while allowing cephalocaudal flexibility. The graft itself is usually fashioned from the conchal cartilage and interposed between the upper lateral cartilages and the mobilized alar cartilage complex. Mechanically, this graft serves as a hinge between the rigid upper frame and the pliable lower complex. When the ear cartilage is harvested for this purpose, the cymba concha is used for columellar struts and derotation grafts, whereas the cavum concha is utilized as an onlay graft.71 The operation is not technically demanding and provides stable results. If improvement in tip projection is also needed, then a columella strut or septal extension graft is often necessary. 3. Septal extension graft (see Fig. 15.40): The septal extension graft is the most popular technique for controlling tip rotation.85,89–91 This is a powerful tool, and when combined with the relative weakness of the nasal septum in Asian patients, sometimes results in deviation. To overcome this problem, various modifications were suggested, as illustrated. Since Asian patients often have thin septal cartilages, septal extension may require additional support from battentype grafts. In South Korea, septal extension grafts are categorized into three types: direct extension, paired

536

SECTION II

CHAPTER 15  • Asian facial cosmetic surgery

Figure 15.39  Asian male rhinoplasty based on the quadripod concept, regarding the septum as a major supporting structure.

A

B

C

Figure 15.40  Types of septal extension graft used in Asian rhinoplasty. (A) Typical Asian septal extension graft while considering the limitation of the septum. (B) Septal extension graft, including the strut. (C) Rib cartilage-based caudal extension graft.

Figure 15.41  Before and after rhinoplasty with septal extension graft. Septal extension graft is an effective method to obtain higher tip projection. The stronger nasal tip framework should be established to overcome the skin tension.

Asian rhinoplasty

537

Figure 15.42  Before and after secondary rhinoplasty to obtain moderate tip rotation. After complete release of scroll area and hinge ligament, septal extension graft with rib-cartilage graft was performed to achieve adequate caudal rotation of the alar cartilage complex. This graft can simultaneously lengthen and project the nasal tip complex.

Figure 15.43  Before and after secondary rhinoplasty to correct severe short nose deformity. A high amount of tip rotation could be achieved by complete release of scar contracture and nasal framework reconstruction using rib cartilage-based L-strut extension graft.

4.

spreader, and paired batten grafts.90 A case of secondary rhinoplasty showing septal extension graft is presented in Fig. 15.42. Rib cartilage L-strut extension graft (see Fig. 15.40C): As the septal extension graft becomes popular in Asian primary rhinoplasty, secondary rhinoplasty often requires additional sources of cartilage. As a result, the rib cartilage graft as a form of septal extension graft or L-strut is becoming popular in Asian rhinoplasty.92,93 Even though rib cartilage provides the surgeon with a sufficient amount of cartilage, warping and tip stiffness may be problematic. A case of secondary rhinoplasty for correction of severe short nose deformity is presented in Fig. 15.43.

How to augment the nasal dorsum 1. 2. 3. 4. 5. 6.

Silicone implant Gore-Tex implant Dermofat graft Wrapped dermis graft Autogenous one-piece rib cartilage Autogenous diced rib cartilage

Silicone implants are the most common material for Asian dorsal augmentation, even though some surgeons prefer PTFE (polytetrafluoroethylene; Gore-Tex, Teflon, Proplast). Despite the reports of many complications related to the use of silicone implants in Asian rhinoplasty, the use of alloplastic materials still prevails in terms of efficacy and cost (Fig. 15.44). However, as expected, numerous complications, such as extrusion, infection, and contracture, can occur in the long term. Therefore, complicated cases require the use of autogenous materials. It includes the dermofat graft, dermis graft, one-piece carved rib cartilage, or diced rib cartilage. Dermofat grafts or dermis grafts from the mid-gluteal fold can be effectively used as a salvage option for resurfacing the nasal dorsal envelope in severely contracted nose with damaged skin envelope. However, since the dermis graft tends to be resorbed over time, this is not recommended for dorsum augmentation (Fig. 15.45). One piece of carved rib cartilage can be used for dorsal augmentation. The tricky part is to carve the costal cartilage precisely to minimize warping complications. In addition, the one-piece carved costal cartilage tends to look too strong or too straight in Asians. Another option is to use the diced rib cartilage wrapped with the temporal fascia. The advantage

538

SECTION II

CHAPTER 15  • Asian facial cosmetic surgery

A

B

Figure 15.44  The most popular nasal tip-plasty methods with cartilage graft in Asians. (A) Before and after primary rhinoplasty, performing dorsal augmentation with silicone implant (B).

Figure 15.45 Before and after secondary rhinoplasty using dermofat graft for dorsal augmentation.  

Asian rhinoplasty

of this is the freedom of shaping; however, to minimize the resorption problem, the dicing should be done finely to avoid the dead space among the particles.

Principles in nasal dorsum augmentation Dorsal augmentation is widely performed in Asian countries. In East Asian countries, alloplastic materials are frequently used, especially in South Korea. When provided with the option between alloplastic and autogenous graft operations, patients will usually choose a simpler procedure that does not require an additional scar. While the issue of alloplastic graft complications is controversial, proponents of alloplastic graft rhinoplasty have reported low complication rates with careful patient selection and technical modifications.

Procedures 1.

2. 3.

4.

5.

6.

7.

8. 9.

Usually, the open approach using the transcolumellar and marginal incision prevails in Asian countries considering the complexity of nasal tip procedures. The transcolumellar incision should be performed on the narrowest width of the columella. Supraperichondrial dissection follows. Sometimes, dissection can be performed in a manner that leaves the fatty tissue. The silicone implant should be positioned under the periosteal plane of the nasal bone. It is recommended to dissect a little wider on the upper part of the nasal bone periosteal area to minimize the capsular contracture of the implant, while dissecting a little tightly on the lower part of the nasal bone periosteum in order to prevent the shifting of the silicone implant. Transverse sling aponeurosis should be released bilaterally in order to achieve maximum redraping of the nasal skin envelope for tip projection or tip rotation. Regardless of the method of tip plasty, the intercartilaginous ligament (scroll ligament) between the upper and lower lateral cartilages should be released in many Asian rhinoplasties to reposition the lower lateral cartilages. The hinge complex should also be released to obtain the maximal tip projection and rotation. Based on the quadripod theory, septum-based nasal tip plasty, such as tip extension suture, derotation graft with conchal cartilage, or septal extension graft, is performed. After the silicone implant is meticulously carved with a blade, it is inserted into the subperiosteal pocket with no-touch technique, such as the insertion of a silicone implant for breast augmentation. To minimize capsular contractures, care should be taken to achieve hemostasis. Sometimes tip onlay graft could be added for a little more tip projection. After confirming the ideal nasal contour, the skin envelope is closed with dressing.

In summary, adequate control of nasal tip rotation and projection, and achieving sufficient dorsal augmentation, is the key concept in the Asian rhinoplasty procedure, as depicted in Algorithm 15.2.

539

Outcomes, prognosis, and complications Compared to patients of Caucasian ancestry, Asian patients are more prone to hyperpigmentation, hypertrophic scarring, and prolonged edema. As such, patients should be properly informed of these risks during the preoperative process. Other complications include asymmetry of the dorsum, ala, or nostrils. Graft visibility does occur, but is not as common a problem because of the thick nasal skin in Asian patients.

Implant deviation Implant deviation is the most common complication after augmentation rhinoplasty in Asian patients. This complication typically occurs when alloplastic materials are placed in an asymmetric pocket through a unilateral vestibular incision via a closed approach. This can be prevented by bilateral incisions when creating a pocket using the closed approach. In the open approach, midline fixation of the implant to the cartilaginous framework may prevent implant movement. For both closed and open approaches, the most critical factor in preventing implant deviation is precise pocket dissection.

Exposure and infection of alloplastic implant Visibility, redness, infection, and skin thinning may indicate the inevitable exposure of the implant. Infected alloplastic materials should be removed with revision rhinoplasty performed after a minimum delay of 3 months. Removal of the implant alone does not prevent subsequent implant failure, and the resulting volume defect should be addressed using autogenous tissue. In Korea, dermal–fat grafts are the most frequently used in such patients. Other types of autogenous grafts include rib cartilage, bone, and diced cartilage (Fig. 15.46).

Capsular contracture Capsular contractures may occur around any alloplastic implant and cause deformities and/or implant extrusion. Capsular contracture is managed by removal of the fibrous capsule, release of the scar adhesion and nasal envelope, and reconstruction of the deformed cartilage framework.

Secondary procedures Forehead augmentation Augmentation rhinoplasty addresses the lateral profile of the midface. Simultaneous forehead augmentation can further enhance the lateral profile in patients with a flat forehead and a low dorsum. Traditionally, custom-made silicone or PTFE implants have been used for forehead augmentation, despite the possibility of seroma and implant-related complications.94 Microfat grafting or augmentation with various cements may also be used to improve the forehead profile in patients undergoing rhinoplasty.

Paranasal augmentation Asian patients presenting with a low dorsum or contracted nose frequently have simultaneous hypoplasia of the paranasal or

540 SECTION II

A­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­l­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­g­­­­­­­­­­­­­­­­­­­­­o­­­r­­­­ithm 15.2 Treatment algorithm for Asian rhinoplasty

Require minimal projection

Require moderate projection

Require severe projection

Require minimal rotation

Require moderate rotation

Selection of dorsal augmentation method

Require severe rotation

Check the patient preference

Check the status of skin envelope

• Suture technique • Columellar strut graft • Tip onlay graft (unilayered)

• Derotation graft • Tip extension suture • Tip onlay graft (multilayered)

• Septal extension graft • L-strut rib cartilage graft

• Tip extension suture • Tongue-ingroove technique

• Derotation graft • Septal extension graft

• L-strut rib cartilage graft

Check the option for augmentation

• Autogenous material • Allogenic material

• • • •

Skin thickness Soft-tissue amount Presence of acne lesion Previous scar contracture

• • • • •

Silicone implant Gore-Tex implant Dermofat graft Wrapped dermis graft Autogenous one-piece rib cartilage • Autogenous diced rib cartilage

The most popular nasal tip plasty methods with cartilage graft in Asians. Alloplasts may be used for dorsal augmentation but should not extend to the nasal tip. Alloplastic materials extending to the nasal tip carry a high risk of extrusion, infection, and deformation of the nasal tip. The implant pocket must be symmetrically dissected to prevent implant deviation from the midline.

CHAPTER 15  • Asian facial cosmetic surgery

Check the amount of nasal tip rotation

Check the amount of nasal tip projection

Asian facial bone surgery

541

Figure 15.46  Salvage rhinoplasty in a patient who had infected alloplastic material and subsequent scar contracture of the entire nose. Autogenous rib cartilage graft with dermis graft was performed to address the skin envelope contracture and volume defect.

premaxillary area. As such, concomitant augmentation of both the nose and paranasal areas has become quite popular in Asian countries. Paranasal augmentation can be performed using PTFE, silicone, or polyethylene implants. This procedure is associated with higher rates of inflammation or chronic infection when compared with alloplastic implants in the nose, and patients should be properly informed of this. Microfat grafts may also be used for paranasal augmentation.

evolved to address the entire facial profile. Profiloplasty is a popular term in contemporary aesthetic facial bone surgery, and it deals with whole profiles from both the frontal and lateral perspectives of the face. To obtain ideal facial proportions and shapes, surgeons need to change each portion based on the ideal proportions of the face (Fig. 15.47).

New perspective for aesthetic facial bone surgeries

Alar base surgery

Many patients presenting for Asian rhinoplasty surgery are also concerned with the width of the nasal base. The biggest concern with this operation is the very real risk of visible scarring, and patients must be completely aware of this fact prior to consenting to the operation. Careful patient selection is an important responsibility for surgeons. When a clear indication exists, alar-based surgery should be performed only after completion of dorsal augmentation and/or tip remodeling. In some instances, nasal tip augmentation may narrow or give the appearance of a narrower nasal base, and the patient may no longer need an alar base operation.

Aesthetic facial bone surgery seeks to recreate the ideal facial contour based on the modification of the facial skeletons.95 Although analysis of the face is mostly done on two-dimensional facial shape, the actual face is a three-dimensional structure that is an integral composite of multiple planes. Likewise, the surgical outcomes of aesthetic facial bone surgery are evaluated in a two-dimensional plane; however, given the fact that the facial contour is three-dimensional, we need to know how to analyze and evaluate the face threedimensionally based on the two-dimensional analysis. In this regard, aesthetic facial bone surgery should be planned from a three-dimensional perspective (Fig. 15.48).

Genioplasty

Three planes on the face

Just as in non-Asian patients, chin projection should always be considered in relation to nasal tip projection and the overall profile of the face. Both osseous genioplasty and augmentation genioplasty with alloplastic materials can yield highly satisfactory results. However, the choice of alloplastic materials with potential complications (infection, contracture, bony erosion, implant displacement) must be weighed against the greater morbidity associated with osseous genioplasty.

When performing aesthetic facial bone surgery, the patient’s main problem should be recognized in advance. If the patient’s major problem is in the sagittal plane, orthognathic surgery can be considered. Since orthognathic surgery mainly deals with the maxillomandibular relationship, sagittal imbalance can be restored with maxillary and mandibular movements. If the facial bone contour problem exists in the axial plane, malarplasty can be considered. Because malarplasty is mostly associated with the axial facial contour, the ideal axial facial contour can be recreated with malarplasty. Finally, if the facial contour problem exists in the coronal plane, mandibuloplasty can be considered. Mandibuloplasty can profoundly improve frontal facial contour, and an ideal frontal facial contour can be made. The description above describes the major goals of each procedure. However, each facial bone surgery, such as orthognathic surgery, malarplasty, and mandibuloplasty, affect all three dimensions simultaneously. For example, although

Asian facial bone surgery Introduction Facial bone contouring surgery was initially limited to mandibular angle and malar reduction in the past, but has now

542

SECTION II

CHAPTER 15  • Asian facial cosmetic surgery

Figure 15.47  Contemporary facial contouring in Asia deals with the whole facial skeletal frames while considering the balance. It has evolved from simple resection or reduction to facial skeleton reshaping. Desired changes should be considered in the three-dimensional aspect.

Figure 15.48  Analyzing the face from different three-dimensional aspects. Coronal, axial, and sagittal plane with facial depth, respectively.

orthognathic surgery can mainly change sagittal imbalance, it affects not only the axial contour but also the coronal contour. Likewise, although axial contouring is the major goal, it also influences the coronal and sagittal contours. The change in mandibuloplasty is also three-dimensional. In this regard, we need to analyze the face from an added perspective. Given that the face has a three-dimensional structure, we need to add the concept of facial depth to each plane (see Fig. 15.48).

Coronal plane with facial depth Baek et al. described two facial frames, including the anterior facial and posterior facial frames.96 In this regard, we would suggest that the face can be categorized into the anterior, middle, and posterior facial frames. Each corresponds to the plane on the chin point, mid-plane between the chin and mandibular angle, and the plane on the mandibular angle. Considering these three facial frames, it would be much clearer to plan aesthetic facial bone surgery. For example, when a mandibuloplasty is planned, the management of the chin is considered on the anterior facial frame, while management of the mandibular angle should be considered in the posterior facial frame. At the same time, mandibular body contouring should be planned on the middle facial frame. The shape and amount of reshaping should be determined separately for these three facial frames. Given that the facial bone contour is an integral

composite of multiple coronal frames, the planning for aesthetic facial bone contour should be continuous based on three facial frames.

Axial plane with facial depth Likewise, the same approach could be possible on the axial plane: anterior, middle, and posterior axial frames. When planning malarplasty, the surgeon needs to plan where and how much malarplasty is performed on each part. If the major problem of the axial facial contour involves zygomatic arch bulging, zygomatic arch reduction should be performed with a focus on the posterior axial facial frame. Malar body reduction would be the major goal of malarplasty if the anterior axial facial frame is the chief complaint of the patient.

Sagittal plane with facial depth The conventional approach for the management of dentofacial deformity is based on the horizontal movement of the maxillomandibular complex. To correct a class III dentofacial deformity, maxillary advancement and mandibular setback were attempted to obtain a normal occlusion. In Asian patients with varying degrees of dentoalveolar protrusion, it is not easy to achieve a natural facial profile using this conventional approach. We suggest another way to correct dentofacial deformity, based on occlusal plane alteration, which can alter the facial profile more naturally. The movement of

Asian facial bone surgery

the maxillomandibular complex arises in the sagittal plane as a rotational vector, which controls the facial height in the anterior and posterior frames. If we consider the anterior and posterior sagittal facial frames simultaneously, the anterior and posterior facial heights should be planned based on the occlusal plane in orthognathic surgery. For example, management of class III dentofacial deformity requires impaction of the posterior nasal spine (PNS) in the posterior facial frame, while clockwise rotation arises in the sagittal plane. It can avoid maxillary advancement, which is not ideal for Asian class III patients who often have prognathic tendencies. Based on this three-dimensional concept, we propose a treatment algorithm for Asian facial bone surgery (Algorithm 15.3).

Access the Historical Perspective section online at Elsevier eBooks+

Diagnosis and patient indication Total facial profiles The facial profile is largely divided into upper, middle, and lower thirds. Aesthetic facial contouring surgery is based on the premise that ideal facial proportions do exist and that this ideal can be achieved through a combination of forehead plasty, rhinoplasty, malarplasty, mandibuloplasty, and/ or genioplasty.107 Orthognathic surgery can markedly correct mid- and lower facial profiles. Based on occlusion, the facial profile in three dimensions should be evaluated as a whole for successful total facial profiloplasty.

Prominent mandible Mandibular prominence occurs in both frontal and lateral profiles. In the frontal view, the prominent mandibular angle contributes to the masculine appearance of a square jaw, which is an issue for female patients. In the lateral view, prognathism is characterized by an acute gonial angle and mandibular protrusion. Evaluation of the mandible, however, should not be limited to the reduction of prominence in these two profiles. Instead, the overall shape of the entire mandible should be considered in the context of the entire facial contour.

Prominent zygoma Prominent cheekbones are considered attractive in the Western world, where they are assigned to youthfulness and considered a feminine facial feature. However, prominent cheekbones are associated with assertiveness and masculinity in the East. Horizontal dimensions, including bitemporal width, are helpful in assessing the lateral component of the zygomatic protrusion, especially that of the arch. Although anterior projection is also considered, this component of the zygoma should be preserved as much as possible to retain the youthful appearance of the midface and to minimize postoperative

543

drooping. In modern malarplasty, the overall shape and position of the malar bone is emphasized to a higher degree than the mere size of the cheekbones.

Chin Genioplasty in Asian patients, either for reduction or advancement, is similar to that performed in non-Asian patients. Park reported narrowing genioplasty, which makes the lower face appear slender and therefore makes the chin appear more feminine. This procedure is appropriate for a trapezoidal or broad chin morphology.

Dentoalveolar protrusion Anterior segmental setback ostectomy (ASO) is indicated in cases of bimaxillary protrusions. Dentoalveolar protrusion is a common tendency in Asian patients and may require orthodontic treatment or ASO. Mild dentoalveolar protrusion might be better treated with orthodontic treatment alone, with ostectomy reserved for patients with significant protrusions.

Surgical techniques and treatments Mandibuloplasty (Fig. 15.49) Mandibuloplasty is a modern term that implies reshaping of the entire mandibular contour (i.e., angle, body, and chin). The mandible should be examined for factors such as mandibular width, length, height, and curvature, along with the occlusal plane and overall facial ratios. In addition, the subjective expectation of the patient should be explored during the consultation and preoperative planning phases. Mandibuloplasty is usually performed using an oscillating saw via an intraoral approach. The senior author prefers the use of a curved reciprocating saw. Meticulous subperiosteal dissection is important for minimizing bleeding and postoperative edema. Critical anatomic structures must be respected, including the inferior alveolar nerve, facial artery, and retromandibular vein. In women, the average distances of the inferior alveolar nerve from the mandibular angle are 23.69 mm for square faces versus 20.66 mm for normal faces. In men, the respective distances are 27.30 mm and 23.28 mm.108 Ostectomy is divided into three different patterns:   Curved ostectomy accompanied by narrowing genioplasty. This procedure deals with the mandibular angle, body, and chin.   Long-curved ostectomy: This procedure is indicated in patients with a prominent mandibular angle with a wide mandibular body and chin. Simultaneous reduction of the mandibular angle and body can result in a much smaller lower facial contour (Fig. 15.50).   External corticectomy with a reciprocating saw: This tangential ostectomy of the external cortex of the mandibular ramus is performed to narrow the bigonial distance in mandibles with lateral flaring in the frontal view. However, this procedure alone may not be sufficient to create a smooth lateral contour109 (Fig. 15.51). Following ostectomy, the secondary angle was smoothed out by burring or multiple smaller ostectomies.

Historical perspective

Historical perspective Malarplasty Reduction malarplasty, first reported in 1983 by Onizuka and colleagues, is based on underpositioning of the osteotomized zygoma through an intraoral approach.97 In 1988, Baek et al. reported 94 cases of reduction malarplasty using a coronal approach.98 In that series, malar prominence was reduced via in situ transposition osteoplasty or via extraction, ex vivo contouring, and implantation of the malar complex. In 1993, Satoh and Watanabe reported outcomes following tripod osteotomy and simultaneous frontoperiorbital lifting through the coronal approach in Japanese patients.99 Cho compared the results of the intraoral and bicoronal approaches.100 Subsequently, Baek and Lee reported that intraoral malar reduction could result in cheek drooping and recommended a combination of reposition malarplasty and facelift to address this issue.101

Mandibuloplasty Baek et al. first reported the mandible angle ostectomy of 42 Asian patients in 1984, and subsequently, in 1994, reported technical refinements based on anatomic classifications of

543.e1

the mandible.3,101 The gonial angle stripper, by Kyutoku et al., was also introduced in 1994.102 Satoh reported a combined approach to mandibular contouring operation, in which both the gonion and mandibular angle were remodeled simultaneously.103 Significant volume changes in the osseous mandible and masseter muscle were reported by Lo et al. in patients who had undergone mandibular contouring operations.104 In Korea, long-curved osteotomy was recently introduced to reduce the body and angle of the mandible.

Orthognathic surgery and anterior segmental ostectomy The orthognathic method of addressing dentofacial deformity was first reported by Obwegeser in 1957.105 Following this, the Baek brothers reported advancement of central portions of maxillary and mandibular bones via anterior segmental osteotomies.106 Taiwanese plastic surgeons Yuray Chen, Philip Chen, and Lunjou Lo have played important roles in developing orthognathic surgery suitable for Asian patients. In Korea, orthognathic surgery has often been performed for aesthetic reasons. New concepts such as clockwise rotation of the maxillomandibular complex and surgery-first orthognathic surgery have been developed and accepted as standard methods in South Korea.

544

SECTION II

CHAPTER 15  • Asian facial cosmetic surgery

Algorithm 15.3 Treatment algorithm for Asian facial bone surgery

Assess the facial bone based on three-dimensional plane

Facial depth in coronal plane

Facial depth in axial plane

Anterior facial frame

Middle facial frame

Posterior facial frame

Is chin width proper?

Is mandible body prominent?

Is mandible angle prominent?

Consider narrowing genioplasty

Consider longcurved osteotomy of mandibular body

Consider mandible angle reduction and external corticotomy

Anterior facial frame

Middle facial frame

Facial depth in sagittal plane

Determination of occlusal plane

Posterior facial frame

Is zygoma body prominent?

Is zygoma arch not too wide?

Consider malar body reduction

Consider malar arch reduction

Class III dentofacial deformity

Cleft related dentofacial deformity

Obstructive sleep apnea

Class II dentofacial deformity or maxillary vertical excess

Clockwise rotation based on PNS impaction

Clockwise rotation based on ANS lengthening

Counterclockwise rotation based on PNS lengthening

Counterclockwise rotation based on ANS impaction

Treatment algorithm for Asian facial bone surgery. ANS, Anterior nasal spine; PNS, posterior nasal spine.

A

B

C

Figure 15.49  Mandibuloplasty, which is a modern term implying entire mandibular contour reshaping, including the angle, body, and chin. (A) Long-curved mandibuloplsty. (B) Narrowing genioplasty with mandibuloplasty. (C) External corticotomy.

Malarplasty (Fig. 15.52) The older concept of malar reduction reduced the bizygomatic width in a single coronal dimension as the primary goal. In contrast, modern malarplasty aims for complete three-dimensional

repositioning of the malar bone into the desired location (i.e., reduction for lateral, setback for anteroposterior, and upward movement for oblique displacements). Each movement vector can be accomplished by simple reduction, setback, or

Asian facial bone surgery

545

Figure 15.50  Long-curved mandibuloplasty. Various factors, such as mandibular width, length, height, curvature, occlusal plane, and overall facial profile, should be considered to obtain the ideal mandibular shape.

Figure 15.51  Mandibuloplasty with genioplasty. Long-curved osteotomy, external corticetomy, and reduction genioplasty were performed. The chin contour was improved both frontally and laterally.

A

B

C

Figure 15.52  Malarplasty aims to reposition the malar bone onto the ideal location through reduction, setback, or upward movement. Based on the movement vector, the osteotomy line onto the body of the malar bone can be modified. (A) Vertically based malarplasty. (B) Obliquely based malarplasty. (C) Horizontally based malarplasty.

rotational malarplasty. For example, the conventional simple zygomatic arch reduction is sufficient for patients with lateral protrusion of the zygoma due to conspicuous zygomatic arch. However, patients with prominent zygoma often have a significant anterior protruding component, which requires

posterior setback of the malar bone in addition to simple arch reduction. Currently, Asian plastic surgeons prefer linear osteotomy with or without bony removal, while maximizing the stability of the malar bone using plate fixation (Fig. 15.53).

546

SECTION II

CHAPTER 15  • Asian facial cosmetic surgery

Figure 15.53  Combined malarplasty and two-jaw surgery. Most Asian plastic surgeons prefer the linear osteotomy without bony removal, while maximizing malar bone stability using plate fixations.

Figure 15.54  Narrowing genioplasty can make the lower face appear slender and produce a more feminine chin contour. After horizontal osteotomy and two vertical osteotomies, two segments are centrally approximated and fixed with microplates.

Intraoral infracture technique with incomplete osteotomy

A bicoronal incision is deemed too morbid, aesthetically speaking, for simple cases of malar reduction. However, this approach allows sufficient exposure of the malar complex for precise multivector mobilization. This approach may be advantageous in middle-aged and elderly patients because it allows simultaneous lifting of the forehead.

width of the chin, (2) long-curved ostectomy including symphyseal or parasymphyseal, and (3) modified reduction genioplasty. For all techniques involving chin contouring, care should be taken to avoid injury to the mental nerve. Narrowing genioplasty, either as a single procedure or in combination with mandible reduction or orthognathic surgery, makes the lower face appear slender and produces a more feminine chin contour. Soft-tissue attachment of the chin is maintained to produce a maximum narrowing effect and maintain blood flow to the bony segments. Horizontal osteotomy and two vertical osteotomies are designed, as shown in Fig. 15.54. The amount of resection in the central segment is determined pre­o­peratively, depending on the width of the chin and patient preference. The two segments are approximated centrally and fixed with microplates and screws. These segments can be projected anteriorly as necessary to correct the profile from the lateral view.

Narrowing genioplasty (Fig. 15.54)

Aesthetic orthognathic surgery

Various operative techniques have been introduced to alter the chin shape: (1) narrowing genioplasty decreases the transverse

Surgical treatment objectives for aesthetic orthognathic surgery differ between Asian and non-Asian patients in that

This procedure may be useful in overcoming the limits of intraoral malar reduction. Infracture of the malar bone is helpful in decreasing the risk of postoperative soft-tissue ptosis and malar reunion. Additionally, the bony step in the malar area often requires a smoother contour. This method may require secure zygomatic arch fixation.

Bicoronal approach

Asian facial bone surgery

dentoalveolar protrusion is more common in the latter group. For example, most cases of class III prognathism are addressed by maxillary advancement and mandibular setback procedures in Western countries. However, this conventional maxillary advancement results in undesirable aesthetic outcomes in Asian patients because the orientation of the occlusal plane has not been addressed (Fig. 15.55). For this reason, clockwise movement of the maxillomandibular complex is more appropriate for Asian patients with prognathism. The maxillomandibular complex is moved in a clockwise manner by posterior impaction of the maxilla and autorotation of the mandible (Fig. 15.56).110 Modern aesthetic orthognathic surgery has been focusing on the maximal use

Figure 15.55  Anatomic planes used in aesthetic orthognathic surgery. ANS, Anterior nasal spine; FH, Frankfort horizontal line; MP, mandibular plane; OP, occlusal plane; PNS, posterior nasal spine; PP, palatal plane; SN, sella-nasion.

547

of the change in occlusal plane-altering orthognathic surgery, which is one example where the power of a change in the occlusal plane is used to improve facial proportions (Fig. 15.57). Alteration of the occlusal plane using clockwise or counterclockwise rotation is useful for improving the aesthetic proportions and posterior pharyngeal airway.101,111 In addition, counterclockwise rotation of the maxillomandibular complex is also useful in patients with obstructive sleep apnea.

Surgery-first orthognathic approach (Fig. 15.58) The surgery-first approach to orthognathic management is a relatively new concept and represents a major paradigm

Figure 15.56  The clockwise maxillomandibular complex movement can be done by posterior maxillary impaction and mandibular autorotation, which is becoming quite popular in Asia. Counterclockwise maxillomandibular rotation can be used for class II dentofacial deformities. ANS, Anterior nasal spine; PNS, posterior nasal spine; Pog, pogonion.

Figure 15.57 Aesthetic occlusal plane-altering orthognathic surgery accompanied by mandibular contouring surgery. Clockwise or counterclockwise occlusal plane alteration is very useful for correcting aesthetic disproportions and posterior pharyngeal airway function. Modern aesthetic orthognathic surgeries have been focusing on the maximal use of the change of occlusal to get the ideal facial proportions.  

548

SECTION II

CHAPTER 15  • Asian facial cosmetic surgery

A

B

C

Figure 15.58  The surgery-first orthognathic approach is a new concept and major paradigm shift in orthognathic surgery. However, a simulation surgery using a dental model is preoperatively performed to create the appropriate wafer and estimate the extent of post-surgical orthodontic treatment. This is critical in our surgery-first approach. The overall procedure is carried out as follows. (A) Preoperatively, the standard model mounting process is performed to assess the patient’s occlusion. (B) In the model setup, teeth that are already adapted into the skeletal discrepancy are simulated and reorganized into their predicted location. Then, simulation of actual orthognathic surgery similar to that of the standard approach is done. (C) At this time, if we revert the teeth position to that before preoperative surgical orthodontic treatment, we could get a model reflecting the condition of orthognathic surgery without preoperative surgical orthodontics. Based on the simulated model surgery, intermediate and final wafers for orthognathic surgery without preoperative surgical orthodontics are made.

A

B

C

Figure 15.59  Surgery-first orthognathic approach: (A) preoperative, (B) immediate postoperative, and (C) long-term postoperative lateral cephalometry. The characteristics of the surgery-first approach are as follows. (1) The direction of the post-surgical treatment is in line with the natural direction of spontaneous dental compensation and muscular forces following orthognathic surgery, thereby decreasing the time to full decompensation. (2) Inevitable aggravation of facial aesthetics during the preoperative surgical orthodontic treatments is avoided in the surgery-first approach. (3) Surgeon-oriented approach. (4) Skeletal first and dentition late correction approach.

shift in orthognathic surgery.110,112 The standard management of dentofacial deformity using orthognathic surgery consists of the following sequence: pre-surgical orthodontic treatment, orthognathic surgery, and post-surgical orthodontic treatment. The aim of pre-surgical orthodontic treatment is the mobilization of dentition in the correct position within the basal bone during the dental decompensation process. However, complete decompensation may not be possible because of mastication forces and spontaneous dental compensation in opposition to the decompensating force. Therefore, post-surgical orthodontic treatment is generally recommended. The characteristics of the surgery-first approach are as follows. (1) Post-surgical orthodontic treatment directs the decompensation process in line with spontaneous dental compensation and muscular forces following orthognathic surgery. This alignment of forces decreases the time required for full decompensation.103 (2) Inevitable aggravation of facial aesthetics during pre-surgical orthodontic treatments is avoided in the surgery-first approach. (3) This is a surgeon-oriented approach. (4) For the skeletal-first and dentition late-correction

approaches, an accurate preoperative dental model is mandatory to simulate immediate postoperative dental occlusal status, which is important for the stability of the actual postoperative occlusion (Fig. 15.59).

Occlusal plane-altering orthognathic surgery (Fig. 15.60) There are four ways to change the occlusal plane during orthognathic surgery: 1. 2. 3. 4.

Clockwise rotation based on posterior nasal spine (PNS) impaction. Clockwise rotation based on anterior nasal spine (ANS) lengthening. Counterclockwise rotation based on PNS lengthening. Counterclockwise rotation based on ANS impaction.

Bimaxillary protrusion: anterior segmental setback ostectomy In this procedure, the anterior portions of the LeFort I segment and mandible were osteotomized and set back. To accommodate this posterior movement, the first or second molar needs

Asian facial bone surgery

to be extracted prior to or at the time of operation. For anterior segmental ostectomy of the maxilla, two different pedicles were used. The palatal pedicle is commonly used for the buccal approach, which provides improved exposure and is technically less demanding. During these procedures, care must be taken to preserve the palatal mucosa. Preoperative and postoperative orthodontic treatments are mandatory for predictable results.

Combined ASO, orthognathic surgery with facial contouring surgery To maximize aesthetic outcomes, Asian plastic surgeons have been trying various combinations of orthognathic surgery, ASO, and facial bone contouring operations.113 In patients with severe dentoalveolar protrusion, orthognathic surgery with ASO is a good alternative to the traditional option of orthognathic surgery with premolar teeth extraction. Today, orthognathic surgery is often combined with mandibuloplasty and/or malarplasty in Korea because it can restore

549

the patient’s profile dramatically. However, this represents extensive remodeling of the facial bone and may adversely affect various facial functions. Therefore, such combination procedures require proper preoperative simulation and planning (Fig. 15.61).

Outcomes, prognosis, and complications Malarplasty Intraoperative complications are rare in patients undergoing malarplasty. Long-term complications include drooping of the cheek tissues and malar bone nonunion. Excessively wide dissection can release the zygomatico-cutaneous ligaments, which is the anatomic basis for soft-tissue ptosis. Poor fixation of the osteotomy can lead to non-union. Unfortunately, fixation of the malar complex in the superior–medial direction is difficult via the intraoral approach. The bicoronal approach can solve this problem by providing access to secure fixation. An alternative method of reducing the risk of malunion is the infracture technique with a greenstick fracture. Less invasive approaches with minimal dissection are being introduced to further reduce the incidence of complications associated with open approaches.

Mandibuloplasty

Figure 15.60  Concept of occlusal plane-altering orthognathic surgery. The various directions of maxillary movement, including maxillary segmentation, are depicted. ANS, Anterior nasal spine; PNS, posterior nasal spine; Pog, pogonion.

A

B

Mandibular angle reduction is associated with various complications.111 The most critical complications are condyle fracture caused by a wayward osteotomy, massive bleeding from the retromandibular vein or facial vessels, and damage to the mental nerve. Condylar fractures must be avoided by precise ostectomy around the posterior border of the mandible, which is facilitated by adequate periosteal dissection and visualization of the posterior border.114 The retromandibular vein cannot be accessed easily through the intraoral approach. Direct coagulation or other means of hemostatic control is not always easy, and failure to control the bleeding must be addressed by manual compression for a duration greater than 30 minutes. The facial artery is sometimes injured during periosteal dissection, which can be addressed by manual compression or direct ligation of the vessel. Fortunately, facial nerve injuries are rare during mandibuloplasty.

C

D

Figure 15.61 Surgery-first orthognathic approach combined with facial contouring surgery. (A,C) Preoperative view without preoperative surgical orthodontic treatment. (B,D) Postoperative view with postoperative orthodontic treatment only.  

550

SECTION II

CHAPTER 15  • Asian facial cosmetic surgery

Asian facelift

descends with aging, Asian faces may look rectangular and boxy in shape (see Fig. 15.62).

Introduction

Preoperative considerations and diagnosis

Facial aging is multifaceted and involves changes in the underlying skeleton, along with many soft-tissue changes. The skin loses its elasticity, resulting in a change in surface properties and descends with the force of gravity. The soft tissue not only sags but also loses its volume, which is the major process of soft-tissue change. All human beings suffer from aging, beginning in their middle age, although there are differences between races, genders, and age groups. A casual observer of the aging Asian face may remark that Asian individuals appear more impervious to the aging process than their “Western” counterparts.115 This observation is true to a certain degree. The pigmented nature of Asian skin may resist photoaging more than the fairer complected races. Similarly, the signs of soft-tissue sagging may also be delayed in time of onset, comparatively showing up one to two decades later than in non-Asian people. Thus, the aesthetic surgeon must understand the dynamics of the aging process specific to the Asian group to produce optimal results. In this section we discuss aging in Asian faces and detail the rejuvenation techniques specific to Asian subjects.

Before the operation, the surgeon should pay attention to the patient’s concerns and desires, the region that bothers the patient, and the amount of correction that the patient expects. General medical histories and medication intake are required, which can affect surgical outcomes. Patients are informed of the treatment options and their expected results, which range from a simple outpatient-based procedure to an aggressive intervention. General changes in facial aging should be primarily assessed during counseling before surgery. These include the formation of nasolabial fold and jowl, loss of mandibular lines, neck rhytides, and platysmal bands. In general, Asian patients prefer facial rejuvenation at a younger age than Western counterparts, usually when they are in their forties and fifties.124,125 They are more concerned with the early sign of facial aging, presented by facial volume depletion rather than the sign of facial sagging and skin laxity. This is the reason why they place more emphasis on the correction of periorbital and midfacial restoration and less emphasis on lower face ptosis and neck sagging.119 Preoperatively, the method of facial rejuvenation should be discussed with the patient in terms of aesthetic desire. Most Asian patients do not want aggressive procedures and fear visible scars. Sometimes, they are interested in simple and less invasive techniques available in outpatient clinics. Minimally invasive techniques such as thread lift, volumetric restoration with fat grafting, or other soft-tissue fillers can be the primary option. Endoscopic techniques also provide less invasive options with relatively small incisions and more accurate dissection planes.126 However, patients should be informed of the limitations that the longevity of such techniques is usually short and only a milder degree of laxity is indicated. Skin-only or subcutaneous facelifts can be another option in patients with redundant skin laxity and deepened nasolabial fold by lifting the cheek with a lateral vector. This procedure may have a risk of hypertrophic scarring, especially in the postauricular region, if there is too much tension on the skin and may aggravate the less animated features of the Asian face. Asian patients should be warned of lengthy healing times during scar maturation due to their skin properties. Patients should be informed of the mainstream facelifts that involve deep-plane manipulation, or SMAS treatment of subperiosteal lift. Deep-plane facelifts can alter the lifting vector to any degree, restore the volume in the midface, and allow long-lasting effects with minimal tension on skin closure. A number of deep-plane techniques have been introduced, but no consensus has yet been reached regarding a clear indication for Asian subjects.

Access the Historical Perspective section online at Elsevier eBooks+

Anatomic considerations in Asian facelifts Asian faces have different characteristics in soft tissue and skeletal nature compared with Caucasian faces.116,119,123 The Asian face has relatively thick skin with greater pigmentation, which allows good skin quality with fewer rhytides and less sagging. A greater amount of collagen in the skin is associated with a more vigorous fibroblast reaction during scar maturation, which may result in hypertrophic scarring and lengthy wound healing. The skin is densely attached to the superficial fascia, known as the superficial musculoaponeurotic system (SMAS) layer. The superficial and deep fascia are firmly connected with the retaining ligaments, but sliding movements are possible between these two planes where blunt dissection is possible. In Asian faces, abundant adipose tissue is frequently encountered in the malar and submalar regions, which triggers the descent of the midface during the aging process. Lifting soft-tissue sagging against dense fibrous connections is a major issue in Asian facelifts (Fig. 15.62). Several differences are also present in the skeletal structure. 119,123 The Asian cranial skeleton is described as brachycephalic, while the Caucasian skeleton has characteristics such as dolichocephalic. Asians tend to have a wide and flat midface characterized by prominent zygoma and retruded midface with small nasal bones. The lower facial skeleton is characterized by a weak chin and a rectangular contour of the mandible. These features are considered masculine and unaesthetic in Asian cultures. In addition, the weaker supportive structure in which the tissues are fixated does not provide an adequate scaffold to achieve excellent outcomes. As the malar fat

Surgical techniques and treatment Extended SMAS facelift (Fig. 15.63) Various facelift techniques using the subcutaneous, SMAS, and subperiosteal planes can be applied to Asian patients. In this section, an extended SMAS facelift technique tailored for Asian subjects is introduced.127,128 Two different planes are encountered in this technique: the skin flap and the SMAS

Historical perspective

Historical perspective The facelift procedure in European and American society has evolved significantly since its introduction in the early 1900s. However, the history of Asian facelifts is considerably shorter. The Asian facelift was introduced by Uchida in 1960. He introduced frontal rhytidectomy, which lowered the dissected frontalis muscle to the middle frontal area, thus weakening the action of the frontalis to reduce wrinkles. In 1983, Onizuka et al. introduced a subcutaneous facelift technique for Japanese subjects based on the differences between Asian and Caucasian anatomy. More elaborate techniques of facial rejuvenation have become available with the introduction of deep plane facelifts in Asian subjects. Shirakabe et al. introduced the SMAS flap technique as a most effective means of facelifts, especially for Asian skin, which has greater possibility of hypertrophic scarring due to its thickness and heaviness, by permitting the advancement of skin with natural tension produced by lifted SMAS.115 They also suggested the

550.e1

“baby model”, that the Asian face resembled that of a baby, which helped understanding of unique properties of the Asian face and emphasized the tailored strategies to meet the Asian concept of youthfulness.116 Lee et al. reported that the subperiosteal facelifts, combined with the subcutaneous approach, provided a more predictable result, with minimal morbidity and multiple lifting vectors that avoided the distortion of the facial flap.117 They found that the Asian feature of prominent skeleton might act as a fulcrum to keep the upward vector secured against gravity.117 Baek et al. combined the bone reduction surgery with the subperiosteal lift technique to avoid the wide-looking, masked face by moving the malar eminence to the more attractive position.118 Other authors also reported a deep-plane technique tailored into Asian subjects with consideration of their ethnic characteristics.119,120 Recently, more simple and less invasive methods of facial rejuvenation using threads, filler, Botox, and fat grafts have gained popularity among Asian subjects, owing to their convenience.121,122

Asian facelift

551

Figure 15.62  Different manifestations of aging change in Caucasian and Asian faces. The Asian face is characterized by thick skin, with greater pigmentation, fewer rhytides, and less sagging in the soft tissue, while the skeletal features including prominent mandible and zygoma, retruded midface, and small nasal bones, are considered aesthetically unfavorable.

A

B

C

D

Figure 15.63 Extended SMAS facelift in the Asian and Western face. (A,B) In Asian faces, the incision in the SMAS is positioned more inferiorly just below the zygomatic arch, and the distal triangular flap is larger than that of Western faces. (C,D) The suture fixation of the SMAS should be positioned below the zygomatic arch not to widen the facial width. In Asian faces, anterior midfacial volume can be augmented by an infolded triangular flap.  

552

SECTION II

CHAPTER 15  • Asian facial cosmetic surgery

flap. Using these two different flaps makes it possible to lift the sagged soft tissue with two different vectors. The most important aspect of facelift in Asian subjects is the selection of an optimal lifting vector. Considering the skeletal nature of the prominent zygoma, descended soft tissue should be repositioned vertically, not obliquely or horizontally. If the lifting vector is incorrect, the facial width will be wider. Injection of secondary agents to augment malar eminence should be dealt with carefully; otherwise, it may result in widening of the midface. Unlike patients from Western populations, extensive

neck dissection with platysmaplasty is not desired by most Asian patients, as the liposuction can provide a favorable outcome without significant morbidity.

Incision and skin flap elevation (Fig. 15.64A,B) The incision is made through temporal, tragal, and postauricular access, as in the general facelift procedure. The location of the incision should be carefully designed to maximize camouflage effect. A curvilinear line is marked from the temple

A

B

C

D

Figure 15.64 Extended SMAS lift with vertical suspension. (A) Incision design and amount of skin flap dissection. (B) After skin flap elevation, the SMAS incision line was marked. (C) The malar SMAS flap was elevated from the underlying musculature, including the orbicularis oris, zygomaticus major, and zygomaticus minor. The cheek SMAS flap was dissected off from the underlying parotid tissue until the anterior masseteric border was reached. The lower platysma–SMAS flap was dissected from the fascia of the sternocleidomastoid muscle to permit the upward movement of the flap. (D) The point of suture fixation is determined by repeatedly pulling the SMAS flap up and down. The vector of SMAS suspension was true vertical direction, with an angle of 90°.  

Asian facelift

and continues to the preauricular area, around the earlobe, and to the retroauricular region. The incision should be placed slightly superior to the periauricular sulcus, and the retroauricular incision should be performed as much as possible to minimize the visible scar. Hair follicles can be protected by tilting the scalpel during the temple incision. In the upper midface, the extent of skin flap elevation is just medial to the zygomatico-cutaneous ligament (McGregor’s patch) around the malar eminence. This region coincides with the medial end of the SMAS incision and the sub-SMAS undermining.128 If the dissection proceeds beyond this area, it may result in excessive lateralization of the malar fat pad. By preserving this attachment to the skin flap, the soft-tissue envelope above this area moves in an upward direction with the mobilization of the SMAS flap, which enables the volume shift from the lower to the upper midface. However, this limited skin flap dissection may leave some bunching of the skin flap after the SMAS is fixed in the cheek area. To correct the bunching of the skin flap, undermining the skin flap in the upward direction is required. If performed downward, the elevated soft tissue regresses to its original position, which is difficult to correct. It is also important to release this region symmetrically in both cheeks; otherwise, the patient may complain about the asymmetry. The amount of bunching correction might be different on each side when the patient has an asymmetric face. In the lower face, subcutaneous dissection begins in the mastoid region. The extent of skin flap elevation is performed until 5 cm inferior to the mandibular angle, and just medial to the anterior masseteric border is reached. The greater auricular nerve is vulnerable during the dissection of the postauricular region, especially in the well-known McKinney’s point, which has a dense fascial attachment underneath the skin.129 A layer of fat should be left in the underlying fascia to protect the greater auricular and lesser occipital nerves. If the patient has a prominent jowl, the skin flap dissection can be extended past the marionette lines to release the mandibular ligament, which helps make the lower face and the upper neck more movable in the upper direction.

SMAS flap elevation (Fig. 15.64C) After elevating the skin flap to the desired extent, a horizontal incision is placed on the SMAS flap just below the inferior border of the zygomatic arch. Then, the incision is extended medially to the point where the zygomatic arch meets the zygomatic body, where it turns upward to the direction of the lateral canthus and then obliquely downward to the uppermost point of the nasolabial fold. The malar SMAS flap is placed more laterally and cephalically in brachycephalic patients. The vertical incision is placed 2 cm anterior to the tragus and travels downward until 5 cm below the mandibular border. The caudal end of the vertical incision meets the sternocleidomastoid muscle, anterior to the greater auricular nerve. The sub-SMAS dissection comprises of two parts: the malarSMAS flap and preparotid-SMAS flap dissection, which finally meet in the center of the midface. As in the skin flap dissection, limited sub-SMAS dissection in the malar area, just medial to the lateral canthus, may prevent widening of the face and provide medially focused volume restoration.130 The malar SMAS flap is elevated from the underlying musculature, including

553

the orbicularis oris, zygomaticus minor, and zygomaticus minor. The malar SMAS flap is dissected over the zygomatic eminence and then downward to release the upper masseteric cutaneous ligaments. The superomedial part of the SMAS incision is intended to make the triangular SMAS flap, which provides volumetric augmentation for subzygomatic hollowness. The cheek SMAS flap is dissected from the underlying subSMAS adipose tissue in the preauricular region. In the midface, the medial endpoint of the SMAS flap dissection occurs just after the release of the zygomatic and masseteric cutaneous ligaments. After releasing these structures, the SMAS is loosely attached to the deep plane and easily moves upward without further dissection. For the lower face, the platysma-SMAS flap is primarily dissected from the underlying subplatysmal fat. The lower platysma-SMAS flap is then dissected from the fascia of the sternocleidomastoid muscle to permit upward movement of the flap. The dissection proceeds 3–4 cm medially until loose attachment between the platysma and the deep fascia is reached. The medial endpoint of the lower SMAS dissection is to the anterior border of the masseter muscle.131

SMAS fixation and skin closure (Fig. 15.64D) The point of suture fixation is determined by pulling the SMAS flap up and down repeatedly. The vector of the SMAS suspension is in the true vertical direction, with an angle of 90°. The distal margin of the SMAS flap is inserted for reinforcement of the fixation and sutured 1 cm below the inferior border of the zygomatic arch. The triangular flap is inverted upside down to provide volumetric support in the subzygomatic region. The amount of the SMAS flap transposition is 1–1.5 cm in a vertical direction with the redundant SMAS tissue being trimmed. The vertical incision is closed with a continuous running suture using Vicryl 4-0. The distal margin of the flap is folded and sutured with an Ethibond 4-0 suture (Ethicon, Norderstedt, Germany). The skin flap is pulled posterolaterally without any tension to prevent scar widening, alteration of hairline, and ear deformity. The skin is sutured after excision of the remaining dog-ear. A drain is routinely applied until the day after the operation. Cases are presented in Figs. 15.65–15.67.

Neck lift Although Asian patients have a tendency to present with a retruded chin, their lower face ptosis and neck sagging are milder than is seen in non-Asian patients. In addition, patients are reluctant to have a midline neck scar, which may be noticeable if the patient has a weak chin. In most Asian patients neck sagging can be corrected with liposuction and suturing of the lateral edge of the platysma to the mastoid periosteum. However, submental lipectomy and additional plastysmaplasty should be considered if the patient has excess fat in the submental region.

Asian male facelift Male facelift surgery in Asians has specific peculiarities in terms of the patients’ desires and anatomic properties. Asian male patients place more emphasis on the correction of nasolabial fold and redundant jawline, and less on the malar fullness

554

SECTION II

CHAPTER 15  • Asian facial cosmetic surgery

A

C

B

D

E

Figure 15.65  Photographs of a 52-year-old female with previous threadlifting in a local clinic. The remnant suture materal was removed intraoperatively. The overall appearance of the face was improved with clear visualization of the jawline and restoration of anterior midfacial volume without widening of facial width. (C) Intraoperative photograph showing remant suture material for thread lift. (A,D) Preoperative photographs; (B,E) 1-year postoperative photographs.

which most female patients consider “youthful”. Unlike nonAsian males, there are few bald patients, but concealing the scar is important. The thickness of the SMAS flap is thinner than that of female patients, so that the surgeon should keep his eyes on the dissection of the flap with regular thickness and facial nerve identification. In general, bleeding is more common in male patients because of the high density of vascularized beard follicles in the subcutaneous plane. Before the operation, the surgeon should focus on the aesthetic desire of the patient and discuss the advantages and disadvantages of facelift surgery with the patient132,133 (Fig. 15.68).

Outcomes, prognosis, and complications The patient is followed up at 5–7 days postoperatively to remove the skin and scalp sutures. Antibiotics are maintained for 5 days postoperatively. The patient can start social activities 7 days postoperatively with caution. Postoperative bleeding is the most common complication of the facelift procedure. Most hematomas were

noted within 24 hours postoperatively. We routinely hospitalize the patient until the day after the operation to check for bleeding. The bleeding point can be identified and promptly coagulated under close observation. As the operation is performed mostly in middle-aged patients, antihypertensive drugs are frequently used to maintain a normo-pressure state. Special caution is given not to take several drugs perioperatively, which may cause antiplatelet activity, including aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and other thrombolytic agents. Certain herbal products, such as ginkgo, may increase the risk of bleeding due to possible anticoagulation effects. Garlics are also known to increase bleeding tendency via platelet inhibition134 (Fig. 15.69). Hypertrophic scars frequently occur in Asian subjects owing to their skin properties. Postauricular incision may infrequently become hypertrophic if not frankly a keloid. Other facial incisions may remain erythematous or become hyper- or hypopigmented for an unacceptable period. The patient should be fully aware of the possibility of scarring and

Asian facelift

A

B

C

D

Figure 15.66  Photographs of a 46-year-old female showing improvement of jawline and upward shifting of the facial volume without facial widening. (A,C) Preoperative photographs; (B,D) 1-year postoperative photographs.

555

556

SECTION II

CHAPTER 15  • Asian facial cosmetic surgery

A

B

C

D

Figure 15.67  Photographs of a 55-year-old female with mild sagging and flat midface. The midfacial volume was restored without widening of facial width, although small jowl amounts remained. (A,C) Preoperative photographs; (B,D) 1-year postoperative photographs.

Asian facelift

A

B

C

D

557

Figure 15.68  Photographs of a 59-year-old male showing significant improvements in the jawline angle, resolution of the nasolabial deepening without widening of facial width. (A,C) Preoperative photographs; (B,D) 1-year postoperative photographs.

postoperative management options. Skin resurfacing therapy using ablative laser often encounters problems such as erythematous color change, which may frustrate the patient during the healing process. In fact, deeper rhytids that benefit from ablative resurfacing are uncommon in Asian patients. We have found that the current nonablative modalities that

address pigmentation provide reasonable outcomes without patient discomfort. The rates of other complications, including seromas, infection, wound dehiscence, asymmetry, nerve injury, alopecia, and ear deformaties, rate are similar to those of non-Asian patients.

558

SECTION II

CHAPTER 15  • Asian facial cosmetic surgery

Figure 15.69  Previous herbal medications tend to increase post-facelift bleeding risks.

Conclusion Asian facelift surgery has unique properties in terms of dynamics of the aging process. Extended facelift can restore the midface volume in Asian patients.

Access the reference list online at   Elsevier eBooks+

Acknowledgment We appreciate the assistance of Dr. Yeon Jun Kim, Dr. Young Chul Kim, and Dr. Hojin Park in writing this chapter.

R­ef­er­en­ces

R­ef­er­en­ces 1. Ohmori K. Aesthetic surgery in the Asian patient. In: McCarthy JG, ed. Plastic Surgery. 3rd ed. Philadelphia, PA: Saunders; 1990:2415–2426. 2. Kang J. Basic principles of aaesthetic surgery. In: McCarthy JG, ed. Plastic Surgery. Philadelphia, PA: Saunders; 1990:829–836. 3. Baek SM, Baek RM, Shin MS. Refinement in aaesthetic contouring of the prominent mandibular angle. Aesthet Plast Surg. 1994;18: 283–289. 4. 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. 2008;122:261–268. 5. Flowers RS, Nassif JM. Aaesthetic periorbital surgery. In: Mathes SJ, ed. Plastic Surgery. 2nd ed. Philadelphia, PA: Saunders; 2006:77–78. 6. Kim YC, Kwon JG, Kim SC, et al. Comparison of periorbital anthropometry between beauty pageant contestants and ordinary young women with Korean ethnicity: a three-dimensional photogrammetric analysis. Aesthet Plast Surg. 2018;42(2):479–490. 7. Kim SC, Kim HB, Jeong WS, et al. Comparison of facial proportions between beauty pageant contestants and ordinary young women of Korean ethnicity: a three-dimensional photogrammetric analysis. Aesthet Plast Surg. 2018;42(3):748–758. 8. Yi CR, Kim MJ, Kim SC, et al. Comparison of facial proportions between Eastern and Western attractive young women. J Craniofac Surg. 2020;31(3):e303–e306. 9. Farkas LG, Katic MJ, Forrest CR, et al. International anthropometric study of facial morphology in various ethnic groups/races. J Craniofac Surg. 2005;16(4):615–646. 10. Burusapat C, Lekdaeng P. What is the most beautiful facial proportion in the 21st century? Comparative study among Miss Universe, Miss Universe Thailand, neoclassical canons, and facial golden ratios. Plast Reconstr Surg Glob Open. 2019;7(2):e2044. 11. Galantucci LM, Deli R, Laino A, et al. Three-dimensional anthropometric database of attractive Caucasian women: standards and comparisons. J Craniofac Surg. 2016;27(7):1884–1895. 12. Sergile O. Mikamo’s double eyelid operation: the advent of Japanese aaesthetic surgery. Plast Reconstr Surg. 1997;99:662–667. 13. Burusapat C, Thanapurirat S, Wanichjaroen N, Pruksapong C, Attainsee A, Jankajorn S. Anthropometry analysis of beautiful upper eyelids in Oriental: new eyelid crease ratio and clinical application. Aesthet Plast Surg. 2020;44(2):392–410. 14. Sforza C, Dolci C, Grandi G, Tartaglia GM, Laino A, Ferrario VF. Comparison of soft-tissue orbital morphometry in attractive and normal Italian subjects. Angle Orthod. 2015;85(1):127–133. 15. Millard DR Jr. Oriental perigrinations. Plast Reconstr Surg. 1955;16:319–336. 16. Hiraga Y. The double eyelid operation and augmentation rhinoplasty in the oriental patient. Clin Plast Surg. 1980;7:553–568. 17. Shirakabe Y, Kinugasa T, Kawata M, et al. The double-eyelid operation in Japan: its evolution as related to cultural changes. Ann Plast Surg. 1985;15:224–241. 18. Sayoc BT. Plastic construction of the superior palpebral fold. Am J Ophthalmol. 1954;38:556–559. 19. Romm S. The changing face of beauty. Aesthet Plast Surg. 1989;13:91–98. 20. Fernandez LR. Double eyelid operation in the Oriental in Hawaii. Plast Reconstr Surg Transplant Bull. 1960;25:257–264. 21. Sayoc BT. Anatomic considerations in the plastic construction of a palpebral fold in the full upper eyelid. Am J Ophthalmol. 1967;63: 155–158. 22. Chen WPD. Upper lid crease terminology and configurations. Asian Blepharoplasty and the Eyelid Crease. 2nd ed. Philadelphia, PA: Elsevier; 2006. 23. Zubiri JS. Correction of the oriental eyelid. Clin Plast Surg. 1981;8:725–737. 24. Baek SM, Kim SS, Tokunaga S, et al. Oriental blepharoplasty: single-stitch, nonincision technique. Plast Reconstr Surg. 1989;83:236–242. This is the pioneer article for Asian mandible angle ostectomy.

558.e1

25. Liu D. Oriental blepharoplasty. Plast Reconstr Surg. 1989;84:698–699. 26. Hin LC. Oriental blepharoplasty – a critical review of technique and potential hazards. Ann Plast Surg. 1981;7:362–374. 27. Weingarten CZ. Blepharoplasty in the Oriental eye. Trans Sect Otolaryngol Am Acad Ophthalmol Otolaryngol. 1976;82:442–446. 28. Dresner SC. Oriental blepharoplasty: anatomic considerations. Plast Reconstr Surg. 1989;84:1003. 29. Choi AK. Oriental blepharoplasty: nonincisional suture technique versus conventional incisional technique. Facial Plast Surg. 1994;10: 67–83. 30. Wong JK. A method in creation of the superior palpebral fold in Asians using a continuous buried tarsal stitch (CBTS). Facial Plast Surg Clin North Am. 2007;15:337–342. 31. Park SH, Shim JS. Classification of blepharoptosis by etiology. J Korean Soc Plast Reconstr Surg. 2008;35:455–460. 32. Kim HS, Hwang K, Kim CK, et al. Double-eyelid surgery using septoaponeurosis junctional thickening results in dynamic fold in Asians. Plast Reconstr Surg Glob Open. 2013;1:1–9. 33. Baik BS, Suhk JH, Choi WS, Yang WS. Treatment of blepharoptosis by the advancement procedure of the Müller’s muscle–levator aponeurosis composite flap. J Korean Soc Plast Reconstr Surg. 2009;36:211–220. 34. Shimizu Y, Nagasao T, Asou T. A new non-incisional correction method for blepharoptosis. J Plast Reconstr Aesthet Surg. 2010;63(12): 2004–2012. 35. de la Torre JI, Martin SA, De Cordier BC, et al. Aaesthetic eyelid ptosis correction: a review of technique and cases. Plast Reconstr Surg. 2003;112:655–662. 36. Kim Y. Correction of blepharoptosis using posterior check ligament sling. J Korean Soc Aesthet Plast Surg. 2009;15:228–233. 37. Chang S, Chen W, Chang Cho I, Ahn TJ. Comprehensive review of Asian cosmetic upper eyelid oculoplasti surgery: Asian blepharoplasty and the like. Arch Plast Surg. 2014;20:129–139. 38. Ahn TJ, Kim KK. Cases of mild ptosis correction with suturemethod. Arch Plast Surg. 2012;18:15–20. 39. Liu D. Ptosis repair by single suture aponeurotic tuck. Surgical technique and long-term results. Ophthalmology. 1993;100:251–259. 40. Older JJ. Levator aponeurosis tuck: a treatment for ptosis. Ophthalmic Surg. 1978;9:102–110. 41. Jordan DR, Anderson RL. The aponeurotic approach to congenital ptosis. Ophthalmic Surg. 1990;21:237–244. 42. Anderson RL, Dixon RS. Aponeurotic ptosis surgery. Arch Ophthalmol. 1979;97:1123–1128. 43. Kumar S, Kamal S, Kohli V. Levator plication versus resection in congenital ptosis – a prospective comparative study. Orbit. 2010;29: 29–34. 44. Hong SP, Song SY, Cho IC. Under-through levator complex plication for correction of mild to moderate congenital ptosis. Ophthal Plast Reconstr Surg. 2014;30:468–472. 45. Shields M, Putterman A. Blepharoptosis correction. Curr Opin Otolaryngol Head Neck Surg. 2003;11:261–266. 46. Bassin RE, Putterman AM. Ptosis in young adults. Int Ophthalmol Clin. 2002;42(2):31–43. 47. Berke RN. Results of resection of the levator muscle through a skin incision in congenital ptosis. AMA Arch Ophthalmol. 1959;61: 177–201. 48. Harvey DJ, Iamphongsai S, Gosain AK. Unilateral congenital blepharoptosis repair by anterior levator advancement and resection: an educational review. Plast Reconstr Surg. 2010;126: 1325–1331. 49. Uchida J. [Triangular flap method in medial and lateral canthotomy]. Keisei Geka. 1967;10:120–123. 50. Lessa S, Sebastia R. Z-epicanthoplasty. Aesthet Plast Surg. 1984;8: 159–163. 51. Mulliken JB, Hoopes JE. W-epicanthoplasty. Plast Reconstr Surg. 1975;55:435–438. 52. Park JI. Z-epicanthoplasty in Asian eyelids. Plast Reconstr Surg. 1996;98:602–609.

558.e2

SECTION II

CHAPTER 15  • Asian facial cosmetic surgery

53. Park JI, Root Z. Epicanthoplasty in Asian eyelids. Plast Reconstr Surg. 2003;111:2476–2477. 54. Oh YW, Seul CH, Yoo WM. Medial epicanthoplasty using the skin redraping method. Plast Reconstr Surg. 2007;119:703–710. 55. Ortiz-Monasterio F. Lateral canthopexy to change the eye slant. Plast Reconstr Surg. 1985;75(1):1–10. 56. Rhee SC, Dhong ES, Yoon ES. Photogrammetric facial analysis of attractive Korean entertainers. Aasthet Plast Surg. 2009;33:167–174. 57. Shin YH, Hwang K. Cosmetic lateral canthoplasty. Aesthet Plast Surg. 2004;28:317–320. 58. Kim MS. Effective lateral canthal lengthening with triangular rotation flap. Arch Plast Surg. 2016;43:311–315. 59. Chae SW, Yun BM. Cosmetic lateral canthoplasty: lateral canthoplasty to lengthen the lateral canthal angle and correct the outer tail of the eye. Arch Plast Surg. 2016;43:321–327. 60. Kim YJ, Lee KH, Choi HL, Jeong EC. Cosmetic lateral canthoplasty: preserving the lateral canthal angle. Arch Plast Surg. 2016;43:316–320. 61. 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 Reconstr Surg. 2011;127(1):396–406. 62. Jeon YR, Rah DK, Lew DH, Roh TS, Kim YS, Choi HL. Pretarsal augmented lower blepharoplasty. Plast Reconstr Surg. 2016;138(1): 74–82. 63. Putterman AM. Cultural differences in pretarsal fullness acceptance. Plast Reconstr Surg. 2017;139:1018–1019. 64. Cong LY, Lee SH, Tansatit T, Hu KS, Kim HJ. Topographic anatomy of the inferior medial palpebral artery and its relevance to the pretarsal roll augmentation. Plast Reconstr Surg. 2016;138(3): 430e–436e. 65. Webster PJ, Wulc AE, Moody BR, Dryden RM, Foster JA. Electrosurgical modification of orbicularis oculi hypertrophy. Ophthal Plast Reconstr Surg. 2000;16:407–416. 66. Mizuno T. Subciliary augmentation of the lower eyelid in Asians using a deep temporal fascia graft: a preliminary report. Aesthet Plast Surg. 2014;38:303–308. 67. Choi Y, Kang HG, Nam YS, Kang JG, Kim IB. Facial nerve supply to the orbicularis oculi around the lower eyelid: anatomy and its clinical implications. Plast Reconstr Surg. 2017;140(2):261–271. 68. Yeop C, Hyun GK, Yong SN. Three skin zones in the Asian upper eyelid pertaining to the Asian blepharoplasty. J Craniofac Surg. 2017;28:892–897. 69. Lee D, Law V. Subbrow blepharoplasty for upper eyelid rejuvenation in Asians. Aesthet Surg J. 2009;29:284–289. 70. Kim YS. Subbrow blepharoplasty using supraorbital rimperiosteal fixation. Aesthet Plast Surg. 2014;38:27–31. 71. Kim HS, Kim KK. Subbrow lift using frontalis sling to correct lateral orbital laxity. Aesthet Plast Surg. 2020;44(6):2119–2126. 72. Toriumi DM, Swartout B. Asian rhinoplasty. Facial Plast Surg Clin North Am. 2007;15:293–307. 73. Rhee SC. Differences between Caucasian and Asian attractive faces. Skin Res Technol. 2018;24(1):73–79. 74. Khoo BC. Augmentation rhinoplasty in the Orientals. Plast Reconstr Surg. 1964;34:81–88. 75. Furukawa M. Oriental rhinoplasty. Clin Plast Surg. 1974;1:129–155. 76. McCurdy JA Jr. Aesthetic rhinoplasty in the non-Caucasian. J Dermatol Surg Oncol. 1986;12(1):38–44. 77. Parsa FD. Nasal augmentation with split calvarial grafts in Orientals. Plast Reconstr Surg. 1991;87:245–253. 78. Shin KS, Lee CH. Columella lengthening in nasal tip plasty of Orientals. Plast Reconstr Surg. 1994;94:446–453. 79. Watanabe K. New ideas to improve the shape of the ala of the Oriental nose. Aesthet Plast Surg. 1994;18:337–344. 80. Han K, Kang J. A custom-made nasal implant: prefabrication from curing of silicone adhesive. Plast Reconstr Surg. 1996;97:436–444. 81. Anderson J.R. The dynamics of rhinoplasty. In: Proceedings of the Ninth International Congress of Otolaryngology. Excerpta Medica

International Congress Series, No. 206. Amsterdam: Excerpta Medica; 1969:708–710. 82. Choi JW, Suh YC, Song SY, Jeong WS. 3D photogrammetric analysis of the nasal tip projection and derotation based on the nasal tip quadripod concept. Aesthet Plast Surg. 2017;41(3):608–617. 83. Jang YJ. Asian rhinoplasty. In: Papel ID, Frodel JL, Holt GR, eds. Facial Plastic and Reconstructive Surgery. 3rd ed. New York, NY: Thieme Medical Publishers; 2009:619–637. 84. Han SK, Lee DG, Kim JB, Kim WK. An anatomic study of nasal tip supporting structures. Ann Plast Surg. 2004;52(2):134–139. 85. Kim TK, Jeong JY. Surgical anatomy for Asian rhinoplasty. Arch Craniofac Surg. 2019;20(3):147–157. 86. Endo T, Nakayama Y, Ito Y. Augmentation rhinoplasty: observations in 1200 cases. Plast Reconstr Surg. 1991;87:54–59. 87. Kim JH, Song JW, Park SW, Oh WS, Lee JH. Tip extension suture: a new tool tailored for Asian rhinoplasty. Plast Reconstr Surg. 2014;134(5):907–916. 88. Paik M. Correction of short nose. J Korean Soc Aesthet Plast Surg. 2005;11:22–26. 89. Paik MH, Chu LS. Correction of short nose deformity using a septal extension graft combined with a derotation graft. Arch Plast Surg. 2014;41(1):12–18. 90. Kim JH, Song JW, Park SW, Oh WS, Lee JH. Effective septal extension graft for Asian rhinoplasty. Arch Plast Surg. 2014;41(1): 3–11. 91. Byrd HS, Andochick S, Copit S, et al. Septal extension grafts: a method of controlling tip projection shape. Plast Reconstr Surg. 1997;100:999–1010. 92. Yeo NK, Jang YJ. Rhinoplasty to correct nasal deformities in postseptoplasty patients. Am J Rhinol Allergy. 2009;23(5):540–545. 93. Lee HJ, Jang YJ. Correction of saddle and short noses. Curr Opin Otolaryngol Head Neck Surg. 2016;24(4):294–299. 94. Wong JK. Forehead augmentation with alloplastic implants. Facial Plast Surg Clin North Am. 2010;18:71–77. 95. 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. 2001;30:611–625. 96. Choi JY, Lee SH, Baek SH. Effects of facial hard tissue surgery on facial aaesthetics: changes in facial content and frames. J Craniofac Surg. 2012;23(6):1683–1686. 97. Onizuka T, Watanabe K, Takasu K, et al. Reduction malar plasty. Aesthet Plast Surg. 1983;7:121–125. 98. Baek SM, Chung YD, Kim SS. Reduction malarplasty. Plast Reconstr Surg. 1991;88(1):53–61. 99. Satoh K, Watanabe K. Correction of prominent zygomata by tripod osteotomy of the malar bone. Ann Plast Surg. 1993;31:462–466. 100. Cho BC. Reduction malarplasty using osteotomy and repositioning of the malar complex: clinical review and comparison of two techniques. J Craniofac Surg. 2003;14:383–392. 101. Baek RM, Lee SW. Face lift with reposition malarplasty. Plast Reconstr Surg. 2009;123:701–708. 102. Kyutoku S, Yanagida A, Kusumoto K, et al. The gonial angle stripper: an instrument for the treatment of prominent gonial angle. Ann Plast Surg. 1994;33:672–676. 103. Satoh K. Mandibular contouring surgery by angular contouring combined with genioplasty in orientals. Plast Reconstr Surg. 1998;101:461–472. 104. 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. 2005;54:615–622. 105. Obwegeser HL. Surgical procedures to correct mandibular prognathism and reshaping of the chin. Oral Surg Oral Med Oral Pathol. 1957;10:677–689. 106. Baek SM, Baek RM. Profiloplasty of the lower face by maxillary and mandibular anterior segmental osteotomies. Aesthet Plast Surg. 1993;17:129–137. The fiirst article for Asian profiloplasty. 107. 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. 2001;30:611–625.

R­ef­er­en­ces

108. Jin H, Park SH, Kim BH. Sagittal split ramus osteotomy with mandible reduction. Plast Reconstr Surg. 2007;119:662–669. New concept of mandible angle ostectomy. 109. Choi JW, Lee JY, Koh KS, et al. Frontal soft tissue analysis using a 3 dimensional camera following two-jaw rotational orthognathic surgery in skeletal class III patients. J Craniomaxillofac Surg. 2014;42: 220–226. 110. Choi JW, Park YJ, Lee CY. Posterior pharyngeal airway in clockwise rotation of maxillomandibular complex using surgeryfirst orthognathic approach. Plast Reconstr Surg Glob Open. 2015;3:e485. 111. Baek SM, Kim SS, Bindiger A. The prominent mandibular angle: preoperative management, operative technique, and results in 42 patients. Plast Reconstr Surg. 1989;83:272–280. 112. Choi JW, Lee JY, Yang SJ, Koh KS. The reliability of a surgery-first orthognathic approach without presurgical orthodontic treatment for skeletal class III dentofacial deformity. Ann Plast Surg. 2015;74: 333–341. 113. Jin H, Kim BH, Woo YJ. Three-dimensional mandible reduction: correction of occlusal class I in skeletal class III cases. Aesthet Plast Surg. 2006;30:553–559. 114. Hwang K, Han JY, Kil MS, et al. Treatment of condyle fracture caused by mandibular angle ostectomy. J Craniofac Surg. 2002;13: 709–712. 115. Shirakabe Y. The Oriental aging face: an evaluation of a decade of experience with the triangular SMAS flap technique in facelifting. Aesthet Plast Surg. 1988;12(1):25–32. 116. Shirakabe Y, Suzuki Y, Lam SM. A new paradigm for the aging Asian face. Aesthet Plast Surg. 2003;27(5):397–402. 117. Lee Y, Hong JJ. Multiplane face lift with the subperiosteal dissection for orientals. Plast Reconstr Surg. 1999;104(1):237–244; discussion 245–236. 118. Baek RM, Lee SW. Face lift with reposition malarplasty. Plast Reconstr Surg. 2009;123(2):701–708. 119. Bergeron L, Chen YR. The Asian face lift. Semin Plast Surg. 2009;23(1):40–47. 120. Kim IG, Oh JK, Baek DH. Personal experiences and algorithm of endoscopically assisted subperiosteal face lift in orientals for 5 years. Plast Reconstr Surg. 2001;108(6):1768–1779; discussion 1780-1781.

558.e3

121. Kang SH, Byun EJ, Kim HS. Vertical lifting: a new optimal thread lifting technique for Asians. Dermatol Surg. 2017;43(10):1263–1270. 122. Kim BJ, Choi JH, Lee Y. Development of facial rejuvenation procedures: thirty years of clinical experience with face lifts. Arch Plast Surg. 2015;42(5):521–531. 123. Sykes JM. Management of the aging face in the Asian patient. Facial Plast Surg Clin North Am. 2007;15(3):353–360. vi–vii. 124. Ryu MH, Moon VA. High superficial musculoaponeurotic system facelift with finger-assisted facial spaces dissection for Asian patients. Aesthet Surg J. 2015;35(1):1–8. 125. Zhang P, Sui B, Ren L, et al. The individualized facelift technique in improving facial asymmetry for Asian patients. Ophthalmic Plast Reconstr Surg. 2018;34(6):516–521. 126. Ramirez OM. Three-dimensional endoscopic midface enhancement: a personal quest for the ideal cheek rejuvenation. Plast Reconstr Surg. 2002;109(1):329–340; discussion 341–349. 127. Charafeddine AH, Zins JE. The extended superficial musculoaponeurotic system. Clin Plast Surg. 2019;46(4):533–546. 128. Stuzin JM, Baker TJ, Gordon HL, Baker TM. Extended SMAS dissection as an approach to midface rejuvenation. Clin Plast Surg. 1995;22(2):295–311. 129. Lee JH, Oh TS, Park SW, Kim JH, Tansatit T. Temple and postauricular dissection in face and neck lift surgery. Arch Plast Surg. 2017;44(4):261–265. 130. Stuzin JM. Restoring facial shape in face lifting: the role of skeletal support in facial analysis and midface soft-tissue repositioning. Plast Reconstr Surg. 2007;119(1):362–376. 131. Lee JH. Asian facial rejuvenation by extended SMAS facelift technique. Plast Reconstr Surg Glob Open. 2017;5(2):e1244. 132. Downs BW, Wang TD. Midcheek and lower face/neck rejuvenation in the male patient. Facial Plast Surg Clin North Am. 2008;16(3):317–327, vi. 133. Pascali M, Botti C, Botti G. Face lifting in bald male patients: new trends and specific needs. Plast Reconstr Surg. 2020;145(1):60–69. 134. Pribitkin ED. Herbal medicine and surgery. Semin Integr Med. 2005;3:17–23.

 

SECTION II •  Aesthetic Surgery of the Face

16 Facial fat grafting Francesco M. Egro, Sydney R. Coleman, and J. Peter Rubin

Access video and video lecture content for this chapter online at Elsevier eBooks+ 

SYNOPSIS

ƒ Facial aging is characterized by fat atrophy and gravitational descent of facial soft tissue. ƒ Careful facial analysis and planning are key for success. ƒ Fat grafting offers a minimally invasive technique to improve facial aesthetic and skin quality. ƒ The Coleman technique for harvesting, processing, and grafting, provides a reliable strategy for consistent results.

Introduction Autologous fat grafting has greatly evolved since its first description in 1800s by Gustav Neuber, where he transplanted fat from the arm to the lower orbit to correct depressed and adherent scars.1 In the early 1900s, Eugene Holländer used a mixture of human and ram fat heated to body temperature to correct facial lipoatrophy.2,3 The German maxillofacial surgeon Erich Lexer published a two-volume book in 1919 that devoted 300 pages to fat grafting for the treatment of various pathologies including facial trauma sequelae and hemifacial microsomia.4 Sir Harold Gillies described in 1920 the use of fat parcels for the reconstruction of facial wounds.5 However, the increasing evidence of fat reabsorption and oil cyst formation leading to unreliable, hard, and fibrotic tissue discouraged the popularization of this technique. Surgeons started relying on other filler products (e.g., silicone, paraffin, celluloid, gutta-percha, or rubber sponges) to fix facial contour abnormalities. Charles C. Miller was one of the first US cosmetic surgeons to describe the use some of these fillers to correct facial aesthetic defects like crow’s feet and nasolabial folds. He also described in 1926 infiltration of a piece of fat (harvested from the abdomen) into facial defects using a special screw piston syringe.6

A major milestone for fat grafting was the introduction of liposuction in the 1980s by Pierre Fournier7 and Yves Gerard Illouz.8 Liposuction not only allowed harvesting of adipose tissue in a safer and more minimally invasive manner but also allowed use of a fat product that was more liquid-like, making infiltration easier and more homogeneous. Despite this great innovation, fat graft survival remained a major issue due to the variable fat reabsorption rate. It was not until Sydney Coleman introduced his technique in 19949 that fat grafting became a more reliable and reproducible option to improve facial aesthetic defects. The key tenets of the Coleman technique are aspiration of small fat aliquots, processing of the fat using centrifugation, removal of unwanted components of the lipoaspirate (i.e., local anesthetic, oil, blood, and other noncellular material), and infiltration of the fat as small aliquots.9 Facial fat grafting is a very helpful tool in the reversal of facial aging. The youthful face appears fuller due to colloidal fluid held in place by a combination of hyaluronic acid, hormones, proteins, and other factors. With aging, these factors are gradually lost and the surrounding fullness disappears. In turn, the facial fat deposits (eyelids, cheeks, above the nasolabial folds, jowl) as well as underlying structures (e.g., submandibular glands and facial skeleton) become more prominent. These changes are further complimented by fat atrophy, loss of skin elasticity, and the gravitational descent of skin, muscle, and fat. González-Ulloa et al. have provided us with great insight on the effects of senility on fat atrophy as the primary factor in aging, and they encouraged plastic surgeons to find ways to reverse fat atrophy by means of facial augmentation.10 Rohrich and Pessa described the presence of deep and superficial facial fat compartments, and how aging is associated with loss of volume in these compartments.11 Coleman along with many others have advocated for facial fat grafting to reverse the signs of facial aging, restore the youthful contours of the face, and its intrinsic qualities of skin texture, elasticity, and color tone.11–13 Fat grafting allows us to address the atrophic changes caused by age in a minimally invasive, safe, effective,

560

SECTION II

CHAPTER 16  • Facial fat grafting

and long-lasting manner. This chapter examines the practical aspects involved in the decision-making and technique for facial rejuvenation using autologous fat grafting (Video 16.1 & Video Lecture 16.1 ).

Diagnosis/patient presentation A detailed history and physical examination should be performed. The first step is to understand the patient concerns and goals of the surgery. A clear explanation of the areas of the face that concerns them is paramount to understand if this problem should be tackled with fat grafting alone or other procedures (e.g., facelift) too. Patients should be asked about prior facial trauma, medical treatments, or surgical procedures. They should be asked about body mass index (BMI), nutritional status, weight fluctuations and plans for future weight loss. Relevant past medical history includes tobacco use status, prior history of infections, prior surgeries, adverse events to anesthesia, prior cosmetic medical or surgical procedures, previous miscarriages, and a personal or family history of venous thromboembolism or bleeding disorders. Of note, prior liposuction or fat grafting can have a major impact on the quality and amount of available adipose tissue. If multiple rounds of fat grafting are planned, the harvesting sites should be strategically planned. Allergies should be noted, including reactions to analgesics and lidocaine (usually part of the tumescent solution). A thorough medication history should be obtained to determine if the patient is on anticoagulant or antiplatelet therapy. After a general physical examination, the surgeon should focus on identifying good harvesting donor sites as well as conducting a thorough analysis of the face. Prior liposuction donor sites should be examined for amount of fat, contour deformities, skin quality and laxity. Facial analysis should be methodical, assessing for facial proportions, volume deficiencies and asymmetries, contour abnormalities, skin texture and quality. Special attention should be given to the temporal area, supraorbital area, malar region, nasolabial folds, lips, jawline, and neck. Fat atrophy will lead to skeletonization and hollowing of the face. The upper third is predominantly affected, while the mid and lower thirds predominantly demonstrate features of sagging. Blood vessels and muscles of facial expression become more visible, creating a frowning and scowling appearance with an increase in folds and lines in the forehead, glabellar, and periorbital regions. The combination of loss of fullness in the upper third of the face (forehead, temple, and brows) and loss of lateral support of the brow gives an illusion of brow ptosis and eyebrow shortening and lateral descent. Orbital and eyelid fat atrophy leads the eyes to become more deepset with increased prominence of the inferior orbital rim and a sunken look. This eventually leads to dermatochalasis, elongation of the lid–cheek junction, and deepening of the tear trough, nasolabial folds, and marionette lines. Malar fat pad atrophy leads to malar skeletonization and increased prominence of the zygomatic arches. Fat atrophy around the lips leads to the orbicularis oris becoming more in contact with the vermilion and mucosa, enhancing perioral wrinkling and deflation of the lips. Changes seen in the upper lip are more variable and include overall lip narrowing, loss of visible vermilion, inversion, increase in

maxillary incisor show, and window shade effect. Lower lip changes include deflation, inversion, flattening of the central pout, central depression loss, and increased mandibular incisor show. Lastly, fat atrophy and ptosis around the mandible creates a less-defined jawline and prominent jowls.

Patient selection There are few contraindications to fat grafting to the face and body. The first contraindication is true for all procedures, which is poor patient health prohibiting anesthesia. Small areas of fat grafting can often be performed under local anesthesia, but anything involving more than a few milliliters of fat usually requires sedation. In addition, patients with unrealistic expectations are not good candidates for this or any other procedure. A contraindication specific for fat grafting is the extremely thin patient who does not have sufficient fat for transfer. Since large volumes of fat are generally not needed for the face, enough fat can usually be harvested in all but the most anorexic patient or muscle-bound body builder. For fat grafting to the hands, breasts, or body, significantly more fat is usually needed, and often there is a limit as to the correction that can be made given the paucity of fat in some patients. Asking the patient to gain weight prior to the procedure only makes sense if the patient is willing and able to maintain that weight afterwards. In aging patients with a tremendous amount of loose, excess skin, fat grafting can be disappointing. These patients are either left with residual skin excess or if completely filled, may have an unusual appearance to their face. In these cases, it is usually advisable to first tighten the skin with a more traditional facelift and then to add volume with fat. The aging patient in Fig. 16.1 represents a typical patient that might present for a facelift. She is instead an excellent candidate for fat grafting to the face, particularly along the jawline and chin, where there is an apparent slight excess of skin secondary to deflation. The jowls and irregular jawline that are present and this degree of laxity in the neck can be improved significantly with fat grafting without any cutting or suspension techniques. By adding volume back into the face, the contours are improved and the skin is effectively tightened and lifted by radial expansion. Younger patients usually do not have as much facial atrophy and subsequent sagging of the skin, but the overall appearance of the face can be changed drastically with a shift in facial proportions. The patient in Fig. 16.2 is an example of how a more balanced upper and lower lip and more defined chin can make the face look more balanced and attractive. The patient in Fig. 16.3 is an example of a chin augmentation in a younger patient to improve the overall facial proportions. The patient in Fig. 16.4 is an example of an upper and lower lip augmentation. Filling the lips gives her a much softer appearance. Patients with more severe deformities such as those seen in Treacher Collins syndrome are excellent candidates for fat grafting. This is true despite the fact that the condition is complex, with both bony and soft-tissue abnormalities. The unusual facial contours present in Fig. 16.5 would be very difficult to address with anything other than fat, as different volumes can be tailored to the specific defects to create a more normal appearance.

Patient selection

A

561

B

Figure 16.1  (A) The patient preoperatively. (B) Rejuvenation of the jawline and neck was accomplished with placement of structural fat along the border of the mandible back to the angle of the mandible and forward into the chin. Significant augmentation of the lower lip also adds to her improved proportion and rejuvenation.

A

B

Figure 16.2  The patient (A) before and (B) 6 years after fat grafting to the lower face: 17 cc to chin; 12.5 cc to the left border of the mandible; and 8 cc to the lower lip. Please note that no fat was placed into the upper lip, so the size of the upper lip can be used as a meter to evaluate the degree of change present.

A

B

Figure 16.3 (A,B) This young woman presented for improved balance of her lower face; 5 cc of fat was placed into her anterior and inferior chin to elongate it. Note that the natural dimple was preserved.  

562

SECTION II

CHAPTER 16  • Facial fat grafting

B

A

Figure 16.4  This 50-year-old woman had fat grafting to her upper and lower lips in three stages to minimize the postoperative swelling. (A) The patient before and (B) 15 months after her last fat grafting procedure.

B

A

Figure 16.5  This 22-year-old woman presented after multiple reconstructive attempts at treating her Treacher Collins syndrome. (A) She presented with not only malproportion of her face, but also impending extrusion of hardware in her zygoma. (B) Diffuse fat grafting from the lateral lower eyelids extending out to the zygomatic arch not only reinforced the thin lateral eyelid skin, but also covered the obvious hardware visible through the thin cheek skin.

A

B

Figure 16.6  (A) This patient presented with idiopathic facial atrophy with the primary involvement on the left side of the face. At her first procedure, 13 cc was placed into the left cheek and 4 cc into the right. At the second procedure, an additional 12.2 cc was placed diffusely over the left cheek and nothing further was done on the right. (B) Shows the patient 15 months after the second procedure.

Patients with facial lipoatrophy are also excellent candidates for fat grafting, regardless of the cause of their disease process. Like Treacher Collins syndrome patients (see Fig.  16.5), these patients have specific soft-tissue defects,

making fat an ideal long-lasting filler. A temporary filler could theoretically be used in a patient such as this, but the volume of product that would be needed on a regular basis would likely be cost-prohibitive (Fig. 16.6).

Surgical technique

Surgical technique The authors use the Coleman fat grafting technique to enhance reliability and graft survival in the face. The key tenets of the technique are aspiration of small fat aliquots, processing of the fat using centrifugation, removal of unwanted components of the lipoaspirate (i.e., local anesthetic, oil, blood, and other non-cellular material), and infiltration of the fat as small aliquots.9

Preoperative markings The patient should be marked preoperatively in a methodical fashion:   Mark the harvesting area and highlight the area of greatest fat prominence   Highlight areas of donor site contour deformities   Mark the areas in the face that need fat grafting, highlighting the areas that require greatest infiltration amount   Highlight facial areas of hollowing, volume depletion, wrinkles, and folds   Highlight superficial blood vessels in the face

Patient positioning Positioning of the patient is based on the selection of the harvest site. Fat can be harvested from anywhere in the body. Furthermore, both animal and human studies have shown no benefit in a specific donor site. Rohrich et al. found no statistically significant differences in adipocyte viability of fat harvested from the abdomen, flank, thigh, and knee.14 Li et al. found no differences in weight, volume, and histologic parameters of fat harvested from upper abdomen, lower abdomen, flank, lateral thigh and inner thigh, and injected in nude mice.15 Similarly, Small et al. demonstrated no difference in volume retention comparing fat harvested from the thighs or abdomen.16 For these reasons, the donor site is selected based on the location where the most fat is available, ease of access, safety, surgeon preference, and patient preference. In the majority of facial fat grafting cases, patients will be positioned supine to provide easy access to the face, abdomen, flanks and thighs. The face and donor sites are then prepared with povidone-iodine and the patient is draped in a sterile fashion.

Harvesting Fat harvesting can be performed under local (with or without nerve block) or general anesthesia based on patient preference and volume of fat required. As one might expect, larger volumes are usually performed under general anesthesia. Small 2 mm incisions are hidden within skin creases, stretch marks, previous scars, or the umbilicus. A Lamis blunt infiltration cannula (Mentor Worldwide LLC, Santa Barbara, CA) is used to infiltrate the solution. For cases under general anesthesia or intravenous sedation, the infiltration solution consists of lactated Ringer solution with added 0.5% lidocaine with epinephrine 1:200,000. For cases under local anesthesia, the

563

infiltration solution consists of 0.5% lidocaine with 1:200,000 epinephrine buffered with sodium bicarbonate (without lactated Ringer solution), and often diluted to half the strength to provide a larger volume while maintaining patient comfort and safety. The solution is left in place for 10 minutes prior to fat harvesting to optimize the vasoconstrictive effect. A blunt-tip nine-hole harvesting cannula (12- or 14-gauge, 15 or 23 cm long, depending on the volume needed) with a Luer-lock attached to a 10 mL syringe is then used to suction the fat. A blunt-tip cannula is preferred because it helps to minimize trauma to the tissues and anchor the fat parcels. The cannula is pulled back and forth in a gentle motion while pulling back on the syringe plunger 1–2.5 mL to create enough negative pressure to harvest the fat, while avoiding excessive pressure that could rupture fat cells. For larger harvesting volumes the authors use the Wells-Johnson Hercules Aspirator Liposuction machine to maximize efficiency. Upon completion of the harvest, the incisions are closed with interrupted absorbable sutures. Common pitfalls of this process include harvesting in the superficial plane, leading to contour deformities, and the use of dry liposuction, leading to excessive bleeding.

Refinement As part of the Coleman technique, the authors utilize centrifugation as a refinement technique. The 10 mL syringes filled with lipoaspirate are capped using a Luer-Lok cap (Becton, Dickinson and Company, Franklin Lakes, NJ) and the plunger is removed. The syringes are placed in a centrifuge and spun at 1286 g for 2 minutes to separate the components of the lipoaspirate. The centrifugation process creates three layers: top supernatant layer contains oil; the middle layer contains purified adipose tissue; and the bottom aqueous layer contains blood and infiltrate solution. The bottom layer is drained by removing the cap. The top oil layer is treated with Codman neuropads (Codman Neuro, Raynham, MA) to wick the excess oil after manually decanting it. The refined fat graft is then transferred to 1 mL syringes ready to be infiltrated. These 1 mL syringes are grouped into high-, intermediate-, and low-density fat because studies have ­ shown that high-density fat graft has better survival than low-density fat graft.17 Thus, higher-density fat graft infiltration should be prioritized.

Infiltration The planned entry points for infiltration are anesthetized with 0.5% lidocaine with epinephrine 1:200,000. Entry points are based on the areas that require improvement. Common sites include the alar base to access the cheek compartments, temporal hairline to access the temporal region, central forehead hairline to access the glabellar area and superior brow, and oral commissure to access the perioral region. Small incisions are made through the skin with an 18-gauge needle or a No. 11 blade. A small volume of 0.5% lidocaine with epinephrine 1:200,000 is then infused into graft sites for anesthesia and local vasoconstriction. Decanted oil from the process can be used to lubricate the incision sites prior to infiltration. The goal of the infiltration process is to maximize the contact surface area between fat parcels and the recipient tissue, to encourage successful neovascularization of the graft. For

564

SECTION II

CHAPTER 16  • Facial fat grafting

Table 16.1  Coleman cannulas used by the authors in facial fat grafting Coleman type I cannula

Completely capped on the tip with a lip extending 180° over the distal aperture. This is the workhorse cannula for most facial fat grafting because it reduces the risk of iatrogenic traumatic injury to underlying structures.

Coleman type II cannula

Similar to type I but it is partially capped. It has a lip extending over the distal aperture approximately 130–150°. This cannula is useful in the majority of situations, but it is a little more traumatic.

Coleman type III cannula

Flat end (not capped) allowing dissection of tissues in cases of fibrotic tissue or old scars, or when subdermal infiltration is needed.

Coleman V-dissector and W-dissector

Sharper cannulas used to release adhesions. Caution is needed to avoid injury to nerves and vessels.

this reason, smaller parcels are infiltrated in layers while the cannula is being withdrawn – usually no more than 0.1 cc (0.1 mL) per pass. To aid in the mission, adequate cannula selection is key. The authors use smaller-gauge (21-gauge) and shorter-length (3–7 cm) Coleman cannulas for facial fat grafting, which consist of three blunt-tipped cannulas as well as W- or V-dissectors (Mentor, Irvine, CA). See Table 16.1 for more details about the types of cannulas used in facial fat grafting. Large fat parcel transfer is at risk of complications such as fat necrosis, oil cysts, and fat resorption. The fat should be injected evenly using multiple passes at different depths and difference trajectories. Avoid putting pressure and molding the fat because of the risk of injury to the adipocytes, leading to fat necrosis and resorption. Fat grafting to lead to facial symmetry and harmony and thus constant analysis and assessment with the contralateral side is essential. The operator should always be aware of the location of the cannula tip to avoid injuries to vital structures. Fat can be injected in the intradermal or subdermal layer to improve wrinkles and skin quality, however, caution should be taken to avoid contour irregularities; it can be injected in the subcutaneous layer to restore soft-tissue volume and re-establish facial proportions; lastly, fat can be injected in the supraperiosteal layer (e.g., mandible or malar region) to change how the soft-tissue envelope drapes over the bony structure of the face. The upper eyelid can be accessed through midforehead, far medial and lateral brow incisions, whereas the lower eyelid can be accessed through lateral eyebrow, lateral inferior temple and midmalar incisions. Our preference is to stay superficial at all times in the subdermal or intra-orbicularis oculi muscle planes, and utilize crosshatching to improve the quality and stability of the structural placement of the fat. Feathering in the lateral eyelid transition zone is needed to avoid an abrupt deepening of the wrinkles in that area (e.g., crow’s feet). Volumes required in the eyelids vary based on age and gender. Younger patients tend to require less than 2 cc in the upper eyelids and 1–3 cc in the lower eyelid, whereas older patients have greater skeletonization and volume depletion, thus needing volumes as high as 5 cc. Fat grafting to the lower eyelids helps resolve the volume depletion, darkened color and texture caused by the thinned skin, which leads to easier visualization of the underlying orbicularis oculi muscle and blood vessels. Eyelids swell quickly, compromising the ability to determine areas of volume deficiency by visual and tactile assessment alike. Rarely, excess fat survives or is injected, and after giving time to settle, one can address these issues by either liposuctioning and smoothing the contour

with small aliquots of fat grafting, or performing direct excision (however, this is more traumatic). Lips infiltration can be performed through commissure (most frequently), midmalar and lateral chin incisions. Infiltration is preferred into the most superficial layer of the lips, just deep to the mucosa and the vermillion. The authors start by enhancing the white roll of the upper lip with 0.75–1.25 cc through a single pass of a cannula; a similar approach is used for the lower lip. Next, oblong protuberances are created on each side of the lower lip just lateral to the midline of the lip, creating a central deficiency which can then be smoothened based on preference. The upper central lip is then inflated with 1.5–4 cc followed by mild smoothening of the lateral one-fifth of the lip. The key is to avoid shaping the lip like a sausage and to maintain a youthful shape. The philtrum can be tackled by either doing a sharp angle during the white roll injection, or one can create separate central injection incisions directly in the vermillion to inject from the philtral columns to the philtrum. Lastly, marionette lines and nasolabial folds can be tackled through midmalar, lateral chin, and commissure incisions. Infiltration is layered from the subcutaneous to submucosal levels and volume varies depending on the severity of the folds: 2–10 cc for nasolabial folds, and 1–3 cc for marionette grooves. Once satisfied with the injected volume and contour, the facial incisions are sutured with interrupted 5-0 absorbable sutures and then infiltrated with 0.2–0.3 cc of concentrated fat using a 22-gauge needle to aid the healing process of the incisions. Whereas the donor site incisions are closed with buried deep dermal 3-0 absorbable sutures.

Postoperative care Patents should intermittently apply cool (but not ice-cold) compresses to the face to reduce ecchymosis and swelling. Patients should rest with the head elevated at 45°. No facial dressings are used. Caution should be used when wearing glasses to avoid compression at the graft site. Deep massage of the face should be avoided for at least 3 months because it can cause fat migration and necrosis. However, light touch can be performed to encourage lymphatic migration. The donor site should be dressed with foam and compressive garments to reduce the risk of seroma and hematoma formation. Patients should avoid exercise for 2-4 weeks. Although most facial fat grafting procedures are usually conducted as an outpatient procedure, patients may need to be monitored overnight if concomitant procedures are performed or if there are any concerns intra/postoperatively (Table 16.2).

Nanofat, platelet-rich plasma, platelet-rich fibrin, and concentrated growth factors

Table 16.2  Preoperative and postoperative patient’s instruction list Preoperative care • • • •

Consider obtaining medical evaluation and clearence Plan work and recovery arrangements Advise smoking cessation 4 weeks prior to surgery Avoid foods, drinks, and herbal supplements that can increase risk of bleeding and bruising. Avoid aspirin, ibuprofen, naproxen, motrin, blood thinners, vitamin E, omega-3, fish oil, and alcohol • Avoid lotions, perfumes, hair products, etc., the day prior to surgery • Nil by mouth after midnight • On the day of surgery avoid wearing jewelry, piercings, make-up, lotions, contact lenses, hair products, deodorant, sunscreen Postoperative care • Rest with the head elevated at 45° • Apply intermittent cool (but not ice-cold) compresses to the face to reduce ecchymosis and swelling • Dress donor site with foam and compressive garments • Avoid pressure or trauma to the face. Caution when wearing glasses to avoid compression at the graft site • Avoid facial dressings • Avoid deep massage of the face for at least 3 months • Avoid exercise for 2–4 weeks

Outcomes, prognosis, and complications Fat grafting can help reverse the aging effects on the face and improve facial contour, symmetry, and aesthetics. Outcomes can be optimized by using a standardized harvesting, refinement and infiltration technique. The Coleman technique offers a reliable method to improve fat graft retention rates. which have been quoted as high as 90%.18 Facial fat grafting is usually well tolerated and safe. Complications are rare and, if they do occur, they are minor in nature and often related to the cosmetic result. These include contour irregularities, fat resorption, overcorrection, undercorrection, and fat graft migration. Multiple rounds of fat grafting might be needed to achieve the desired results. Contour irregularities may present as lumps or divots, which can occur if the injection pattern is not homogeneous, too superficial, and large aliquots are infiltrated. Fat graft migration may occur in areas of great mobility such as the perioral or glabellar regions. Thus the patient should be cautioned not to overuse facial expression muscles postoperatively. Very rarely, major complications occur, including infection, injury to deeper structure, and fat embolization. Infections may originate from mucosal or skin flora, contaminated equipment, or accidental foreign body retention. To minimize this risk, surgeons should consider using chlorhexidine gluconate scrub prior to the prep solution of choice, and should avoid using woven cotton sponges during the refinement process because microfibers can get trapped within the lipoaspirate (hence the use of neuropads instead). Another major concern is the injury to structure underlying the donor and recipient sites. Fat can be harvested from all over the body

565

but most frequently from the abdomen, flanks, and thighs. The harvesting liposuction cannula is at risk of damaging important structures like nerve, vessels and muscle, as well as the potential for intra-abdominal injury. For safety reasons, we recommend using a blunt-tip, mid- to large-gauge cannula and harvest tissue above muscle fascia. Facial anatomy is very complex and a good anatomical foundation is needed prior to injecting fat in this region. Injury to muscle, nerve, and vessels can lead to pain, ecchymosis, hematomas, temporary motor or sensory nerve injury. Lastly, the most severe complication is fat embolization leading to strokes or blindness due to retrograde flow into the internal carotid or ophthalmic artery. Great care should be taken when infiltrating fat in the face and some safety measures can be taken. The tip of the cannulas should be blunt because sharp cannulas are more likely to perforate vessels; the infiltration should consist of small volumes injected with each pass to avoid a continuous column of graft accumulating in the ophthalmic or internal carotid arteries; and lastly, surgeons should have a good knowledge of facial anatomy to avoid injury to major vessels.

Nanofat, platelet-rich plasma, plateletrich fibrin, and concentrated growth factors Fat grafting has evolved through the years. Nanofat has emerged in 2013 as an evolutionary technique to harvest microfat by mechanical emulsification.19 The emulsification process entails various steps: first, vigorous shifting (approximately 30 passes) of the microfat from a full 10 mL syringe to an empty one through a 2.4 mm female-to-female Luer-Lok connector (Tulip Medical, San Diego, CA); second, a repeated 30 passes using a smaller 1.2 mm female-to-female Luer-Lok connector (Tulip Medical, San Diego, CA); third, the processed fat is then passed through a double 400 or 600 μm filter (Tulip Medical, San Diego, CA) to remove connective tissue remnants. Nanofat has been described as being infiltrated into recipient tissue either as an isolated agent or in combination with other techniques such as microneedling, which facilitates the delivery of nanofat into the papillary dermis level.20,21 Nanofat has been demonstrated to assist facial rejuvenation by a reduction of rhytides and enhancement of skin texture.21 With greater understanding of fat grafting, various techniques have been attempted to promote rapid neovascularization of fat grafts, which in turn enhance fat grafting volume retention. Autologous platelet products have been investigated and these include platelet-rich plasma (PRP), platelet-rich fibrin (PRF), and concentrated growth factor (CGF). PRP is derived from anticoagulated whole blood through double-spin centrifugation. Mixed fat grafting-PRP infiltration has shown improved neovascularization and graft retention in preclinical studies,22 but clinical data remain controversial about the true clinical benefits of this technique with clinical trials not demonstrating improvement in skin elasticity and graft volume maintenance.23 PRF is a new type of platelet concentrate that can be obtained in a single centrifugation step at 3000 rpm for 10 minutes and then cut into 1 mm3 pieces, which are then mixed with the prepared fat at a ratio of 1 : 2. This three-­ dimensional fibrin structure contains concentrated platelets

566

SECTION II

CHAPTER 16  • Facial fat grafting

and growth factors, which are believed to cause a gradual release of angiogenic growth factors and cytokines. Animal studies comparing PRP and PRF have shown that PRF mixed fat grafting increases blood vessel density, volume retention, and quality of the graft.24,25 CGF is a product that concentrates a large number of growth factors and CD34 stem cells in small volume of plasma. This preparation is produced by means of a commercially available CGF centrifuge, which produces four layers: first, superior serum layer; second, buffy coat layer; third, growth factor and stem cell layer; fourth, lower red blood cell layer. The CGF layer is then isolated and mixed with the fat graft. Studies have shown that fat graft mixed with CGF leads to improved vascularity, fibrosis, and fat graft weight compared to PRP and PRF.26

Access the reference list online at   Elsevier eBooks+

Conclusion Fat grafting has greatly evolved over the past century and has proven to be a powerful and reliable tool to reverse the signs of aging and improve the aesthetic harmony of the face. Here we have outlined the authors’ preferred technique to harvest, refine, and infiltrate fat graft for facial contouring and highlighted the possible complications and importance of preventive measures to ensure patient safety remains the priority. The ability to improve the facial aesthetics and skin quality with a minimally invasive technique like fat grafting has revolutionized the management of aesthetic patients and should be in every plastic surgeon’s armamentarium.

References

References 1. Neuber GA. Fetttransplantation. Chir Kongr Verhandl Deutsche Gesellsch Chir. 1893;22:66. 2. Holländer E. Über einen Fall von fortschreitenden Schwund des Fettgewebes und seinen kosmetischen Ersatz durch Menschenfett. Münch Med Wochenschr. 1910;57:1794–1795. 3. Holländer E. Die kosmetische Chirurgie. In: Joseph M, ed. Handbuch der Kosmetik. Leipzig: von Veit; 1912:689–690. 708. 4. Lexer E. Die freien Transplantationen. Stuttgart: Enke; 1919–1924. 5. Gillies HD. Plastic Surgery of the Face. London: Frowde, Hodder, Stoughton; 1920. 6. Miller CC. Cannula Implants and Review of Implantation Technics in Esthetic Surgery. Chicago: Oak Press; 1926:25–30 66–71. 7. Fournier PF. Microlipoextraction et microlipoinjection. Rev Cir Esthét Langue. 1985;10:36–40. 8. Illouz YG. The fat cell “graft”: a new technique to fill depressions. Plast Reconstr Surg. 1986;78:122–123. 9. Coleman SR. The technique of periorbital lipoinfiltration. Oper Techn Plast Surg. 1994;1:120–126. 10. González-Ulloa M, Flores ES. Senility of the face – basic study to understand its causes and effects. Plast Reconstr Surg. 1965;36:239–246. 11. Rohrich RJ, Pessa JE. The fat compartments of the face: anatomy and clinical implications for cosmetic surgery. Plast Reconstr Surg. 2007;119(7):2219–2227. 12. Coleman SR, Katzel EB. Fat grafting for facial filling and regeneration. Clin Plast Surg. 2015;42(2015):389–394. 13. Egro FM, Coleman SR. Facial fat grafting: the past, present, and future. Clin Plast Surg. 2020;47(1):1–6. 14. Rohrich RJ, Sorokin ES, Brown SA. In search of improved fat transfer viability: a quantitative analysis of the role of centrifugation and harvest site. Plast Reconstr Surg. 2004;113(1): 391–395. discussion 396–397. 15. Li K, Gao J, Zhang Z, et al. Selection of donor site for fat grafting and cell isolation. Aesthetic Plast Surg. 2013;37(1):153–158.

566.e1

16. Small K, Choi M, Petruolo O, Lee C, Karp N. Is there an ideal donor site of fat for secondary breast reconstruction? Aesthet Surg J. 2014;34(4):545–550. 17. Allen Jr RJ, Canizares Jr O, Scharf C, et al. Grading lipoaspirate: is there an optimal density for fat grafting? Plast Reconstr Surg. 2013;131(1):38–45. 18. Parrish JN, Metzinger SE. Autogenous fat grafting and breast augmentation: a review of the literature. Aesthet Surg J. 2010;30(4):549–556. 19. Tonnard P, Verpaele A, Peeters G, Hamdi M, Cornelissen M, Declerq H. Nanofat grafting: basic research and clinical applications. Plast Reconstr Surg. 2013;132(4):1017–1026. 20. Tonnard P, Verpaele A, Carvas M. Fat grafting for facial rejuvenation with nanofat grafts. Clin Plast Surg. 2020;47(1):53–62. 21. Verpaele A, Tonnard P, Jeganathan C, Ramaut L. Nanofat needling: a novel method for uniform delivery of adipose-derived stromal vascular fraction into the skin. Plast Reconstr Surg. 2019;143(4):1062–1065. 22. Seyhan N, Alhan D, Ugur Ural A, Gunal A, Cihad Avunduk M, Savaci N. The effect of combined use of platelet-rich plasma and adipose-derived stem cells on fat graft survival. Ann Plast Surg. 2015;74(5):615–620. 23. Willemsen JCN, Van Dongen J, Spiekman M, et al. The addition of platelet-rich plasma to facial lipofilling: a double-blind, placebocontrolled, randomized trial. Plast Reconstr Surg. 2018;141(2):331–343. 24. Xiong S, Qiu L, Su Y, Zheng H, Yi C. Platelet-rich plasma and platelet-rich fibrin enhance the outcomes of fat grafting: a comparative study. Plast Reconstr Surg. 2019;143(6):1201e–1212e. 25. Keyhan SO. Use of platelet-rich fibrin and platelet-rich plasma in combination with fat graft: which is more effective during facial lipostructure? J Oral Maxillofac Surg. 2013;71(3):610–621. 26. Hu Y, Jiang Y, Wang M, Tian W, Wang H. Concentrated growth factor enhanced fat graft survival: a comparative study. Dermatol Surg. 2018;44(7):976–984.

SECTION II  •  Aesthetic Surgery of the Face

17 Editors’ perspective: nose Alan Matarasso

Nose surgery is often considered the most complex aesthetic surgery operation. It represents the epitome of aesthetic surgery operations and surgeons. Separate societies and meetings exist in order to educate plastic surgeons about rhinoplasty. Indeed, no aesthetic operation other than the nose has the numerous anatomic nuances that are encountered or the intricate form and function relationships, the terminology, the complex analysis of cosmetic and airway issues, or the cause-and-effect consequences that occur both immediately and delayed. Moreover, the nose often represents the defining characteristic of a patient’s facial features. So, when surgery is performed, often at a young age, it is something that the patient lives with for the rest of their life. We recognize that all elective plastic surgery carries a heavy burden due to operating on a healthy patient for non-essential indications and reaching for a subjective ‘perfect’ result. That onus only increases in nasal surgery. Every operation begins with understanding the anatomy involved, the ideal goals and then how to achieve them. In nose surgery the functional and aesthetic components need to be recognized, reconciled, and mastered. Proponents of different methods have advocated for: open versus closed, the order of steps in the procedure, the types of sources of grafts or reshaping sutures used, whether to pack the nose or not, the postoperative management and so on. Surgeons frequently achieve satisfactory outcomes when using different techniques. Over the years as nasal surgery has become increasingly refined, it has been firmly established that aggressive cartilage reduction techniques that we witnessed in the 1970s and 1980s are to be avoided, thereby preserving more native cartilage, adding cartilage grafts as indicated, and incorporating suture reshaping techniques. While every nose operation is subtly different,

there are fundamental maneuvers that are appropriate for many primary, non-traumatic rhinoplasties that surgeons can master and that serve as a template. Recently, a renewed consideration has been on ‘dorsal preservation rhinoplasty’, a method which preserves the intrinsic shape of the dorsum and is sometimes performed using piezoelectric equipment to assist in the pushdown of the nasal pyramid. Also, the role of non-surgical injections and filler techniques have been elucidated as a modality for primary and secondary nasal improvement. Throughout these textbooks we have benefited from the knowledge, hard-earned perspective, wisdom, and experience of seasoned expert surgeons. Rarely is anything totally invented de novo; more often, medicine and surgery builds upon prior knowledge, making incremental advances. Rhinoplasty is a prime example of the subtle nuances that advance a technique to improved outcomes. In addition to the expert technical knowledge proffered in these chapters is the considerable, invaluable patient management advice submitted. For example, rhinoplasty swelling is a well-known occurrence that takes a lengthy time to resolve. Managing a patient throughout that period, when they cannot avoid observing and judging their results or obsessing over it frequently, can sabotage even the best results. Sage advice from these authors about adjunctive use of tape, splints, and injections can make the difference between a happy patient with a good result or an unhappy patient with a good result. The astute reader will glean a career’s worth of advice in these chapters that their own trial and error could not have withstood in daily practice, from the most expert and experienced rhinoplasty surgeons.

 

SECTION II •  Aesthetic Surgery of the Face

18 Nasal analysis and anatomy Rod J. Rohrich, and Paul N. Afrooz

  Access video lecture content for this chapter online at Elsevier eBooks+

SYNOPSIS

ƒ Surgery begins with a careful preoperative analysis utilizing standardized measurements. ƒ All tissues including bone, cartilage, and soft tissue may contribute to any one measurement, e.g., nasal length. ƒ Nasal anatomy is considered within the context of facial shape, facial proportions, and the size and shape of adjacent structures. ƒ Knowledge of nasal anatomy facilitates the use of an algorithmic approach to surgery that increases the predictability of surgery. ƒ A knowledge of blood supply increases the safety of the open approach to rhinoplasty. ƒ Most nasal problems can be analyzed by the component structures and their relationship to one another.

Introduction A thorough understanding of nasal anatomy enables the practitioner to accurately perform reconstructive and aesthetic rhinoplasty.1 Rhinoplasty is recognized as one of the most difficult procedures in plastic surgery, and accomplishing predicable results is a challenging task for the surgeon. A discussion of nasal anatomy begins with a description of the terms commonly used. These terms are the language that describes nasal anatomy, shape, and form. Surgery begins with a careful preoperative analysis utilizing standardized measurements (Video Lecture 18.1 ). One must accurately describe the deformity in order to establish an operative goal. Suboptimal results often occur as a direct result of failure to recognize one or more features prior to surgery.2 All tissues including bone, cartilage, and soft tissue may contribute to any one measurement, e.g., nasal length. This is the main reason that understanding nasal anatomy is so

critical to the performance of successful rhinoplasty surgery. Most nasal issues can be analyzed by individual components and their relationship to one another.3 Nasal anatomy is considered within the context of facial shape, facial proportions, and the size and shape of adjacent structures.4 The size and position of the chin, facial width, and facial height are examples of factors that may influence the operative goal. A basic knowledge of blood supply increases the safety of the open approach to rhinoplasty. This information is also important to avoid injury to the angular artery during external percutaneous osteotomies, and to avoid inadvertent intravascular injections.5 Knowledge of nasal anatomy combined with the ability to preoperatively analyze the nose facilitates the use of an algorithmic approach to surgery that increases the predictability of surgery. The nose is described employing a standardized terminology (Fig. 18.1). These terms allow standardized measurements to be defined (Fig. 18.2). The nasolabial angle gives an approximation of tip rotation relative to the Frankfort horizontal plane, drawn through the external auditory canal to the orbital rim. The nasofrontal angle is defined from the glabella to radix to nasal tip. Ranges exist for these measurements and vary according to gender (Fig. 18.3). The normative range for tip projection, the distance from the alar crease to the nasal tip, is calculated in three ways and described later in the text. The tip-defining points seen on anterior view are located where the lateral crura begin to diverge. The crura themselves consist of three sections or parts, each with its own curvature. The pyriform aperture, best visualized on basal view, corresponds with the bony aperture of the maxilla along the inferior nasal passage (Fig. 18.4). The algorithm for preoperative assessment follows that previously described.1 First, the relationship of the nose to the face is analyzed. The nose is thus considered in the context of overall facial proportions for precise analysis. A simple technique for understanding facial proportions is the fractal technique of thirds: the upper, middle, and lower face vertical heights are considered to be equal thirds. The lower

Introduction

Radix

Keystone area

Dorsal hump

Figure 18.1  Standardized terminology of external nasal landmarks exists, which facilitates a discussion of proportionate and disproportionate nasal aesthetics. These landmarks, essentially reference points of nasal topography, often relate directly to the shape and relationship of underlying structures.

569

Supratip

Scroll area

Tip

Alar groove

Nasal dorsum

Alar groove

Infratip lobule

Lobule Nostril sill

Columella

Alar cheek groove

Nostril rim Nostril sill

Nasofrontal angle Horizontal facial plane

Columellar– labial angle Nasolabial angle

Figure 18.2  Angular measurements assess multiple factors, such as nasal length, alar base position, and lip aesthetics.

Nasal length Cephalic border Nasal tip

Figure 18.3  Tip projection, a critical measurement in preoperative analysis, is defined as the maximal distance from alar base to the nasal tip.

Tip projection

Tipdefining points

Weak triangle

Columellar lobular angle

face is the distance from the alar base to the chin (menton). This is further divided into thirds with the distance from the alar base to lip crease (stomion) being one-third of this height. Frontal view allows nasal length to be analyzed relative to lower facial proportions. One measurement suggests that the distance from radix to tip-defining points is equal to the distance from stomion to menton (Fig. 18.5). The nose is viewed from the frontal view (Fig. 18.6). A line drawn from the glabella, radix through the middle lip and

Soft triangle

Caudal border lower lateral cartilage

chin helps to assess nasal deviation. The vertical line drawn from the radix to the midline lip and chin analyzes several structures. It helps to determine septal deviation, the position of the nasal bones and upper vault, and points out asymmetries of the lower lateral cartilages.6 The dorsal aesthetic lines are determined by a line drawn from the medial brow to the tip-defining points and should be two gently diverging curves. These can be judged relative to vertical lines drawn from the medial brows through the lateral nostril (Fig. 18.7).

570

SECTION II

CHAPTER 18  • Nasal analysis and anatomy

Medial crus

Lateral crus Medial crus

Figure 18.4  The lower lateral cartilages, comprising the lower third nasal vault, have three defined segments. These segments are determined by where the lower lateral cartilages display marked changes in curvature.

R

T S

M

Figure 18.5  General guidelines exist to assess nasal aesthetics in relation to the rest of the face. One guideline suggests that nasal length is equal to lower facial height. M, Menton; R, radix; S, stomium; T, tip.

The distance between the alar bases is approximately equal to intercanthal width. Alar shape is analyzed on frontal view and has a gull wing-shaped curve, defined by the curvature of the lateral and middle crura (Figs. 18.8 & 18.9). The lateral view is then reviewed. As with the frontal view, the nose is analyzed in the context of position and facial proportions (Fig. 18.10). On lateral view, the alar base should lie slightly anterior to the medial canthus. The upper lip is slightly anterior to the lower lip; the lower lip is slightly anterior to the chin. This analysis can reveal micro- or macrogenia, as well as skeletal disharmonies, including maxillary retrusion with a retrodisplaced alar base. The nose itself is analyzed in lateral view beginning with the position and depth of the nasal root at the nasofrontal angle (radix). The radix lies at a point between the lash line and supratarsal crease with the eyes in horizontal gaze. The

Figure 18.6  A line drawn from midline glabella to menton helps to assess nasal symmetry. This simple method is one of the best means to analyze septal deviation and the position of the nasal bones. It also emphasizes asymmetries of the maxilla or mandible.

depth of the radix, or the nasion–medial canthal distance, is approximately 15 mm. The radix is an important point that helps to define the nasofrontal angle, defined as the angle formed by the frontal bone and a line drawn parallel to the nasal bone. If the naso­ frontal angle is positioned more anteriorly or superiorly than normal, the nose appears elongated, and the tip projection will appear less, while if the nasofrontal angle is more posterior and inferior than normal, the nose will look shorter, and the tip will appear to project more. The radix forms the cephalic end for the measurement of nasal length, which is the distance from the radix to the nasal tip. Normally, nasal length is equal to the distance from stomion to menton (Fig. 18.11). The nasal dorsum is then analyzed. Ideally, the nasal dorsum lies slightly behind a line drawn from the radix to the nasal tip, more so in females than in males. The supratip break occurs cephalad to the tip-defining points and 2–3 mm behind the line from radix to nasal tip in women (Fig. 18.12). A slightly lower value is more desirable in males. The nasolabial angle is then assessed. It is formed by a line drawn through the anterior and posterior ends of the nostril and the vertical facial plane. The nasolabial angle is usually 95–100° in females and 90–95° in males (Fig. 18.13). This is slightly different than the columellar–labial angle, which is formed by the columella and the upper lip, an angle that is often influenced by a prominent caudal septum, which gives the impression of increased tip rotation despite a normal nasolabial angle. Another determinant of tip rotation is the columellar– lobular angle, formed at the junction of the columella and the infratip lobule. The columellar–lobular angle represents the

Blood supply

571

Figure 18.7  The dorsal aesthetic lines should be a gentle curve from brow to tip.

Nasal horizontal Frontal plane

Figure 18.8  For measurements, especially angular values, to be reproducible, head position is standardized. Here the Frankfort horizontal is shown: the line from the external auditory canal to the orbital rim is parallel to the horizon.

junction between the middle and medial crura. The ideal columellar–lobular angle is 30–45° in females. The relationship between the ala and columella is then assessed. A line drawn through the long axis of the nostril should bisect the oval formed by the nostril in lateral view (Fig. 18.14). A greater distance below the long axis may indicate a hanging columella, and a greater distance above the long axis may indicate retracted ala. This issue is reviewed more thoroughly in Chapter 19.

Tip projection is then assessed. Tip projection is defined as the distance from alar base to the nasal tip (see Fig. 18.13). If 50–60% of the tip lies anterior to the vertical line adjacent to the most projecting part of the upper lip, tip projection is considered normal. If it is >60%, the tip may be overprojected. Inadequate tip projection is suggested by a value 2mm: Spreader Grafts; Unilateral, bilateral, symmetrical, asymmetrical

Dorsal Reduction < 2mm: No Spreader Grafts

CLOSE ALL EXCEPT ONE INTERCARTILAGINOUS INCISION

RADIX, DORSAL, OR TIP GRAFT PLACEMENT AS NEEDED

Flow chart for planning rhinoplasty steps: dorsum high relative to lower third. Diagnose: low radix/low dorsum, tip projection, narrow middle vault (internal valvular competence), malposition (external valvular competence).

Prioritizing the septal graft specimen for augmentation

Algorithm 20.1B—Cont’d

Radix Low for Base Size:

Radix Good Height for Base Size: No Radix Graft

Radix Graft, Fit to the defect: Best graft on top, other shorter layers as needed Alar Walls Unsupported

Supported

Alar Wall Grafts, Unilateral or Bilateral as needed, Filling the Unsupported Skin ; Simulate normal lateral crural contour Tip

Projecting

Inadequately Projecting

Tip Grafts, always multiple, texture and number suited to the patient’s aesthetic goals and soft-tissue cover Close All Remaining Incisions

Nostrils Normal

Nostrils Still Too Large (Recall that Tip Grafts alter nostril / tip lobular proportion)

Alar Wedge Resections, External only or External / Vestibular Skin

Bony Vault

Bony Vault Wider than Middle Vault

Bony Vault Narrower than Middle Vault

Osteotomies, Unilateral or Bilateral to Narrow a Wide Bony Vault

Packs and Splint

629

630

SECTION II

CHAPTER 20  • Closed technique rhinoplasty

to splint the septum in the midline as much as possible and an onlay dorsal graft to hide remaining asymmetries. After spreader grafts are placed, caudal slippage can be avoided by a single 4-0 plain catgut transfixing suture placed at the septal angle. The surgeon can count on the functional improvement that they impart.

Lateral wall and columellar grafts Cartilage provides the ideal lateral wall graft for asymmetry, split tangentially or crushed to fit the defect. Where sufficient cartilage is unavailable, ethmoid will correct asymmetries in the deviated nose. When the dorsum has been raised several millimeters, lateral wall grafts are often necessary to

Algorithm 20.2A Dorsum Low Relative to Lower Third Intercartilaginous Incision(s) Skeletonization

Nose Normal Length: Narrow over bony, upper vaults

Nose Long: Narrow over bony vault, Wide over middle vault

Dorsal Rasping For Adherence If Dorsal Graft Planned

Transfixing Incision: No, Nasal Length Good Length

Transfixing Incision: Yes, Nose Long

Shorten Caudal. Membranous Septum ± Upper Lateral Cartilage Caudal Margins

Alar Cartilage Modification

Lateral Crura Orthotopic: Do Nothing or Retrograde Resection, 2-3 mm

If Tip Lobule Is Large, Nostril Small: Footplate Resection Spreader Graft Tunnels If Independently Needed (e.g., Dorsal Augmentation < 2 mm)

Lateral Crura Cephalically Rotated: 1.Do nothing, 2.Retrograde Resection, 2-3 mm, 3.Transpose Lateral Crura, or Resect and Replace

Septoplasty / Harvest Ear, Rib Cartilage, Calvarial Bone

RESECTIONS, GRAFT HARVESTING DONE: GRAFT PLACEMENT Dorsal Augmentation < 2mm: Spreader Grafts; Unilateral, bilateral, symmetrical, asymmetrical

Dorsal Augmentation > 2mm: No Spreader Grafts

CLOSE ALL EXCEPT ONE INTERCARTILAGINOUS INCISION

GRAFT PLACEMENT AS NEEDED

Flow chart for planning rhinoplasty steps: dorsum low relative to lower third. Diagnose: low radix/low dorsum, tip projection, narrow middle vault (internal valvular competence), malposition (external valvular competence).

Prioritizing the septal graft specimen for augmentation

Algorithm 20.2B—Cont’d Dorsum Low for Base Size: Dorsal Graft

Dorsum Good Height for Base Size: No Dorsal Graft

Dorsal Graft, Fit to the defect: Best graft on top, cartilage underfill as needed

Alar Walls Supported

Unsupported

Alar Wall Grafts, Unilateral or Bilateral as needed, Filling the Unsupported Skin

Tip

Projecting

Inadequately Projecting

Tip Grafts, always multiple, texture and number suited to the patient’s aesthetic goals and soft-tissue cover

Close All Remaining Incisions

Nostrils Normal

Nostrils Still Too Large (Recall that Tip Grafts alter nostril / tip lobular proportion)

Alar Wedge Resections, External only or External / Vestibular Skin

Bony Vault

Bony Vault Narrower than Middle Vault

Bony Vault Wider than Middle Vault

Osteotomies, Unilateral or Bilateral to Narrow a Wide Bony Vault

Packs and Splint

631

632

SECTION II

CHAPTER 20  • Closed technique rhinoplasty

reconstruct the pyramidal shape or mask the edges of a dorsal graft. Slivers of cartilage that remain can provide filler grafts to correct columellar notching from prior open rhinoplasty scars or retraction after trauma or surgery. I often revise the columellar scars by excision or Z-plasty, both of which are effective, at the same time. Augment the columella through a short lateral incision in the membranous septum and place grafts anterior to the medial crura till you have achieved the shape you want.

Tip grafting (Fig. 20.18) The concept of grafting the primary tip or correcting supratip deformity by augmentation rather than further reduction began the evolutionary thinking from which the modern rhinoplasty paradigm derived.91 Technical variations have been described,91–106 but the principle remains the same. The surgeon who uses tip grafts commonly finds that they not only increase tip projection but also alter tip lobular and nostril contour; increase lobular volume (reducing relative nostril size); impart a different ethnic character; and enlarge the nasal base, therefore changing the balance between dorsal height and tip projection. The two most common graft designs are multiple “shield” grafts described by Sheen91,92 and the cephalic transverse onlay graft described by Peck.106 The Sheen method effectively lengthens the middle crural segment and therefore increases tip projection; it is anatomical and very versatile and so is my favored technique.

A

D

B

E

The clinical problems that tip graft variations can solve increase with experience, but the following generalities apply: 1. Graft number and substance must suit the soft-tissue cover and the patient’s aesthetic goals: more substantial grafts are required beneath tissues that are thicker or stiffer (e.g., scarred from prior rhinoplasties), and softer grafts are needed under thinner skin to avoid surface irregularities or visibility. 2. Tip angularity varies inversely with the number of grafts used. The normal nasal tip is supported not by the anterior presenting edge of a single rectangular or shieldshaped cartilage but by the broad surfaces of the two alar cartilage domes. A single, solid graft will support only the tip at its single projecting end; in the thin-skinned patient, this design produces an unnatural artifact. The more grafts the surgeon places, the more underlying support diffuses and the less angular the tip becomes. To avoid graft visibility, the surgeon should always use multiple tip grafts (Fig. 20.19). Sheen realized that early in his experience with tip grafting.92 Surgeons who cite visibility of a single graft as the argument against tip grafts have not become familiar with the variations Sheen described 40 years ago. 3. Tip symmetry is paradoxically easier to produce with multiple grafts than with a single graft. Healing forces contracting on six graft edges can rotate a single graft

C

Figure 20.18  (A–E) A primary patient with a low dorsum in which dorsal/tip graft strategy can be used. Resection of upper lateral “shoulders” at their connection to the septal edge to narrow the middle vault, minimal retrograde tip reduction, spreader grafts (to control middle vault width), dorsal, and tip grafts with osteotomies completed the reconstruction. Dorsal augmentation has improved proportion. This is a very safe strategy and one much more likely to work than attempts to bring the large tip in line with the patient’s low dorsum. Postoperative views are at 2.5 years. (E) Schematic of the surgical correction.

Selection and use of additional graft donor sites and other augmentation materials

633

angle of rotation and “tip-defining point” where none exists, e.g., in supratip deformity or the contracted, scarred lobule. Other grafts can then be placed anterior to it to fill out the lobular part. The same strategy is effective in patients desiring substantial tip projection.

Technical details

A

B

Tip grafts are placed through an infracartilaginous incision on the side from which the surgeon operates. It is important to dissect the recipient pocket adequately but not so liberally that the surgeon loses control of placement. Notice in Fig. 20.16 (31) that pocket creation is two handed: my non-­ dominant hand is creating the shape I want to see and my dominant hand dissects it. By doing so, I create a dead space. Tip grafts fill the dead space. That’s the concept. Complete access incision closure is mandatory to minimize infection; the grafts should be manipulated as little as possible and rinsed in saline and an antibiotic solution before inserting them. The author now places tip grafts in almost every patient, except for those whose preoperative tip aesthetics are excellent (Fig. 20.20).

Routine postoperative care Dressings

C

D

Figure 20.19  Changes in many nasal regions are “global”, not “regional”. The saddle nose should affect only supratip height, but it does much more. Patient preoperatively (A) and after septal collapse (B). (C) Schematic of the surgical plan: rib cartilage maxillary augmentation, dorsal, caudal support, tip, and lateral wall grafts. All are necessary to correct the protean, “global” effects of loss of septal support. (D) A 15-year postoperative view.

4.

and produce an asymmetric appearance. It is easier to place at least two grafts, one angled toward the dome on each side, to distribute forces and to recreate normal anatomy. If the second graft still leaves a deficiency on one side, the surgeon can add more into the lobular part for symmetry with care not to disturb the first two pieces. Tip grafts are fixed by the dressing. Ethmoid or vomer “buttresses” prevent posterior graft displacement. Augmentation in a lobule whose alar cartilages are intact is different from augmentation in a contracted postoperative lobule from which the alar cartilages have been partially or completely removed. The former case can be treated by selective augmentation of the deficient areas with multiple softened grafts.28,78 In the latter case, there is no cartilage remnant to act as a “backstop” for any grafts placed anterior to it and no remaining structure to determine middle crural length and angle. Therefore, an initial buttress graft, usually of ethmoid or vomer and slightly smaller than the primary tip grafts, should be inserted first to define the posterior edge of the pocket and control the anterior position and angle of the main grafts. This buttress graft creates an

Assuming that septal or turbinate surgery has been performed, the nose is packed with 7-cm strips of petrolatum gauze impregnated with bacitracin/mupirocin ointment and layered over No. 18 suction catheters placed in the floor of each nasal airway. Although patency may last only a few days, the tubes do help equalize middle ear pressure and allow some airflow, for which all patients (particularly those anxious about packing) are grateful. Packing and tubes ordinarily remain for 6–7 days, by which time normal mucus production has returned and they can be removed painlessly. The packing should not overstuff the nose or dislodge repositioned nasal bones. In the absence of septal resection or turbinectomy, smaller packs can be used and need to remain for only 24–48 h. I prescribe oral antibiotics appropriate for upper airway organisms as prophylaxis against suppurative sinusitis while packs are in place. The nasal splint is fashioned from layers of ½-inch paper tape placed across the dorsum, tip, and cheeks so that cloth tape of the same width, layered over it, does not touch the skin itself. Several layers of moistened 2-inch plaster are cut to fit and secured with another layer of cloth tape. The splint must be applied precisely but not too tightly; the nasal tip skin is at greatest risk. Particularly in patients whose scarred or contracted tip lobules have been expanded by grafts, tip color should be checked frequently in the postoperative period and the tip sling cut and nasal packs or splint removed as necessary. Even in the primary rhinoplasty patient, nasal circulation is not inviolable.

Selection and use of additional graft donor sites and other augmentation materials Although the nasal septum is the most “plastic” of the autogenous sources for nasal reconstruction, septal cartilage and

634

SECTION II

CHAPTER 20  • Closed technique rhinoplasty

of primary rhinoplasty patients. Other autogenous sites are available; each has its particular idiosyncrasies and optimal uses.

Conchal cartilage

A

B

C

D

E

F

Figure 20.20  Preoperative (A,C,E) and 5-year postoperative (B,D,F) photographs of a patient reconstructed by dorsal reduction; vertical wedge lateral genua resections; radix, spreader, and multiple tip grafts. Note that tip grafts have altered tip lobular shape and changed the lobular/nostril ratio, appearing to decrease nostril length (no alar wedge resections were performed). Tip lobular width still balances alar base width. The columella remains narrow; there are no iatrogenic deformities.

bone are not always present in adequate amounts even in the primary rhinoplasty patient (i.e., where the septum may be largely bony). I coined the term “graft-depleted patient”66 to describe this phenomenon, which I still see in about 10%

Unmodified cartilage from the conchal floor supplies excellent grafts for spreader grafts, alar cartilage replacement, or nasal tip. It is possible to use rolled ear cartilage for the dorsum.107 Although many surgeons harvest conchal cartilage through a postauricular incision, the anterior approach provides the surgeon a better view of the quality and contour of the available cartilage. By either route, it is critical to preserve the posterior conchal wall to avoid deforming the donor ear; even so, substantial donor cartilage can be harvested. The ear should be isolated from the nose during harvesting and gloves and instruments changed prior to returning to the rhinoplasty itself. These precautions minimize the chance of transferring gram-negative organisms (especially Pseudomonas) from the external auditory canal into the nasal incisions. Conchal cartilage forms an excellent dorsal graft for deep, asymmetric defects beneath a thick soft-tissue cover. The method of trimming, rolling, and fixing the graft has been described by Sheen.107 For shorter, shallower defects or under thinner soft-tissue cover, crushed conchal cartilage is not ideal but can be used instead of rib, but it is always a compromise. Because of their rubbery consistency and thickness, however, single pieces of solid conchal cartilage flatten and deform as the overlying soft tissues compress them and do not make good dorsal grafts.

Calvarial bone The calvarial outer table supplies grafts well suited for the reconstruction of long, shallow (2–3 mm), symmetric dorsal defects beneath thin soft-tissue covers. These grafts must be harvested with exceeding care because intracranial injuries have been described.108,109 Some surgeons have been discouraged by the long-term results of calvarial bone, but the author used it in 50 patients with only two cases of partial absorption in the supratip. Other surgeons have reported similar success with even larger series.109 The grafts must be harvested under low speed using an electric burr and cold chisel, keeping the bone cool with saline irrigation to avoid overheating. Bony union is the rule. Calvarial grafts need not be immobilized by external fixation if their position can be maintained by limited dissection and splinting. Where the soft tissues are distorted or the nasal base has collapsed, wire cerclage fixation at the root is necessary, a circumstance that is uncommon in the primary patient. Because of its utility in providing all other graft needs, I now use costal cartilage in preference to calvarial grafts.

Costal cartilage Costal grafts, not commonly necessary in primary rhinoplasty, are excellent for nasal reconstruction. Slices of costal cartilage (as a single bivalved graft or two-piece) can fill the maxillary arch, and solid or crushed will support the lateral nasal walls, columella, or tip. The notoriety of rib grafts to warp postoperatively can be decreased by noting that ribs progressively calcify as patients age (especially beyond 40 years). The more calcification, the more the distorting perichondrial forces are

The postoperative course

overcome. I always use the smallest rib that will suffice (8th, 9th), so that less modification and therefore less disruption of internal stresses occurs. I no longer use threaded, longitudinal K-wires as internal splints because one or even two wires have not been consistently reliable; rib can pull away from the wires and deform anyway.110 In older patients, I use carved dorsal grafts stiffened by calcification or crushed perichondrial/cartilage strips; in younger patients, I use whole rib cut to length or laminates. Sutured perichondrial/cartilage laminates constructed from thin, matching anterior and posterior surfaces (perichondrium outward) provide a stable graft that has been uniformly effective in our series of 95 patients.111 Laminates are very reliable and are my preferred dorsal augmentation method unless very thin crushed perichondrial/ cartilage slices suffice.

Alloplastics Except in the single circumstance of maxillary augmentation (described later), I do not use alloplastic materials for three reasons. First, literature reports share the same characteristics: limited, incomplete follow-up of patients, and complication rates defined only as infection or extrusion. Compared with autogenous materials for which infection, extrusion, and even resorption are rare, such data are unconvincing. No alloplastic material has yet demonstrated the success and complication rate that matches autogenous grafts. Second, the rationale for use of alloplastic materials is always their simplicity for patient and surgeon while avoiding the pain and inconvenience of autogenous grafts. The latter disadvantages are real but largely controllable by the surgeon’s experience; the former apply only in the perioperative period. Whereas alloplastic materials offer the convenience of not having to be harvested, they are decidedly inconvenient if they become infected or extrude. Finally, the patient in whom the surgeon wishes to use alloplastic materials most is the one for whom they are least suitable, i.e., the tertiary patient whose soft tissues are scarred and thin and whose best donor sites have been exhausted. These are the patients who understandably want a simple solution but are least likely to benefit from alloplastic materials, and whose tight, hypovascular beds will be least hospitable to them. Alloplastics are virtually never a lifetime solution in the nose.

Maxillary augmentation Maxillary augmentation is my sole exception to using alloplastics in selected patients. Immobile and deep beneath the thick soft tissues of the upper lip, Gore-Tex (1 mm expanded polytetrafluoroethylene, W.L. Gore & Associates, Flagstaff, AZ) can be rolled and placed through a short incision in the nasal floor. With the nose isolated by adherent drapes and a no-touch technique, a subperiosteal dissection should be carried high across the maxillary arch tight against the pyriform aperture; the implant must be carefully centralized, and good soft-tissue closure must be achieved. The implant can be rolled so that it augments primarily the central lip or the perialar areas, depending on preoperative lip configuration. Gore-Tex is pliable and therefore not noticeable to most patients; the augmentation result appears to be stable. Complications are low. In a current series of more than 545 patients over 36 years, only 6 Gore-Tex implants have required removal (exposure during

635

a dental procedure infection) (see Fig. 20.23). Alloplastic maxillary augmentation should not be performed in patients who have undergone cleft lip repair because of unacceptable late extrusion rates. Use cartilage or bone grafts instead.

The postoperative course As difficult as nasal surgery is acknowledged to be for the surgeon, it is even more difficult for the patient, who (particularly after primary rhinoplasty) does not know what to expect; has high, perhaps even unrealistic expectations, despite the surgeon’s preoperative counseling; and is fearful of complications and anxious for a perfect result. Added to the usual postoperative worries are the unsolicited opinions of interested family members and friends who intensify the patient’s worries by volunteering their opinions. The postoperative course after rhinoplasty is complex and offers the surgeon an opportunity to make a positive experience out of what otherwise might be a negative one (or vice versa). Surgeons who do not see their patients after the dressings are removed are missing the chance to observe usual and unusual postoperative courses and to develop the skills and experience that would otherwise lead to consistent postoperative success. The nasal splint and any remaining packing are removed on postoperative days 6–7. Despite better symmetry, a straighter bridge, or increased tip contour, most patients are worried 1 week after surgery and need repeated assurance that the nose is still swollen. The airway, however, should be appreciably better when packing is removed, an instant reward for the patient after a week of bandages and buys time for the surgeon in the patient who seeks immediate gratification. By day 10, the nose has begun to assume a much better shape, and most patients’ confidence builds from there. Patients should be seen as needed during the first 2 weeks after surgery to clean the nose of secretions that have accumulated around intranasal sutures, to ensure that edema has not displaced the nasal bones, and to educate the patient about changes to be expected over the ensuing weeks and months. I see my patients every 3–4 months until the end of the first postoperative year and yearly thereafter, if possible, adjusting for patients who travel from a distance. Patient and surgeon always learn something from each postoperative visit. Some changes predictably occur during the postoperative period. The degree of change (see above) depends on the degree of disparity between preoperative and postoperative skeletal volume, how well the interdependent skeletal areas have been rebalanced, and how well the re-formed skeleton supports the soft tissues. The bigger the disequilibrium, the greater the postoperative change. The following sequence occurs in most patients during the first postoperative year: 1. The nose becomes longer and “de-skeletonizes” as nasal and upper lip edema abate, so that the nasolabial angle decreases and the nostrils become less visible. 2. The nasal base rotates caudally, depending on skin elasticity and the degree of skeletal support; the long preoperative nose has the greatest tendency to elongate postoperatively. 3. The profile assumes its final postoperative shape sooner than the frontal view; the nose narrows for at least 12–18 months, particularly in the middle third. During this time,

636

4. 5.

SECTION II

CHAPTER 20  • Closed technique rhinoplasty

the unsupported middle vault narrows and demarcates from the caudal edges of the bony vault. The nasal skin tries to assume its preoperative shape, a characteristic that has particular implications for tip grafting: the flatter, more contracted preoperative tip will compress tip grafts and alter postoperative contour more than the larger tip with a more pliable soft-tissue cover, a phenomenon that the surgeon must anticipate when placing tip grafts. Skeletal irregularities or asymmetries may appear (and sometimes disappear). Areas of underlying skeletal change or grafts may become visible and suggest the need for revision; conversely, early postoperative improvement may become obscured by soft-tissue contraction and thickening. As the surgeon becomes more experienced, postoperative changes become more interpretable and the surgeon’s advice becomes more reliable. As with good physical therapy after hand surgery, at least 50% of the patient’s happiness and as much as 90% of the surgeon’s intraoperative and postoperative judgment are determined by lengthy and conscientious follow-up.

A

B

Variations on the standard Nasal deviation (Fig. 20.21) The asymmetric nose is common and difficult to correct. In the acute fracture when bony displacement is the primary defect, closed reduction is effective. However, when the injury has been primarily septal or cartilaginous, closed or even open techniques in the acute situation are often incompletely effective. The surgeon who diagnoses an asymmetric nose as a bony problem alone when septal injury is a substantial component will find that manipulation of the nasal bones or attempts to “twist” the septum into its prior position are incompletely successful and that the prevalence of residual deformity is high. In the healed deviated nose, the required techniques are identical to those already discussed. Several specific principles should be followed: 1. Asymmetric maneuvers must be done to an asymmetric nose to achieve symmetry. The strategy for correcting nasal deviation should consider the cephalic, middle, and caudal nasal thirds individually. A nose may appear asymmetric despite a symmetric bony vault. In such cases, no treatment of the bony vault may be indicated, and the surgeon must devote greater attention to the displaced cartilaginous parts. In general, the bony vault is treated by no osteotomy or unilateral osteotomy; the middle third by placement of asymmetrically thick spreader grafts (wider on the side that has collapsed further medially, with or without onlay grafts) and/ or onlay grafts for symmetry; and the caudal third by resection of the septal angle and submucosal caudal septal resection and replacement as a free graft. 2. The strategy for achieving symmetry also depends on whether the nasal dorsum is convex or concave. When the deviated nose has a convex bridge, the hump is often its most asymmetric part. By reducing bridge height, the surgeon also removes the area of greatest deflection and therefore makes a straighter nose even before

C

D

E

F

Figure 20.21  Preoperative (A,C,E) and 6-year postoperative (B,D,F) photographs of patient with an asymmetrical nose treated with dorsal resection, vertical 2 mm wedge resection of the lateral genua to narrow the tip, asymmetrically thick spreader grafts, a dorsal camouflage graft, right lateral wall graft, and tip grafts. Columella is undamaged; her tip lobule is slightly narrower. Her “ball” tip lobular shape is preserved, her specific preference. The patient determines the normal.

performing any other maneuvers. Conversely, when the nasal dorsum is low and asymmetric relative to a large nasal base, the surgeon can frequently achieve more symmetry by camouflaging the deflection with a straight

Variations on the standard

3.

dorsal graft or by aligning the anterior septal edge with spreader grafts.112–117 Deflection of the septal angle is a frequent cause of misalignment of the nasal base; resection of the septal angle releases the soft tissues at the nasal tip, allowing them to move toward the midline. However, septal angle or dorsal resection sufficient to correct the asymmetry may simultaneously produce a nasal bridge that is now too low and therefore requires augmentation to re-establish postoperative balance and middle vault support. A deflected septal angle can be aligned by asymmetrically thick spreader grafts, placing the thicker graft on the side toward which the septal angle is deflected. In addition, I expose a deflected caudal septal edge through a hemi-transfixing incision, resect it, and place it between the membranous septal flaps as a free graft. Because the deflected part is no longer attached, it remains in the midline permanently.

Rhinoplasty in men Although the diagnostic and technical aspects of rhinoplasty performed on men do not differ from those performed on

637

women, there are other differences. Men have larger frames, heavier bones, thicker skin, and historically have been more likely to involve themselves in contact sports and in work with high physical demands. Men are also judged to be most attractive when they best represent their phenotype – that is, when they “look male”: defined jaws, strong foreheads, and larger noses.75 It is also true that men can have turbulent postoperative courses. In my previous survey of 1000 consecutive rhinoplasty patients, men represented 30% of the disruptive or needy patients and 40% of those with body image distortion, although they only represented 22% of the population studied.118 This is not to say that men cannot be very good rhinoplasty patients (Fig. 20.22). However, the following generalities almost always apply:   Men

tolerate larger noses than women; that is, shape is more important than size.   Bridge height is important. Most men prefer a straight (or even convex) dorsal line to one that is concave with retroussé.   Men want noses that “look male”; not too short, not too narrow, and not too small.

A

B

C

E

F

G

D

Figure 20.22 Patient with all four anatomical traps that predispose to unfavorable results: low radix, narrow middle vault, inadequate tip projection, and alar cartilage malposition. Treated with dorsal reduction, lateral crural repositioning, radix, spreader, and tip grafts. Preoperatively (A,C,E) and 1 year later (B,D,F). (G) Schematic of the surgical correction.  

638

SECTION II

CHAPTER 20  • Closed technique rhinoplasty

  Secondary

male patients most often complain of a bridge that is too low and need dorsal grafts. Be conservative in resections.   Whereas some women say, “I don’t care how well I breathe as long as my nose is pretty”, men expect excellent postoperative airways.

that all changes are intentional and reflect the patient’s aesthetic and ethnic sensibilities.

Cleft lip nasal deformity Although patients who have undergone lip and nasal repair in infancy (which may have involved only dissection of the lower lateral cartilage on the cleft side) do not, strictly speaking, constitute a “primary rhinoplasty deformity”, they often require definitive corrections during the teen or early adult years. The classic anatomic characteristics have been described elsewhere.120–125 The septal, maxillary, nasal base, and alar cartilage abnormalities that typify the unilateral or bilateral cleft lip may be managed by many of the methods designed for aesthetic rhinoplasty. The deformity is always complex and must be analyzed in terms of the symmetry of each nasal third, maxillary arch contour, columellar support, septal obstruction, valvular competence at the internal and (particularly) external valves – especially on the cleft side, alar cartilage contour, vestibular webbing or atresia, and tip support (Fig. 20.23). What is frequently characterized as a “short columella” may reflect inadequate tip projection instead and is best managed by increasing the tip projection without columellar lengthening. Also commonly overlooked or unrecognized is cephalic rotation of the alar cartilage lateral crus on the cleft side. Additional techniques are required for deformities uncommon to the usual primary rhinoplasty: maxillary augmentation (which does as

Ethnic rhinoplasty Beauty is subjective. There are patients whose private aesthetics are quite specific, and patients who simply want the surgeon to remove the bump and restore the airway. Every patient deserves to have his or her aesthetic goals and personal identity respected by the surgeon. In my view, therefore, there is no such thing as “ethnic rhinoplasty”. The point for the surgeon to remember, however, is that some patients’ ethnic backgrounds shape their aesthetic goals in one of two ways: either retaining ethnic characteristics or changing them. But the surgeon must ask. One of the most common motivations for secondary rhinoplasty is the loss of a familial, ethnic, or personal nasal characteristic.119 The principles of forming and performing the surgical plan, however, do not differ. The surgeon trying to correct a low, broad dorsum and a large nasal base covered by thick soft tissues faces the same imbalances and the same challenges regardless of the patient’s gender or ethnic background. The interaction with each patient sets the plan. It is only important

A

E

B

F

C

D

Figure 20.23  Preoperative (A,C,E) and 3-year postoperative (B,D,F) photographs of a patient with a right unilateral cleft lip deformity treated by rib cartilage maxillary augmentation, dorsal, right alar wall, and tip grafts. The patient declined the right alar lobular excision that I would have preferred to perform.

Variations on the standard

much as any correction to change the cleft facies appearance), excision of alar rim skin correction of vestibular webbing, coronal composite grafts, and creation or relocation of the alar crease, all on the cleft side . The primary repair has frequently constricted the nostril on the cleft side and may have displaced the alar base medially. When the alar base is properly positioned, nostril stenosis can be improved by axial or sagittal composite grafts from the alar lobule or ear.126,127 When the nostril stenosis and alar base malposition occur simultaneously, however, an inferiorly based transposition flap lateral to alar base or a crescentic island flap vascularized by subcutaneous and musculocutaneous perforators is effective.128,129

Older patients Older, of course, is relative. Two important considerations for the older patient are (1) how long dissatisfaction with the nose has been present and (2) any structural characteristics that may suggest alterations in the surgical plan. It is therefore wise to inquire how long the patient has been unhappy with his or her nasal shape. For some patients, it has been since their teen years. These patients can tolerate more significant changes. Alternatively, the patient whose unhappiness with his or her nasal shape is recent may simply be

639

noticing aging changes. The surgeon’s task in these cases is to restore the nose, as far as possible, to its previous, more youthful appearance.130,131 Older nasal bones are thinner and more brittle (and may comminute with osteotomy), and the bony arch must be able to support eyeglasses. Soft tissues have become atrophic and less elastic, and tend to wrinkle instead of tighten, making some intraoperative judgments more difficult and contraction to a reduced framework less probable. Cartilages may have become more rigid, and many patients believe that their tips have grown larger with time. Whether this reflects actual cartilaginous growth, elongation or thinning of soft tissues, or even absorption of the bony vault creating a new imbalance is not yet known. Tips that were adequately projecting in prior years begin to hang from the septal angle, causing an apparent curvature in the lower nose (see Fig. 20.8).

Rhinophyma Rhinophyma (Fig. 20.24) is the perfect setting for real reduction rhinoplasty. Rhinophymatous noses really are too large, distorted by sebaceous and vascular overgrowth, chronic inflammation, exudates, and sometimes grotesque soft-tissue excesses. The diseased tissues must be reduced, either by tangential or

A

B

C

E

F

G

D

Figure 20.24 Preoperative (B,D,F) and postoperative (C,E,G) photographs of a patient with rhinophyma treated by shaving the external skin, and delayed spreader and radix grafts. The original premorbid nose (A) is not always well proportioned. Aim for the original, not an unrealistic ideal.  

640

SECTION II

CHAPTER 20  • Closed technique rhinoplasty

direct excision. While the excised surface heals, skin texture changes, usually smoother and hypopigmented, even scarred, depending on excision depth. Patients must be forewarned of the latter possibility, but few object because the deformity is so significant and so inaccurately associated with ethanol abuse. Three principles can guide the surgeon treating rhinophyma: 1. Not every nose with rhinophyma was originally small and straight. Before beginning the excision, try to visualize the patient’s real underlying contour, and obtain old photographs if possible (see Fig. 20.24A). The objective is to reduce the nose but produce as little scarring as possible. Compromise may be necessary. 2. Do not assume that every nose was well balanced before it became diseased: some had dorsal humps and low radices, some had inadequate tip projection, and some were already too long. Your patient may need a second rebalancing procedure (e.g., dorsal or tip grafts). Skin excision cannot correct skeletal deformities. 3. Plan excisions according to the nasal planes and aesthetic units to minimize distracting color and contour discontinuities.132

The donor site-depleted patient This is a term I coined some years ago, and though donor site depletion is more common in the secondary patient whose donor sites have previously been harvested, even the primary rhinoplasty patient may be donor site-depleted if the septum is bony and yields minimal usable cartilage (a circumstance somewhat more likely in the non-White or post-traumatic nose). In one series,133,134 17% of the primary rhinoplasty patients had nasal septa that were at least 75% bony and supplied insufficient donor material for the patient’s requirements (Fig. 20.25 ). A few principles are helpful in such patients: 1. Internal valvular reconstruction can be accomplished by either spreader grafts or dorsal grafts with equivalent functional effects. 2. External valvular reconstruction can be accomplished by lateral-crural shaped cartilage or bone grafts that span the area of collapse, or by composite skin/conchal cartilage grafts. 3. Tip reconstruction may be accomplished by selectively grafting the skeletally deficient lobular parts using crushed grafts in limited pockets. 4. A dorsal graft that reaches only to the lower nasal third can be extended by a second graft placed caudal and inferior to it. The thicker supratip skin will hide the overlap and produce a smooth line. 5. Single-unit dorsal grafts are still needed for dorsal defects in thin-skinned patients; not all patients can be treated with minimal donor material.

Problems in the postoperative course Unlike other plastic surgical operations that are technically or conceptually difficult, rhinoplasty has fewer of the complications that traditionally plague surgeons. Most rhinoplasty surgeons never see lacrimal duct or extraocular muscle injury after rhinoplasty; even septal perforation is relatively infrequent. Because of its very nature, however, most rhinoplasty complications are

directly related to an insufficiently complex understanding of the structural interdependencies in the nose, incorrect diagnosis, or technical difficulties, all of which are under the surgeon’s control and can be decreased by planning and operative technique. The following complications are listed in decreasing frequency as they are recognized in patients seen in consultation.

Iatrogenic airway obstruction More common than any complication, and entirely preventable, is a decrease in postoperative airway size, particularly unfortunate if it is new and iatrogenic. Although attributed by some authors to the use of an intercartilaginous access incision or the narrowing effects of osteotomy,135,136 much more common causes are increased internal valvular incompetence from resection of the middle vault roof and external valvular incompetence from alar cartilage resection, particularly in cases of cephalic rotation of the lateral crura. Airway obstruction from loss of skeletal support due to surgery may be avoided by a preoperative evaluation that identifies short nasal bones, narrow middle vault, or alar cartilage malposition, and establishing valvular competence in each patient. Substantial dorsal or spreader grafts correct internal valvular incompetence with equal efficacy; collapsing external valves can be stiffened by autogenous cartilage.135 Less commonly, new airway obstruction may be caused by the inadvertent loss of tip support (through septal collapse or excessive dorsal or alar cartilage reduction), excessive alar wedge resection (treated by composite grafts or local flaps), or resection of nasal lining (which should only be performed at the membranous septum to shorten the nose). Inadequate or excessive shortening misdirects the air stream that should flow posteriorly along the nasal floor. Patients with excessively long noses often relieve their airway obstructions by supporting their nasal tips; here, even osteotomy may be counterproductive by decreasing skeletal volume.136 The over-shortened nose can be improved by dorsal grafts, resection of the posterior caudal septum, and coronally oriented composite grafts.126,137 Osteotomy has been indicted as a cause of decreased postoperative airflow, although many authors have now concluded that osteotomy rarely decreases nasal airflow, partly because septal and valvular surgery is so effective in secondary patients. The passion of many patients for “small” noses and the aggressiveness of some osteotomy techniques, however, can produce narrow pyriform apertures, in which case excision of the lateral lips of the pyriform apertures improves the patient’s symptoms. Finally, inadequate turbinate resection may leave residual obstruction; more commonly, excessive turbinate resection produces a sense of obstruction (presumably from loss of the normal baffling and resistance functions), nasal dryness, and clear, persistent rhinitis. Insufficient turbinate resection is easy to correct; excessive resection and its sequelae have no current accepted and effective treatment. An improvement in nasal appearance should never decrease airway size; virtually all rhinoplasty patients can maintain or improve function if the surgeon remembers the hierarchy of functional interrelationships that exist (i.e., valvular function at the top) and plans the operation accordingly.

Skeletal problems Irregularities or asymmetries may occur in any modified skeletal structure; their visibility varies with the thickness of the

Problems in the postoperative course

A

B

A

B

C

D

C

D

Figure 20.25  Primary rhinoplasty in a graft-depleted patient. Dorsal reduction, no alar cartilage modification, radix, spreader, tip, and alar wall grafts. Tip and alar wall grafts were fit into limited pockets to obtain the maximal effect from minimal material. (A,B) Preoperative and 1-year postoperative frontal views. (C,D) Preoperative and 1-year postoperative lateral views.

640.e1

Figure 20.26  Classical supratip deformity with collapsed internal and external nasal valves and distorted nostrils. Resection of the disfigured middle crura and dorsal, spreader, tip, and composite skin/cartilage alar wall grafts quadrupled airflow and reduced her deformities (A,B) Preoperative and 3-year postoperative frontal views. (C,D) Preoperative and 3-year postoperative lateral views. Notice that the lower nose looks smaller even though tip projection is greater, the result of improved balance by lengthening the dorsal line.

Problems in the postoperative course

soft-tissue cover. Irregularities at the caudal edges of the bony vault are often attributed to inadequate reduction but more often represent middle vault collapse, which causes the caudal end of the bony arch to stand out in relief; treatment is spreader or dorsal grafts,6 not further bony resection (Fig. 20.26 ). A palpable or visible low point may appear in the midline of the nasal bridge, either intraoperatively or postoperatively.138 This “mid-dorsal notch” has been interpreted as an untidy resection of the cartilaginous dorsum but is actually a soft-tissue phenomenon that occurs where the thinner, upper nasal skin thickens in its transition to the supratip and therefore represents the cephalic end of the supratip deformity (or the midpoint of the “inverted-V” deformity associated with middle vault collapse) and indicates dorsal over-resection; it should be treated by augmentation. A new frontal asymmetry may develop when dorsal resection has uncovered a high septal deviation. The high septal deviation can be camouflaged by splinting the anterior septal edge with spreader grafts of unequal thickness, adding any necessary onlay grafts for additional symmetry.

Soft-tissue problems As much as graft quality, soft-tissue quality determines the beauty of the final result. Skin that has been damaged by previous surgeries may be unevenly thick, can be assumed to be hypovascular, and may not adapt or cover a rebuilt underlying skeleton (which itself may be constructed of suboptimal materials) evenly. Nasal circulation can never be taken lightly. Surgeons who routinely assume that the wider dissection of the open approach is superior in heavily scarred secondary cases should rethink their philosophy. Even the best open rhinoplasty surgeons lose nasal tip or columellar skin, usually from excessive dissection in scarred tissues or columellar closure under tension. This is a catastrophe in cosmetic cases. The surgeon must always remember that the surgical principles that apply everywhere in the body apply to the nose.

Graft problems Skeletal problems caused by grafts rank third overall only because fewer surgeons augment than reduce. However, they are my own most frequent unfavorable results. For those surgeons who augment often, graft imperfections are the most common reason for secondary revision. Dorsal grafts must be carefully contoured and placed in pockets that limit their movement. Similarly, tip grafts may produce unacceptable asymmetries or visible edges. Graft visibility depends on the number and substance of the augmentation material as well as the characteristics of the soft-tissue cover. The surgeon who uses multiple grafts will find tip symmetry easier to achieve and graft visibility less likely. Fortunately, the techniques described here minimize changes in normal anatomy. There are no non-anatomical struts. There are no permanent sutures. If a dorsal graft has moved, dissect it free and reposition. If a tip is under- or over-augmented or asymmetrical, make appropriate adjustments.

Intraoperative and postoperative hemorrhage Even a few extra drops of blood can cloud the field or float grafts out of position postoperatively. There are two

641

patterns of excessive intraoperative bleeding: constant slow, multifocal bleeding starting at the first injection; or normal hemostasis for 2–3 hours, then multifocal bleeding, even from areas previously treated. Each requires different management. The first pattern often indicates factor VIII deficiency; even normal patients can acquire anti-factor VIII antibodies during childbirth. The treatment is DDAVP (desmopressin acetate) 0.3 µg/kg, which has been used for hemophilia A, von Willebrand’s disease, and diabetes insipidus. If the problem is known, pretreatment begins 30 minutes preoperatively. Re-dosing is not usually necessary. Uncommon side effects are headache, nausea, and cramps. The second pattern manifests as normal hemostasis for 2–3 hours, then multifocal bleeding, even from areas previously treated, and indicates a circulating fibrinolysin, commonly seen following heart surgery, abruptio placentae, some cancers, and antidepressants, now so commonly prescribed. This pattern is treated with Amicar (aminocaproic acid), a fibrinolysis inhibitor that inhibits plasminogen activators. The clinical picture must be distinguished from disseminated intravascular coagulation, of course rare during rhinoplasty. Aminocaproic acid is given as a 4–6 g loading dose, followed by 1 g intravenous hourly until discharge, and then 1 g orally four times per day until the risk of hemorrhage has passed. Side effects are headache, glomerular capillary thrombosis, bradycardia, and hypotension. Because of the possibility of renal tubular clots, pre-administration urinalysis is mandatory. Unfortunately, the problem cannot be screened by routine bleeding studies: prothrombin time (PT), partial thromboplastin time (PTT), and platelets are normal in most cases; some patients, however, do have a history of previously undiagnosed hemorrhage. The link to serotonin reuptake inhibitor antidepressants is postulated to be platelet serotonin depletion, leading to abnormal bleeding.139 It is theoretically ideal but impractical to have all patients stop antidepressants for 2 weeks preoperatively. Consequently, I order a urinalysis to rule out microscopic hematuria so that aminocaproic acid can be given safely during surgery if the need arises. A recent alternative is tranexamic acid, which has a similar clot-stabilizing mode of action, binding to plasminogen and therefore inhibiting plasmin formation and fibrinolysis. Intravenous dosage is typically 0.5–1 g by slow injection three times per day. Alternatively, the initial dose can be followed by an infusion of 25–50 mg/kg over 24 hours, reduced in patients with renal failure. Rare patients classically re-bleed between postoperative days 5 and 10. At particular risk are patients who have undergone turbinectomy or taken antidepressants, herbals, or vitamins that interfere with platelet function. The surgeon’s major task is to elicit cooperation from the frightened patient and family; as occurs so often in upper gastrointestinal hemorrhage, the calmed patient frequently stops bleeding. The surgeon should see the patient personally, remove packs, suction the airway, and identify the site of bleeding. When bleeding does not stop, reinsertion of an absorbent pack soaked in phenylephrine hydrochloride is necessary. The need for posterior packs fortunately occurs less frequently, but the surgeon should be familiar and comfortable with their use before the occasion arises.

642

SECTION II

CHAPTER 20  • Closed technique rhinoplasty

Septal perforation Perforations occasionally occur after difficult septoplasties but can be minimized by cautious dissection over the vomer, by repairing tears in the mucoperichondrial flaps, and by placing 1 mm silicone splints on each side of the septal partition before the nose is packed. Even with these precautions, the occasional septal perforation may be unavoidable and is usually asymptomatic. Small perforations may cause a curious whistling; larger ones cause crusting, epistaxis, and rhinitis as the turbulent airflow spins through the perforated mucosa. Epistaxis frequently reflects an area of exposed septal cartilage or bone. Repairing septal perforations is difficult; recurrence after local or even distant flaps in the largest series is still high. In symptomatic perforations, it is usually possible to identify and eliminate areas of exposed septal skeleton and repair the mucoperichondrial flaps to obtain a perforation with a healed, stable surface. If symptoms can be alleviated in this manner, closing the perforation itself is not usually necessary. I always tell patients if I see a perforation that I have caused, partly to educate and reassure them, and also so that another physician does not have to do it.

Rhinitis Temporary rhinitis may occur for several weeks postoperatively as the lining readjusts to better airflow when an obstructed airway has been corrected. Most preoperative rhinitis stops because the nose no longer has turbulent, drying airflow that stimulates turbinate function. Patients who have been chronic nose-blowers must be encouraged to break the habit after surgery so that they do not keep the positive feedback loop going now that the obstruction has been corrected. Persistent rhinitis, however, is uncommon unless excessive turbinectomy has been performed. The proponents of turbinectomy minimize this sequela,140,141 but it is a troublesome entity for which there is yet no consistently effective treatment.

Circulatory problems Circulatory complications are extremely uncommon after closed rhinoplasty. During primary endonasal rhinoplasty, the surgeon can make intercartilaginous and infracartilaginous incisions with or without alar wedge resections without fear of circulatory compromise as long as the incisions are not made longer than is necessary, skeletonization is appropriately limited, the dermis is not thinned, and packs and dressings are not placed tightly. Differentiation of the tip lobule from the dorsum (the desirable “supratip break”) reflects not overcorrection of the cartilaginous dorsum but rather adequate dorsal height and tip projection. If these factors are absent, the surgeon cannot produce a supratip depression by excessively tight taping, dermal sutures, or steroid injections. The surgeon should plan incisions to provide necessary access and minimize the amount of dissection.

Infection Bacterial infection is mercifully rare after rhinoplasty and septal surgery142–150 but has become more common with the emergence and increasing prevalence of methicillin-resistant Staphylococcus aureus (MRSA) as a community-acquired pathogen.151 We screen all patients for MRSA and treat positive cases with mupirocin.

Many surgeons use antibiotics while postoperative packing is in place, although their absolute necessity has not been established. Patients with chronic septal perforations from trauma or cocaine are special cases, and often have unusual nasal organisms (Pseudomonas, Enterobacter, Escherichia coli). We prep these patients with twice daily lavage with gentamicin 80 mg and dexamethasone 12 mg in 1 liter of normal saline for six weeks and confirm its success preoperatively with cultures; this pretreatment has so far been highly effective. Toxic shock syndrome, cavernous sinus and nasofrontal abscess, and even endocarditis are extremely rare but have been reported. Limited but especially troublesome infections occur infrequently in areas of tissue compromise, with excessive manipulation, or where conchal cartilage grafts have been placed carrying Gram-negative organisms from the external auditory canals. Those are avoidable by pretesting for MRSA and good surgical technique.

Septal collapse Loss of cartilaginous support has protean effects because the intact septal partition is necessary for normal bridge contour, nasal length, base support, middle vault (and internal valvular) competence, and upper lip carriage (see Figs. 20.5 & 20.19). The required reconstruction is therefore predictably complex. The surgeon may minimize the possibility of septal collapse by identifying those patients with unhealed or unstable septal fractures and by leaving a minimum 15 mm width of undissected septal cartilage and mucoperichondrium along the dorsum to avoid jeopardizing septal support if unexpected, unhealed fracture lines are encountered. I have had four in my 43-year career: two were present but unrecognized before surgery; one I created by narrowing the dorsal strut too much to harvest grafts; one I cannot explain. I treated them with K-wire fixation through the septum and nasal bones and a septal dorsal graft. None required late surgery.

Red nose The “post-rhinoplasty red nose” is a cutaneous manifestation of postoperative circulatory readjustment and is displayed varyingly in patients; many never develop this condition, whereas others develop it after the first rhinoplasty. At particular risk are patients whose scarred or immature tips have been expanded by grafts. Patients with facial telangiectases develop red noses more frequently; most improve spontaneously during the first postoperative year. When the condition persists, laser treatment is simple and effective. Nasal tip discoloration in the early postoperative period cannot be ignored. Even when the access wound has not been closed under tension, internal pressures caused by grafts, packing, postoperative edema, and taping may render a carefully placed dressing too tight. Remove the tape sling if tip color is not perfectly normal. Even at 24 hours, graft position will not be lost.

Obscure complications Lacrimal duct injury (presumably from lateral osteotomy) was described in a 1968 series,152 in which the incidence of lacrimal obstruction in a 27-patient group was 78%; later studies have confirmed this rare possibility.153,154 Reports have also

Secondary rhinoplasty

appeared of orbital floor and extraocular muscle injury after osteotomy. Such events are unlikely if the surgeon knows and controls osteotome position. Cerebrospinal fluid rhinorrhea, pneumocephephalus, cavernous sinus thrombosis, meningitis, permanent anosmia, recurrent intradermal cysts, and blindness after corticosteroid injection for supratip deformity have been reported but are fortunately uncommon.155–160 Serious but rare (0.02% in a pooled series of 12,672 cases) complications have been reported after calvarial bone graft harvesting: hemiparesis; hemiplegia (in a patient with platelet disorder); epidural hematoma; subdural infection; dural, brain, or sagittal sinus lacerations; aphasia; persistent speech defect; and temporal hemianopia. Adverse events are extremely rare in the hands of surgeons experienced with proper bone harvesting technique.108 Alloplastics placed during rhinoplasty have their own litany of postoperative problems. The reader is encouraged to become familiar with these misadventures before incorrectly assuming that alloplastic reconstructions are inherently less troublesome than autogenous materials.161–170

The unhappy patient In a perfect world, the relationship between the surgeon and the aesthetic surgery patient would be even more favorable than in other medical encounters. Although it may be optimal for patient and surgeon to like each other, this is not always necessary or possible for the frightened cancer patient or the intoxicated emergency department patient. In the elective cosmetic case, everything should be different. Differences do exist in aesthetic surgery, but perhaps not as expected. Where the risks and complications are as real as in non-elective procedures and where the emotional investment may be even greater, patients expect more than passable outcomes without complications. Patients desire excellent results, even “perfect” results, from procedures that are technically difficult, that change appearance, and that have profound ramifications for that complex part of the human psyche that we call “body image”. In aesthetic surgery, it is important for patient and surgeon to like each other. The surgeon–patient relationship is always tested when things do not go as planned. It is these circumstances that measure the surgeon’s equanimity and test the degree to which “informed consent” has been obtained. It is here that the patient must understand the difference between the uncontrolled and the uncontrollable. The patient is often seeing a “problem” that he or she cannot necessarily identify but that well-meaning but uninformed friends or family members have interpreted instead. In a sound relationship with the surgeon, education and reassurance will support the patient until the problem resolves or until it can be corrected. There is a special group of patients who seem impossible to satisfy, are depressed and demanding of surgeon and staff, and are inconsolable when the result does not meet their expectations. Recent research indicates that many of these patients have histories of childhood abuse or neglect that create body shame – very different from body dissatisfaction (see below).171–189

Identity of the previous surgeon The identity of the prior surgeon also creates distinct differences in management. The surgeon evaluating his or her own

643

unhappy patient has the advantage of knowing the operative circumstances, the characteristics of the donor material, and the patient’s personality, but has the disadvantage of having to manage both the patient’s disappointment and his or her own. Alternatively, the surgeon evaluating someone else’s unhappy patient need not overcome disappointment with the current result but has less information about the original deformity, the patient’s tissue idiosyncrasies and donor material, the procedures themselves, and the patient’s personality and goals. Particularly when a patient is angry with the prior surgeon, it is imperative that the secondary surgeon has confidence that the patient (1) has realistic surgical goals and understands what is needed to achieve them and (2) appreciates that the original operating surgeon was doing his or her best to produce the patient’s original goals. Until these criteria can be satisfied, the surgeon is wise to delay surgery.

The decision to re-operate The patient counseled properly before surgery knows that resolution of swelling takes time and that the final appearance may not stabilize until the end of the first postoperative year or later. In practice, waiting for the final outcome is a bigger challenge for some patients (and surgeons) than for others. Accordingly, the surgeon should withhold the decision to reoperate for at least 1 year, until the postoperative result has stabilized. In some patients or after multiple surgeries, even more time may be necessary. If problems are instead treated as they appear, the revision will be piecemeal. The nature and degree of revision, and who should perform it, depend on the same factors involved in the prior rhinoplasty. Patient and surgeon must understand each other explicitly because secondary surgery itself is often geometrically more difficult than the primary operation. Regardless of the overt indications, patient and surgeon must not abandon the priorities of safety, function, and aesthetics, in that order. Rhinoplasty does not own its reputation by accident.

Secondary rhinoplasty Space does not permit the discussion of endonasal secondary rhinoplasty. The author’s analysis and techniques are available elsewhere.187 The most common problems requiring secondary rhinoplasty are iatrogenic or uncorrected airway obstruction; failure to recognize and treat the critical anatomical traps described earlier (low radix or low dorsum, inadequate tip projection, narrow middle vault, or alar cartilage malposition); supratip deformity; problems of length or balance; problems resulting from nasal implants; technical problems related to grafting; intolerable loss of identifiable racial, familial, or personal characteristics119; or deformities caused by previous open rhinoplasty.

Why primary and secondary rhinoplasty are the same operation There are surgeons who will perform primary rhinoplasty but not revisions. That is understandable, but for the surgeon who has learned rhinoplasty phenomenology, anatomical traps, principles of balance, grafting techniques, and airway management, the two operations can be viewed as only variations on a surgical theme. If the surgeon is economical in incisions,

644

SECTION II

CHAPTER 20  • Closed technique rhinoplasty

maintains or establishes equilibrium, removes or repositions deforming parts, maximizes functional support, and uses grafts to create balance, contour, and structure, there is really no difference between primary and secondary rhinoplasty except the donor sites. The secret to good secondary rhinoplasty is good primary rhinoplasty – not only performing but understanding the operation and the genesis of its various postoperative shapes. Because secondary shapes are not limitless but form patterns (see Table 20.1), the solutions form patterns (see Tables 20.1 & 20.2). By studying photos of secondary patients before they had surgery, the surgeon can become facile at recognizing patterns of nasal response and deformity, so that secondary shapes not only indicate the predisposing anatomy that produced them but also the procedures that will correct them.

Deformities caused by prior open rhinoplasty As the open approach has become more common, deformities unique to that surgery are increasing and worsening (Figs. 20.24 & 20.27). In the author’s practice, the prevalence of secondary rhinoplasty patients who had their original surgeries performed through the open approach has risen from 28%

A

B

to over 95% in the past 35 years. The deformities caused by that approach are distinct from those that characterize prior endonasal rhinoplasty – often much more severe, some currently uncorrectable, and more commonly involving the nasal base (e.g., wide or deformed and notched columellae, excessively narrow tips, hard columellar struts, unacceptable scars, alar rim notching, alar collapse, and draining sinuses or intercurrent cellulitis from buried permanent sutures). The putative cause of alar wall deformities has been discussed earlier.79 In contrast, those patients originally treated endonasally most commonly seek secondary rhinoplasty for a dorsum that is too high or a nose that is too long. In a review of 100 consecutive cases,190 secondary patients treated by the open approach had more presenting complaints (5.6 vs. 2.6 for closed rhinoplasty patients) and had undergone more procedures before seeking correction from another surgeon (3.1 vs. 1.2 for the closed rhinoplasty patients). That review was in 2002; the problem has only worsened since. The deformities most commonly produced by the open approach are those involving the anatomical parts encountered first during surgical exposure (the columella, alar cartilages, and alar rims) or by those procedures that can be performed more easily or more aggressively through the open approach (e.g., columellar struts and alar cartilage suturing). Some secondary deformities are easier to correct than others. The nose previously operated through the open approach contains more scar and permanent sutures, making the dissection difficult and the resection of uncorrectable deformities tedious. Struts may have widened the columella but not produced adequate tip projection; the struts will have to be interrupted or removed and tip projection produced by tip grafts. The surgeon should assume that the nasal circulation has been irreversibly damaged and proceed cautiously. In some cases, the secondary surgeon is operating under skin that may behave as if it had been irradiated. Excessively scarred or damaged skin can be improved significantly by intradermal and subdermal fat grafts. For this reason, the curious and unjustifiable strategy of some surgeons to treat the severely damaged tertiary nose by a wide, aggressive, open dissection runs counter to surgical principles followed everywhere else in the body and is hard to defend when soft-tissue loss occurs; I have seen many such cases, even from the best technicians. The surgeon who performs both open and closed rhinoplasty in different circumstances would therefore be wise to consider performing the open approach on the primary, unscarred nose, and the closed approach for the scarred, hypovascular, damaged nose, rather than the other way around.191

How to understand our most unhappy patients C

D

Figure 20.27  Common examples of noses deformed by previous unsuccessful open rhinoplasty. Deformities of the external valves, alar rims, and columella (A,B), draining sinuses (C), and cellulitis from permanent sutures (D) occur but are not discussed. Some deformities are uncorrectable.

The first criterion of body dysmorphic disorder (BDD) is preoccupation with a “perceived” physical imperfection that is “not observable” or appears “slight” to others and provokes significant patient distress and compensatory behaviors.192 Our most troublesome patients do not fulfill BDD criteria, but instead are those with real deformities who want surgery, or more surgery, but who remain persistently dissatisfied, even with results that met their goals.178,179

How to understand our most unhappy patients

The landmark CDC-Kaiser Permanente adverse childhood experiences (ACE) study demonstrated that childhood trauma is common.193–195 Further, ACEs can generate a sense of shame, i.e., personal defectiveness, which children frequently blame on themselves.196 The most common type of shame associated with childhood trauma is body shame,197–199 namely, “I am ‘worth-less’ because of the way I look”, thus providing the theoretical link to plastic surgery. If body shame, and not deformity, drives surgery, it becomes easier to understand why even successful operations might not satisfy these patients.173–179,200,201 We performed the ACE survey and the body shame component of the Experience of Shame Scale 202 on 218 patients (Table 20.3). Compared to the CDC/Kaiser medical population, our patients had higher overall ACE prevalences (79.8% vs. 64%), emotional abuse (41% vs. 11%), emotional neglect (38% vs. 15%), family substance abuse (36% vs. 27%), and family mental illness (29% vs. 19%, all p 4 Factors

Highest risk

Intermittent pneumatic compression device and elastic compression stocking on patient at all times while not ambulating + Lovenox 40 mg subcutaneously daily postoperative

BMI, body mass index; CHF, congestive heart failure; DVT, deep venous thrombosis; HIT, heparin-induced thrombocytopenia; HRT, hormone replacement therapy; MI, myocardial infarction; OCP, over-the-counter progesterone; PE, pulmonary embolism. Data from Hatef DA, Kenkel JM, Nguyen MQ, et al. Thromboembolic risks assessment and the efficacy of enoxaparin prophylaxis in excisional body contouring surgery. Plast Reconstr Surg. 2008;122:269–279.

Emerging technology

measure, first-generation cephalosporins are administered perioperatively within 30 min of the incision unless the patient has a known history of methicillin-resistant Staphylococcus aureus (MRSA), in which case vancomycin is administered preoperatively. There is no indication for routine postoperative antibiotics after the perioperative dose in standard liposuction. Late complications of liposuction include seroma, persistent edema, paresthesias, hyperpigmentation, and contour irregularities. Seromas following aggressive liposuction are rare and thought to be secondary to overzealous treatment of an area. It appears to be technique dependent rather than technology specific. Loose reapproximation of cannula access sites, postoperative compression garments, and expressing residual fluid over liposuction areas at the end of procedure all can potentially reduce the incidence of seroma formation.71 Postoperative edema and ecchymosis occur to a varying extent in all patients. Prolonged edema can occur up to 3 months postsurgery and is best treated with supportive care and lymphatic massage. Significant ecchymoses may result in hemosiderin deposition and ultimately hyperpigmentation. This can be challenging to eliminate. Postoperative paresthesia/ dysesthesia can occur in all forms of liposuction. The sensory changes are usually temporary and can take up to 12 weeks to recover, but recovery is generally felt to be quicker with SAL than with UAL.83 There is no current data addressing the sensory changes associated with new technology or LAL. With regard to aesthetic outcomes, the most common late postoperative complication from liposuction is contour deformity or irregularities. Up to 20% of patients can present with, or will complain of, some sort of contour irregularity.84,85 Mild irregularities are often present after suctioning and are treated conservatively with lymphatic massage as swelling and edema resolve. Once a contour deformity is identified, it is best to define the etiology. Blind suctioning of the surrounding areas is not often the correct treatment and can significantly worsen the problem. Once a proper assessment of the etiology is made, then treatment can either be directed at re-injecting the fat in the over-resected region or suctioning the adjacent areas in order to reduce the prominence of the concavity and blending the adjacent areas. The most comprehensive data on treating contour deformity is from Chang, where he presents a multimodality approach to assessing and treating contour deformity to achieve long-term results.84,85 UAL has a decreased incidence of contour deformities versus traditional SAL in our hands. It is the preferred method for secondary liposuction cases in which fat grafting is not indicated. Careful preoperative analysis, planning, and proper informed consent all help to minimize the risk of postoperative contour irregularity.

Emerging technology The non-invasive dissolution of fat is an extremely attractive concept for patients. Many new technologies are being developed to facilitate this, with varied reports of success.

Injection lipolysis The earliest version of non-invasive fat dissolution was ‘mesotherapy’, which is a general term that describes percutaneous

721

injection of a medication or other agent into the mesoderm. A variety of applications have been described, the most popular of which has been reduction of subcutaneous fat by dissolution.86 The concept dates back to 1952 and involves injection of phosphatidylcholine, deoxycholate, and/or other agents that are purported to dissolve fat. Widespread marketing and patient desire to avoid anesthesia have allowed mesotherapy and its variants to gain popularity because of their “non-invasive” nature. However, large-scale studies are not available for evaluation. Park et al.87 showed no discernible difference in the treatment in lower extremities with mesotherapy by measurement or CT scan evaluation. “Lipodissolve” is considered by some, but not all, practitioners to be a variant of mesotherapy. It is the injection of a standardized solution into the subcutaneous fat, rather than the mesoderm. The use of these products in the US is controversial and not supported by the FDA. Warnings from the FDA caution providers against its unproven use and false marketing claim.88 Several studies on safety and efficacy are available for review. Common side effects reported include hyperpigmentation and persistent pain, and 12% of patients had cosmetic outcomes that were less favorable than expected.89 Due to lack of scientific data and adequate studies and outcome results, the use of mesotherapy or its variants is not currently recommended, unless performed in conjunction with a clinical trial. The most highly studied injectable lipolytic agents is Kybella (Allergan Inc., Irvine, CA) or deoxycholic acid, which is a cytolytic agent that physically destroys the adipocyte cell membrane when injected. Kybella obtained FDA approval for improvement of moderate to severe convexity or fullness associated with submental fat in adults. Safety and efficacy of use of Kybella outside of the submental region has not been established and is not recommended. The cytolytic effect of deoxycholic acid is powerful, and injection should only be performed by experienced physicians with proper training in injection technique. Knowledge of submental anatomy is essential to avoid injury to neuromuscular, vascular, lymphatic, and salivary structures. Adequate pre-platysmal fat is assessed by skin pinch while the patient contracts the platysma muscle, and injection is administered in a grid pattern with 1-cm intervals between sites. Injection should be administered midway into the pre-platysmal fat layer, at least 1–1.5 cm below the inferior border of the mandible; special attention should be paid to anatomical distortion due to prior surgical or aesthetic procedures. Large, randomized placebo-controlled clinical trials have supported the safety and efficacy of Kybella in submental contouring by means of clinical observation and magnetic resonance imaging (MRI) evaluation.90,91 Common adverse events include injection site reactions, such as pain, swelling, induration, bruising, numbness, and erythema. Less commonly seen adverse events are marginal mandibular neuropraxia, skin ulceration, and dysphagia. Complications are related to injecting in proximity to vulnerable anatomic structures, so injection technique is of utmost importance.

Non-invasive devices Available non-invasive “lipo-contouring” devices deliver transcutaneous energy to the subcutaneous fat layer either by ultrasound, radiofrequency, tissue cooling (cryotherapy),

722

SECTION III

CHAPTER 25.2  • Liposuction: a comprehensive review of techniques and safety

low-level laser therapy, physical massage, or some combination of these modalities. All devices have differing characteristics that may influence suitability for a particular practice, such as operator dependence, delegation capabilities, maintenance, and consumables. These devices lack the evacuation phase that is inherent to liposuction, so fat clearance is accomplished by a physiologic macrophage-mediated phagocytic process. All FDA-cleared devices have demonstrated safety profiles fit for use in the US, and studies have demonstrated no effect on serum lipid levels and hepatic function. While these devices have been shown to be safe, the non-invasive lipo-contouring market is largely industry driven, with most scientific data on device efficacy published after devices are granted FDA clearance. While efficacy is shown in preclinical and clinical studies for nearly all these devices, caution is recommended in guaranteeing reproducibility of these results for two reasons. First, these devices did not gain popularity because of scientifically documented results, but because of industry sponsorship. Secondly, results in non-invasive body contouring are exceedingly difficult to objectively quantify, and reported results must be interpreted critically. These technologies have varying levels of efficacy and can only be adequately evaluated by well-designed clinical trials. Radiofrequency-assisted liposuction (RFAL) ablation of fat cells works by an oscillating electromagnetic current delivering energy to the fat cells, in turn, creating heat and causing destruction of the cells and subsequent phagocytosis.92 The additional thermal energy delivery has been purported to stimulate soft-tissue contraction due to immediate contraction of collagen fibers and/or neo-collagen deposition.93 RFAL consists of a monopolar point source with grounding pad or an asymmetric bipolar configuration that does not require a grounding pad.94 The bipolar configuration permits higher internal energy near the target adipocytes while maintaining a cooler temperature externally to stimulate skin tightening but limiting potential thermal skin injury.94 The highest level evidence is from a large retrospective review utilizing bipolar RFAL in multiple treatment areas; results indicate high levels of patient satisfaction with fat removal and skin tightening with minimal adverse events including swelling and nodules.95 “Cryolipolysis” has become a popular modality for non-invasive fat reduction. The concept is controlled cooling of the subcutaneous fat, with selective destruction of fat cells without epidermal or dermal injury due to adipose tissue’s relative sensitivity to cold. Injured adipocytes then undergo apoptosis and are cleared by a macrophage-mediated process. CoolSculpting (Zeltiq Aesthetics, Pleasanton, CA) has gained FDA clearance and is currently approved for fat reduction in the thigh, abdomen, and flanks in patients with BMI less than 30.

Typical treatment times are 1 h, and multiple handpieces may be used concurrently. Studies have shown a 15%–25% fat reduction in areas treated, and potential side effects are transient neuropraxia, induration, pain, erythema, and ecchymosis.96–99 Another potential catastrophic adverse outcome that has recently been under further investigation is paradoxical adipose hyperplasia thought to be a result of incomplete adipocyte injury and resultant repair.100 A large review of 2114 patients that received 8653 cycles of cryolipolysis demonstrated an incidence of PAH ranging from 0.11% to 0.05%.100 Patients should be educated regarding this rare but catastrophic potential adverse outcome. Non-invasive fat removal has become a major player in the area of body contouring. There is a clear role for it now and in the future as technology continues to improve. We do not believe it will replace liposuction, but will be another appropriate option that may be offered to patients with focal adiposity or who may not wish to undergo surgery. It is important to keep in mind that until adequate scientific validation of these devices is performed outside of manufacturer influence, any discussion of potential benefit is strictly advertisement and market driven. Physician oversight and patient evaluation will be critical to determine which patients may be candidates for non-surgical contouring and which may benefit from a surgical procedure. As new technology is continually being introduced, we must temper our enthusiasm and base treatment on solid, scientific evidence. Device manufacturers often provide scant, if any, objective data to support claims such as skin tightening, reduced pain, and improved aesthetic results, especially when compared with the gold standard of SAL.

Conclusion Over the past three decades, the procedure of liposuction has evolved and become consistently one of the most popular cosmetic procedures performed around the world. As evidenced by the large numbers of devices in clinical development and active clinical use, there remains a duty by the clinician to monitor not only the safety of the device but also the true efficacy. Although touted as a relatively simple procedure, the process of liposuction/liposculpture is as much an art as science. As such, the physician must understand the pathophysiology of both the patient and disease process in order to effectively treat the patient and achieve safe and aesthetically pleasing results. The authors are confident that liposuction will remain one of the most popular procedures performed in the years to come, and we must thus remain committed to the common goals of patient safety and improved aesthetic outcomes.

Bonus content for this chapter can be found online at Elsevier eBooks+ Fig. 25.2.10 The intraoperative data sheet records: essential information from the operative procedure. Fig. 25.2.13 The Liposonix (Bausch & Lomb, New Delhi, India) ultrasonic liposuction machine.

Access the reference list online at   Elsevier eBooks+

Fig. 25.2.14 The VASER system. (Solta Medical, Bothell, WA, USA) (Han X, Yang M, Yin B, et al. The efficacy and safety of subcutaneous radiofrequency after liposuction: a new application for face and neck skin tightening. Aesthet Surg J. 2021;41(3):NP94-NP100. doi: 10.1093/asj/sjz364.)

References

References 1. Illouz YG. History and current concepts of lipoplasty. Clin Plast Surg. 1996;23:721–730. 2. American Society for Aesthetic Plastic Surgery. Cosmetic Surgery National Data Bank. Available at: https://www.surgery.org/ media/statistics. 3. Lockwood TE. Superficial fascial system (SFS) of the trunk and extremities: a new concept. Plast Reconstr Surg. 1991;87:1009–1018. This landmark paper describes anatomical studies detailing the anatomy of the superficial fascial system. The findings of this report form the basis for widely accepted surgical strategies in body contouring. 4. Rohrich RJ, Beran SJ, Kenkel JM. Ultrasound-Assisted Liposuction. St Louis: Quality Medical Publishing; 1998. 5. Kenkel JM, Janis JE, Rohrich RJ, et al. Aesthetic body contouring: ultrasound-assisted liposuction. Oper Tech Plast Reconstr Surg. 2003;8:180–191. 6. Rohrich RJ, Smith PD, Marcantonio DR, et al. The zones of adherence: role in minimizing and preventing contour deformities in liposuction. Plast Reconstr Surg. 2001;107:1562–1569. 7. Rosenbaum M, Prieto V, Hellmer J, et al. An exploratory investigation of the morphology and biochemistry of cellulite. Plast Reconstr Surg. 1998;101:1934–1939. 8. Uebel CO, Piccinini PS, Martinelli A, Aguiar DF, Ramos RFM. Cellulite: a surgical treatment approach. Aesthet Surg J. 2018;38(10):1099–1114. https://doi.org/10.1093/asj/sjy028.PMID: 29432568. 9. DiBernardo BE. Treatment of cellulite using a 1440-nm pulsed laser with one-year follow-up. Aesthet Surg J. 2011;31(3):328–341. https://doi.org/10.1177/1090820X11398353.PMID: 21385743. 10. Nikolis A, Enright KM, Sapra S, Khanna J. A multicenter, retrospective evaluation of tissue stabilized-guided subcision in the management of cellulite. Aesthet Surg J. 2019;39(8):884–892. https://doi.org/10.1093/asj/sjy274. PMID: 30312363. 11. Sadick NS, Goldman MP, Liu G, et al. Collagenase Clostridium histolyticum for the treatment of edematous fibrosclerotic panniculopathy (cellulite): a randomized trial. Dermatol Surg. 2019;45(8):1047–1056. https://doi.org/10.1097/ DSS.0000000000001803. PMID: 30829779; PMCID: PMC6693937. 12. Trussler AP. Body Contouring. Selected Readings in Plastic Surgery. Dallas: Selected Readings in Plastic Surgery Inc; 2009:10–22. 13. Rohrich RJ, Broughton G 2nd, Horton JB, et al. The key to long term success in liposuction: a guide for plastic surgeons and patients. Plast Reconstr Surg. 2004;114:1945–1952. 14. Kenkel JM, Lipschitz AH, Luby M, et al. Hemodynamic physiology and thermoregulation in liposuction. Plast Reconstr Surg. 2004;114:503–513. Hemodynamic parameters during large-volume liposuction procedures were assessed. Metrics generally remained within safe ranges, but low body temperature was uniformly observed. 15. Kenkel JM. Safety considerations and avoiding complications in the massive weight loss patient. Plast Reconstr Surg. 2006; 117(1 suppl):74S–83S. 16. Broughton G, Crosby M, Coleman J, et al. Use of herbal supplements and vitamins in plastic surgery: a practical review. Plast Reconstr Surg. 2007;119:48e–66e. 17. Geerts WH, Bergquist D, Pineo GF, et al. Prevention of venous thromboembolism: American College of Chest Physicians evidenced based clinical practice guidelines (8th edition). Chest. 2008;133(suppl):381S–453S. 18. Hoyos AE, Millard JA. VASER-assisted high definition lipoplasty. Aesthetic Surg J. 2007;27:594–604. 19. Hoyos AE, Perez ME, Domínguez-Millán R. Variable sculpting in dynamic definition body contouring: procedure selection and management algorithm. Aesthet Surg J. 2021;41(3):318–332. https://doi.org/10.1093/asj/sjaa133. 20. Hoyos A, Perez M. Arm dynamic definition by liposculpture and fat grafting. Aesthet Surg J. 2012;32:974–987. 21. Danilla S, Babaitis RA, Jara RP, et al. High-definition liposculpture: what are the complications and how to manage them? Aesthetic

722.e1

Plast Surg. 2020;44(2):411–418. https://doi.org/10.1007/s00266019-01475-6. Epub 2019 Aug 20. 22. Smith H. Photographic Standards in Ultrasound-Assisted Liposuction. St Louis: Quality Medical Publishing; 1998:100–114. 23. Iverson RE, Lynch DJ. Practice advisory on liposuction and the ASPS Committee on Patient Safety. Plast Reconstr Surg. 2004;113:1478–1490. This document represents the findings of the ASPS's Committee on Patient Safety with regard to liposuction. 24. Horton JB, Reece EM, Broughton G, et al. Patient safety in the office-based setting. Plast Reconstr Surg. 2006;117:61e. 25. American Society of Anesthesiologists Task Force on Perioperative Management of Obstructive Sleep Apnea Practice guidelines for the perioperative management of patients with obstructive sleep apnea: a report. Anesthesiology. 2006;104:1081–1093. 26. Stephan PJ, Coleman J, Rohrich RJ. Obstructive sleep apnea implications for the plastic surgeon and ambulatory surgery centers. Plast Reconstr Surg. 2009;124:652–655. 27. Fodor PB. Wetting solutions in aspirative lipoplasty: a plea for safety in liposuction. Aesthet Plast Surg. 1995;19:379–380. 28. Rohrich RJ, Beran SJ, Fodor PB. The role of subcutaneous infiltration in suction-assisted lipoplasty: a review. Plast Reconstr Surg. 1997;99:514–519. 29. Klein JA. Tumescent technique for local anesthesia improves safety in large volume liposuction. Plast Reconstr Surg. 1993;92:1085–1098. 30. Klein JA. Tumescent technique for regional anesthesia permits lidocaine doses of 35 mg/kg for liposuction. Dermatol Surg Oncol. 1990;16:248–263. This paper addresses the pharmacokinetics that permit the use of high concentrations of lidocaine in tumescent liposuction. Tumescent liposuction is advocated as sustained analgesia and minimal blood loss are achieved with this technique. 31. Iverson RE, Pao VS. MOC-PS(SM) CME article: liposuction. Plast Reconstr Surg. 2008;121(4 suppl):1–11. 32. Klein JA. Intravenous fluids and bupivacaine are contraindicated in tumescent liposuction. Plast Reconstr Surg. 1998;102:2516–2519. 33. Matarosso A. Lidocaine in ultrasound-assisted liposuction. Clin Plast Surg. 1999;26:431–439. 34. Perry AW, Petti C, Rankin M. Lidocaine is not necessary in liposuction. Plast Reconstr Surg. 1999;104:1900–1902. 35. Physician’s Desk Reference 2011. Montvale: PDR Network; 2011: 1084–1085. 36. Ostad A, Kageyama N, Moy RL. Tumescent anesthesia with lidocaine dose of 55 mg/kg is safe for liposuction. Dermatol Surg. 1997;22:921–927. 37. Kenkel JM, Lipschitz AH, Shepherd G, et al. Pharmacokinetics and safety of lidocaine and monoethylglycinexylidide in liposuction: a microdialysis study. Plast Reconstr Surg. 2004;114:516–526. 38. Hatef DA, Brown SA, Lipschitz AH, et al. Efficacy of lidocaine for pain control in subcutaneous infiltration during liposuction. Aesthet Surg J. 2009;29:122–128. 39. Danilla S, Fontbona M, de Valdés VD, et al. Analgesic efficacy of lidocaine for suction-assisted lipectomy with tumescent technique under general anesthesia: a randomized, double-masked, controlled trial. Plast Reconstr Surg. 2013;132:327–332. 40. Paik AM, Daniali LN, Lee ES, Hsia HC. Local anesthetic use in tumescent liposuction: an American Society of Plastic Surgeons survey. Ann Plast Surg. 2015;74(2):145–151. https://doi. org/10.1097/SAP.0000000000000420. PMID: 25590254. 41. Failey CL, Vemula R, Borah GL, et al. Intraoperative use of bupivacaine for tumescent liposuction: the Robert Wood Johnson experience. Plast Reconstr Surg. 2009;124:1304–1311. 42. Swanson E. Prospective study of lidocaine, bupivacaine, and epinephrine levels and blood loss in patients undergoing liposuction and abdominoplasty. Plast Reconstr Surg. 2012;130(3):702–722. https://doi.org/10.1097/ PRS.0b013e31825dc408. PMID: 22929254. 43. Lipschitz AH, Kenkel JM, Luby M, et al. Electrolyte and plasma enzyme analyses during large-volume liposuction. Plast Reconstr Surg. 2004;114:766–777.

722.e2

SECTION III

CHAPTER 25.2  • Liposuction: a comprehensive review of techniques and safety

44. Brown SA, Lipschitz AH, Kenkel JM, et al. Pharmacokinetics and safety of epinephrine use in liposuction. Plast Reconstr Surg. 2004;114:756–763. 45. McKee DE, Lalonde DH, Thoma A, Glennie DL, Hayward JE. Optimal time delay between epinephrine injection and incision to minimize bleeding. Plast Reconstr Surg. 2013;131:811–814. 46. Abboud NM, Kapila AK, Abboud S, Yaacoub E, Abboud MH. The combined effect of intravenous and topical tranexamic acid in liposuction: a randomized double-blinded controlled trial. Aesthet Surg J Open Forum. 2020. https://doi.org/10.1093/asjof/ojab002. 47. Rodríguez-García FA, Sánchez-Peña MA, de Andrea GT, et al. Efficacy and safety of tranexamic acid for the control of surgical bleeding in patients under liposuction. Aesthetic Plast Surg. 2021. https://doi.org/10.1007/s00266-021-02486-y. Epub ahead of print. PMID: 34351508. 48. Cansancao AL, Condé-Green A, David JA, Cansancao B, Vidigal RA. Use of tranexamic acid to reduce blood loss in liposuction. Plast Reconstr Surg. 2018;141(5):1132–1135. https://doi. org/10.1097/PRS.0000000000004282. PMID: 29697607. 49. Rohrich RJ, Raniere J Jr, Beran SJ, et al. Patient evaluation and indications for ultrasound-assisted lipoplasty. Clin Plast Surg. 1999;26:269–278, viii. 50. Trott SA, Beran SJ, Rohrich RJ, et al. Safety considerations and fluid resuscitation in liposuction: an analysis of 53 consecutive patients. Plast Reconstr Surg. 1998;102:2220–2229. 51. Rohrich RJ, Leedy JE, Swamy R, et al. Fluid resuscitation in liposuction: a retrospective review of 89 consecutive cases. Plast Reconstr Surg. 2006;117:431–435. 52. Commons GW, Halperin B, Chang CC. Large-volume liposuction: a review of 631 consecutive cases over 12 years. Plast Reconstr Surg. 2001;108:1753–1767. 53. Mohammed BS, Cohen S, Reeds D, et al. Long-term effects of large-volume liposuction on metabolic risk factors for coronary heart disease. Obesity (Silver. Spring). 2008;16:2648–2651. 54. Tabbal GN, Ahmad J, Lista F, Rohrich RJ. Advances in liposuction: five key principles with emphasis on patient safety and outcomes. Plast Reconstr Surg Glob Open. 2013;1(8):e75. https://doi. org/10.1097/GOX.0000000000000007. 55. Wall SH. Jr., Lee MR. Separation, aspiration, and fat equalization: SAFE liposuction concepts for comprehensive body contouring. Plast Reconstr Surg. 2016;138(6):1192–1201. https://doi. org/10.1097/PRS.0000000000002808. 56. Rebelo A. Power-assisted liposuction. Clin Plast Surg. 2006;33:91– 105, vii. 57. Fodor PB. Power-assisted lipoplasty versus traditional suctionassisted lipoplasty: comparative evaluation and analysis of output (Letter). Aesthetic Plast Surg. 2005;29:127. 58. Rohrich RJ, Beran SJ, Kenkel JM, et al. Extending the role of liposuction in body contouring with ultrasound-assisted liposuction. Plast Reconstr Surg. 1998;101:1090–1119. 59. de Souza Pinto EB, Abdala PC, Maciel CM, et al. Liposuction and VASER. Clin Plast Surg. 2006;33:107–115. 60. Jewell ML, Fodor PB, de Souza Pinto EB, et al. Clinical application of VASER-assisted liposuction: a pilot clinical study. Aesthet Surg J. 2002;22:131–146. 61. Garcia O, Nathan N. Comparative analysis of blood loss in suction-assisted liposuction and third generation internal ultrasound-assisted liposuction. Aesthetic Surg J. 2008;28:430–435. 62. Woodhall KE, Saluja R, Khoury J, et al. A comparison of three separate clinical studies evaluating the safety and efficacy of laser-assisted lipolysis using 1,064, 1,320 nm, and a combined 1,064/1,320 nm multiplex device. Lasers Surg Med. 2009;41:774–778. 63. DiBernardo BE, Reyes J. Evaluation of skin tightening after laser-assisted liposuction. Aesthet Surg J. 2009;29:400–407. 64. DiBernardo B. Evaluation of skin shrinkage and skin tightening in laser lipolysis vs. liposuction: a randomized blinded split abdomen study. Lasers Surg Med. 2009;41:80. 65. Prado A, Andrades P, Danilla S, et al. A randomized, double blind, controlled clinical trial comparing laser-assisted lipoplasty with suction-assisted lipoplasty. Plast Reconstr Surg. 2006;118:1032–1045.

66. Hunstad JP, Aitken ME. Liposuction: techniques and guidelines. Clin Plast Surg. 2006;33:13–25. 67. Pitman GH, Giese SY. Body contouring: comprehensive liposuction. In: Mathes SJ, editor. Plastic Surgery. Vol. 6. Philadelphia: Elsevier; 2006:193–240. 68. Lehnhardt M, Homann HH, Daigeler A, Hauser J, Palka P, Steinau HU. Major and lethal complications of liposuction: a review of 72 cases in Germany between 1998 and 2002. Plast Reconstr Surg. 2008;121(6):396e–403e. https://doi.org/10.1097/ PRS.0b013e318170817a. PMID: 18520866. 69. Gingrass MK, Greenberg L. Liposuction of the trunk and lower extremities. In: Mathes SJ, ed. Plastic Surgery. Vol. 6. Philadelphia: Elsevier; 2006:273–290. 70. Hoyos AE, Millard JA. VASER-assisted high definition liposculpture. Aesthetic Surg J. 2007;27:594–606. 71. Stephan PJ, Kenkel JM. Updates and advances in liposuction. Aesthetic Surg J. 2010;30:83–97. 72. Koehler J. Complications of neck liposuction and submentoplasty. Oral Maxillofac Surg Clin North Am. 2009;21:43–52, vi. 73. Rooijens PP, Zweep HP, Beekman WH. Combined use of ultrasound-assisted liposuction and limited-incision platysmaplasty for treatment of the aging neck. Aesthetic Plast Surg. 2008;32:790–794. 74. Hughes CE 3rd. Reduction of lipoplasty risks and mortality: an ASAPS survey. that Aesthet Surg J. 2001;21:120–127. This survey was designed to examine changes that American Society for Aesthetic Plastic Surgery (ASAPS) member surgeons have made in response to the 1998 recommendations from the 1998 Lipoplasty Task Force. A major complication rate of 0.2602% and a mortality rate of 0.0021% were reported. 75. Young VL, Watson ME. Prevention of perioperative hypothermia in plastic surgery. Aesthet Surg J. 2006;26:551–571. 76. Matarasso A. The anatomic data sheet in plastic surgery: graphic and accurate documentation for standardized evaluation of results. Plast Reconstr Surg. 1993;91:734–738. 77. Gilliland MD, Coates N. Tumescent liposuction complicated by pulmonary edema. Plast Reconstr Surg. 1997;99:215–219. 78. Grazer FM, Meister FL. Complications of tumescent formula for liposuction (editorial). Plast Reconstr Surg. 1997;100:1893–1896. 79. PS News Bulletin. ASPRS urges members to exercise caution in lipoplasty procedures; task force call for scrutiny of training, large volume removals. Chicago: The American Society of Plastic Surgeons; 1998, Jan 26. 80. Hatef DA, Kenkel JM, Nguyen MQ, et al. Thromboembolic risks assessment and the efficacy of enoxaparin prophylaxis in excisional body contouring surgery. Plast Reconstr Surg. 2008;122:269–279. 81. Davison SP, Venturi ML, Attinger CE, et al. Prevention of thromboembolism in the plastic surgery patient. Plast Reconstr Surg. 2004;114:43e–51e. 82. Heitmann C, Czermak C, Germann G. Rapidly fatal necrotizing fasciitis after aesthetic liposuction. Aesthetic Plast Surg. 2000;24:344–347. 83. Trott SA, Rohrich RJ, Beran SJ, et al. Sensory changes after traditional and ultrasound-assisted liposuction using computerassisted analysis. Plast Reconstr Surg. 1999;103:2016–2025. 84. Chang KN. Surgical correction of postliposuction contour irregularities. Plast Reconstr Surg. 1994;94:126–136. 85. Chang KN. Long term results of postliposuction contour irregularities. Plast Reconstr Surg. 2002;109:2141–2145. 86. Matarasso A, Pfeifer TM. Plastic Surgery Educational Foundation Data Committee. Mesotherapy for body contouring. Plast Reconstr Surg. 2005;115:1420–1424. 87. Park SH, Kim DW, Lee MA, et al. Effectiveness of mesotherapy on body contouring. Plast Reconstr Surg. 2008;121:179e–185e. 88. Rittes PG. The lipodissolve technique: clinical experience. Clin Plast Surg. 2009;36:215–227. 89. Duncan DI, Hasengschwandter F. Lipodissolve for subcutaneous fat reduction and skin retraction. Aesthet Surg J. 2005;25:530–543. 90. Jones DH, Carruthers J, Joseph JH, et al. REFINE-1, a multicenter, randomized, double-blind, placebo-controlled, phase 3 trial with

References

ATX-101, an injectable drug for submental fat reduction. Dermatol Surg. 2016;42(1):38–49. 91. Rzany B, Griffiths T, Walker P, et al. Reduction of unwanted submental fat with ATX-101 (deoxycholic acid), an adipocytolytic injectable treatment: results from a phase III, randomized, placebo-controlled study. Br J Dermatol. 2014;170:445–453. 92. Blugerman G, Schavelzon D, Paul. A safety and feasibility study of a novel radiofrequency-assisted liposuction technique. Plast Reconstr Surg. 2010;125(3):998–1006. 93. Shridharani SM, Broyles JM, Matarasso A. Liposuction devices: technology update. Med Devices (Auckl). 2014;7:241–251. https:// doi.org/10.2147/MDER.S47322. 94. Chia CT, Marte JA, Ulvila DD, Theodorou SJ. Second generation radiofrequency body contouring device: safety and efficacy in 300 local anesthesia liposuction cases. Plast Reconstr Surg Glob Open. 2020;8(9):e3113. https://doi.org/10.1097/GOX.0000000000003113. 95. Cook J, DiBernardo BE, Pozner JN. Bipolar radiofrequency as an adjunct to face and body contouring: a 745-patient clinical

722.e3

experience. Aesthet Surg J. 2021;41(6):685–694. https://doi. org/10.1093/asj/sjaa417. 96. Coleman SR, Sachdeva K, Egbert BM, et al. Clinical efficacy of noninvasive cryolipolysis and its effects on peripheral nerves. Aesthet Plast Surg. 2009;33:482–488. 97. Zelickson B, Egbert BM, Preciado J, et al. Cryolipolysis for noninvasive fat cell destruction: initial results from a pig model. Dermatol Surg. 2009;35:1462–1470. 98. Nelson AA, Wasserman D, Avram MM. Cryolipolysis for reduction of excess adipose tissue. Semin Cutan Med Surg. 2009;28:244–249. 99. Avram MM, Harry RS. Cryolipolysis for subcutaneous fat layer reduction. Lasers Surg Med. 2009;41:703–708. 100. Nikolis A, Enright KM. A multicenter evaluation of paradoxical adipose hyperplasia following cryolipolysis for fat reduction and body contouring: a review of 8658 cycles in 2114 patients. Aesthet Surg J. 2021;41(8):932–941.

 

SECTION III •  General Aesthetic Surgery

25.3

Correction of liposuction deformities with the SAFE liposuction technique Simeon H. Wall Jr. and Paul N. Afrooz

Access video lecture content for this chapter online at Elsevier eBooks+

SYNOPSIS

ƒ Liposuction is growing in popularity and technological sophistication but sometimes results require revision. ƒ Revision and secondary liposuction differ. Although much of the information in this chapter pertains to both procedures, the focus will be on secondary procedures. ƒ When considering repeat liposuction, surgeons must accept that the result will never be as good as could have been achieved from an optimally performed primary liposuction, and the risk of serious injury is greater. ƒ In repeat liposuction, resistance may be due to an undesirable structure but could also be fibrotic subcutaneous tissue secondary to scarring. ƒ The loss of differential resistance in repeat liposuction is the primary reason that it is fraught with complications. ƒ SAFE is an acronym for Separation, Aspiration, and Fat Equalization. ƒ In repeat cases, a fourth step is frequently added that can include fat shifting, fat grafting, and release processes to address any residual defects or volume deficiencies.

Introduction Liposuction is growing in popularity and technological sophistication. It has become safer, faster, more effective, and more predictable. Surgeons performing liposuction understand the anatomy of fat and fluid management better. Advances in instrumentation and technique yield more predictable outcomes with less disruption of vascularity. However, sometimes the results require revision. Revision and secondary liposuction differ. Revision is a repeat operation typically performed by the same surgeon to improve the initial result, or deal with something not or suboptimally addressed in the primary procedure. Secondary liposuction is frequently performed by a different surgeon, and is usually far more extensive than a revision. Secondary

procedures are usually performed more than a year after the initial procedure, whereas revision procedures may fall within a year of the original surgery. Although much of the information in this chapter pertains to both procedures, the focus will be on secondary procedures, both types falling under the more generalized term of repeat liposuction. An unfavorable result may not be the only reason patients present for repeat liposuction. Many patients request repeat procedures for further reduction of an area already treated, having either gained weight or simply wanting further contouring of the area. Most commonly, however, patients are dissatisfied with contour deformities from the initial procedure. These can range from skin waviness, to divots and depressions. Patients can also have skin damage associated with these deformities in the form of hemosiderin deposition, pigmentary changes, and scarring from thermal or avulsive techniques. Internal scarring causes tethering, tightness, and a worsening appearance with positional changes or skin tension. External scarring is typically seen with thermal liposuction, leading to entry site burns or internal burns to the overlying skin, but can also be seen from non-thermal means, as a result of overaggressive or avulsive liposuction that devascularized the overlying skin (Fig. 25.3.1).

Challenges of repeat liposuction Many surgeons avoid repeat liposuction altogether. However, when considering repeat liposuction, surgeons must accept (1) the result will never be as good as could have been achieved from an optimally performed primary liposuction, and (2) the risk of serious injury is greater. Several factors contribute to the difficulty of repeat liposuction. Liposuction itself hinges on the premise that there is a relatively low-resistance, subcutaneous adipose layer between the higher-resistance overlying superficial fat and dermis and the underlying musculoskeletal structures. Fat is less dense and easier to disrupt than most surrounding tissues. Once this plane

724

SECTION III

CHAPTER 25.3  • Correction of liposuction deformities with the SAFE liposuction technique

A

B

C

D

Figure 25.3.1  (A–D) Examples of contour deformities from liposuction. (© 2017 Simeon Wall Jr.)

has been manipulated or disrupted, it becomes scarred and adherent, rendering navigation more difficult. For example, in primary liposuction, when significant resistance is encountered at the tip of the cannula, it generally indicates that an unwanted structure has been encountered and the cannula should be redirected. In repeat liposuction, resistance may be due to an undesirable structure, but could also be fibrotic subcutaneous tissue secondary to scarring. The surgeon must be able to discern the cause of this resistance and determine whether to continue with the high-resistance pass or stop and redirect. The loss of differential resistance in repeat liposuction is the primary reason that this is fraught with complications such as skin “end hits”. This is due to the surgeon’s tendency to redirect the cannula superficially, preferring to err superficially rather than into deeper, more vital structures. Loss of the

low-resistance plane can also result in potentially fatal abdominal perforation or damage to deeper structures. Cannula injury to skin and body structures, vascular disruption, major bleeding, musculoskeletal injury, and internal organ perforation have all been reported and are underreported in the literature. While these injuries are possible with any liposuction, they are far more likely to occur in repeat liposuction due to increased tissue resistance and scarred, confluent tissue beds that require more passes of the cannula with greater force.

The dose–response curve The dose–response curve is applicable to liposuction, wherein the dose is the amount of fat removed and the response is

Paradigms for the treatment of fat

subcutaneous irregularities until a threshold of contour deformity is reached. Despite considerable progress, including better safety in large-volume liposuction, no technologies introduced thus far have been able to break this “dose– response curve”. The introduction of many internal thermal technologies over the years has compounded this dose–response curve with the addition of the thermal load on the tissues, contributing further to inflammation and fibrosis. Repeat liposuction is usually significantly longer than primary procedures, due to scarring and the necessity of more passes to obtain a smooth result. Because the duration of liposuction is also directly related to fat removal, the prolonged duration further increases the likelihood of creating contour deformities due to excess fat removal. Frequently, repeat liposuction patients also require fat grafting, adding both complexity and additional procedure time. For all of these reasons, the method of liposuction utilized for both primary and secondary cases is crucial to obtaining satisfactory results.

Adjunctive energy modalities In traditional liposuction, the dose–response curve refers to the propensity toward contour deformities as the amount of fat removal increases. Thermal methods of liposuction (laser,

ultrasonic, radiofrequency, and others) can cause contour deformities related to thermal injury varying with the type and power of the device. Furthermore, thermal injury caused by these devices is not restricted to targeted fat, but may affect untargeted fat, as well as the supporting stromal network of tissue (Figs. 25.3.2 & 25.3.3). Particularly in repeat cases, fibrotic tissues require longer treatment times. This is associated with more thermal damage, fibrosis, scar formation, and often more contour deformities. For these reasons, the senior author has abandoned internal thermal liposuction technologies and opted to use strictly fat-preserving techniques for all cases (Fig. 25.3.4).

Paradigms for the treatment of fat Two paradigms are proposed for treating fat in body contouring. In fat grafting, effort focuses on optimal graft survival by maintaining a healthy recipient bed through preservation of supporting structures and vascularity. In contrast, in liposuction, the paradigm seems to be removal of fat with little regard for supporting structures. On one hand, the recipient bed is treated as delicately as possible, while on the other, liposuctioned fat and its bed are treated differently. Non-selective fat removal can be destructive to supporting structures while lending itself to contour deformities and increasing

B

A

Figure 25.3.2  (A,B) Examples of fibrotic and scarred areas after thermal liposuction. (© 2017 Simeon Wall Jr.)

A

B

Figure 25.3.3 (A,B) Examples of extensive subcutaneous scar tissue after liposuction of the abdomen. (© 2017 Simeon Wall Jr.)  

725

726

SECTION III

CHAPTER 25.3  • Correction of liposuction deformities with the SAFE liposuction technique

Liposuction with laser / UAL / RF

Laser / UAL / RF creates thermal injury

Cell death, inflammatory response

Fibrosis and scar formation

Dermis adheres to fascia

Contour deformities

Figure 25.3.4  Process of repeat liposuction with thermal devices. RF, radiofrequency; UAL, Ultrasound-assisted liposuction.

complexity of revision. Therefore, we believe in a single, comprehensive paradigm in treating fat: to augment, redistribute, or reduce to a desired contour, while preserving the remaining fat and surrounding structures.

Indications and contraindications Many of the indications and contraindications for repeat liposuction are similar to those for primary liposuction. Good candidates have a body mass index (BMI) of 30 or below, good diet and exercise habits, and have reasonable expectations. In patients seeking repeat liposuction due to the re-accumulation of fat, these factors become even more important. Patients who were not adherent to their initial postoperative care regimen, or who quickly gained weight following previous surgery, may not be ideal for a repeat procedure. Sometimes, patients requesting repeat procedures may not have had a previous positive experience. In these situations, one must explain the risks, benefits, and limitations of a secondary procedure. Unreasonable expectations (i.e., those unlikely to be achieved by available techniques) are a contraindication. It is recommended to wait at least 1 year and sometimes longer prior to performing a secondary procedure. This time is needed for the resolution of all swelling so that tissues are optimally soft, pliable, and elastic. Furthermore, a stable bed is necessary for the addition, redistribution, and subtraction of fat. Typically, the longer the time interval between the original surgery and the repeat operation, the better the chances for successful improvement.

Patient evaluation Some patients have such a paucity of fat after their initial liposuction procedure that it may not be possible to perform a

repeat procedure. Even with the SAFE liposuction (SAFELipo) process, some residual fat is necessary to create a smooth and natural-appearing contour. Solely relying on fat grafting to create a smooth appearance is difficult and should be approached cautiously.

Preoperative planning and preparation Sequential compression devices are applied to the lower extremities prior to anesthesia induction and utilized throughout surgery and until the patient is ambulatory. Passive and active warming is employed from an hour before surgery until discharge. A core temperature below 36°C at any time during surgery has been shown to increase bleeding, postoperative nausea and vomiting, and wound infection.

Surgical technique Anesthesia Repeat liposuction is typically performed under general anesthesia. With the exception of minor refinements, repeat liposuction is best not performed under local, tumescent, or conscious sedation for many of the same reasons that these methods are avoided for large-volume primary liposuction, and for one additional reason – the dense scar tissue that is frequently encountered limits the surgeon’s ability to painlessly pass infiltration and liposuction instruments. However, this may be dictated by surgeon preference.

Markings Contrary to the simple topographical markings made in most primary liposuction cases, repeat liposuction procedures typically require clearly delineated topographical markings of hills, valleys, and other irregularities. Although a “spot approach” is not used, it is still prudent to have a detailed map of the areas to be reduced, blended, or augmented. Areas are usually delineated with concentric black rings for reduction and cross-hatched markings in red for areas of redistribution or augmentation. Reference and orientation marks are quite useful and aid in symmetry when changing positioning (Fig. 25.3.5).

Patient positioning Positioning for repeat liposuction is as for primary liposuction. We avoid the prone position and have found it unnecessary. Adequate padding of all pressure points is important, as is careful prepping and draping. A single, whole-body prep with the sterile field extending from the neck down to the end of the bed is utilized so that the patient can be turned during the procedure without any additional prep. Repeat liposuction using the SAFELipo process is typically performed in three positions – supine, and left and right lateral decubitus positions. In addition to access, it is postulated that turning the patient into the lateral decubitus positions may reduce the risk of deep vein thrombosis and pulmonary embolism, as venous pressure is decreased on the elevated

Surgical technique

727

was carried out using a Klein needle for the infusion phase, followed by approximately 20 min of waiting to allow for maximum vasoconstriction of the tissues before performing step 1 of the SAFELipo process. Dr. Daniel Del Vecchio and the senior author proposed the utility of performing simultaneous separation and tumescence (SST) in the course of applying the SAFELipo process. Wall and Del Vecchio further refined this consolidation of steps, finding an optimal set of instruments, flow rates, and delivery techniques to ensure better and quicker vasoconstriction, with the added benefit of simultaneously effecting a significant amount of fat separation. In this technique, the infiltration of the wetting solution is combined with step 1, fat separation. This drastically reduced the time needed for maximum vasoconstriction to take effect, while also streamlining the procedure by combining these two aspects of the surgery.

Step 1: Separation

Figure 25.3.5  Example of preoperative marking. (© 2017 Simeon Wall Jr.)

side, thereby decreasing pooling and improving pelvic venous drainage. Performing liposuction from these three positions can prevent contour deformities, including “shark bites” in the mid-buttocks and other liposuction stigmata. The lateral decubitus position most closely resembles the normal, standing position. This allows contouring to match the position the patient sees themselves in a mirror. Furthermore, this position allows for treatment of the upper abdomen, while the supine position may not, due to the hyperextended supine position of the abdomen, interference from the underlying ribcage, and adherence of the tightened abdominal skin to the underlying framework. In lateral decubitus, the patient’s upper abdominal skin can be pulled away freely from the underlying ribs, which are not as protuberant in this position given increased abdominal flexion.

Technique SAFE is an acronym for Separation, Aspiration, and Fat Equalization, representing the steps carried out in primary liposuction and offering comprehensive fat management. In repeat cases, a fourth step is frequently added that can include fat shifting, fat grafting, and release processes to address any residual defects or volume deficiencies (Video Lecture 25.3.1 ). Liposuction requires the adequate infusion of wetting solution to minimize blood loss, provide additional anesthesia, and increase the working space by volume expansion. In primary cases, a typical superwet infusion is utilized, with a ratio of 1 : 1 or 1.5 : 1 infusion to aspiration. However, in repeat procedures, volume expansion of the target zone is essential to adequately traverse the tissue planes; therefore, a tumescent approach with a ratio of 2 : 1 or even 3 : 1 is frequently needed. In the past, this step

Fat separation was originally carried out with an angled variation of a Becker basket cannula but is more efficiently performed with an angled exploded cage fat separator. This step accounts for approximately 40% of the total procedural time. Fat separation is performed using power-assisted liposuction (PAL) without suction to maximize the movement and effect of the wings on the exploded cage cannulas and to minimize effort and surgeon fatigue during liposuction. However, all aspects of SAFELipo can be accomplished manually without power, albeit much less efficiently. The angled cannulas or dissectors have a blunt tip and “wings” or baffles that create highand low-pressure zones adjacent to the wings of the cannula. These low-pressure zones allow fixed fat globules to dislodge and detach from their surrounding attachments, separating these droplets of fat from each other and from their supporting networks of blood vessels and stromal tissues without the disruption of these vessels and stroma. This mechanical emulsification, or separation, process changes the solid fat architecture into a more liquid, less dense, environment in the targeted areas, creating a treatment zone of low-resistance emulsified fat and higher-resistance untreated areas above (skin) and below (musculoskeletal structures) the target zone. This creates a differential resistance in the treatment planes, which is crucial to safely and easily navigate through the area during the second step of aspiration. In repeat liposuction, creating this differential resistance is critical because the natural differential resistance between the fat and surrounding layers has been obliterated due to scarring and adhesions from prior procedures. This fibrotic bed typically manifests as an inability to pass the infiltration or liposuction cannulas through the tissues. This may lead to end hits to the skin or damage to deeper structures, and in the past has been almost unavoidable. The fat separation step allows the surgeon to regain the lost differential resistance between these planes, allowing the target zones to be navigated more easily. Whether the goal is to remove more fat, redistribute remaining fat, or add more fat to the area, the resistance differential of the targeted zone has been re-established and is more similar to that of a primary liposuction procedure. The supporting structures and blood vessels are spared since they remain solid and distinct from the targeted, emulsified fat that is preferentially aspirated.

728

SECTION III

CHAPTER 25.3  • Correction of liposuction deformities with the SAFE liposuction technique

Fat separation does not equate to undermining of tissue. Therefore, tissue and blood vessels surrounding the fat are left intact. This process is analogous to shaking an apple from a tree, a relatively gentle procedure, as opposed to cutting off an entire branch. The desired endpoint is loss of resistance of all targeted fat, demonstrating that the target zone has been adequately mechanically emulsified.

Step 2: Aspiration Following separation, a more conventional cannula (e.g., a 2.7-, 3-, or 4-mm PAL long port single or double Mercedes) with smaller, less aggressive, and numerous ports is utilized to aspirate the emulsified fat. Because the fat has already been separated, this process is fast and almost entirely bloodless and can be accomplished with smaller, less aggressive cannulas with minimal trauma to surrounding fat left behind. This residual fat is needed to provide a smooth, natural contour. Fat aspiration usually encompasses approximately 40% of the total treatment time. However, the amount of time needed in repeat liposuction can be highly variable due to variable amounts of fat to be aspirated. If very little fat aspiration is needed, step 2 may be used only in predetermined fat donor areas for fat harvest. In contrast to standard liposuction, which utilizes tremendous negative pressure to forcibly avulse fat and supporting structures in their natural, high-resistance state, the mechanically emulsified fat that has been separated is suctioned preferentially out of the subcutaneous layer, leaving behind an intact supporting network.

Step 3: Fat equalization The third step of SAFELipo is fat equalization, and similar to step 1, this step is performed with the exploded cage probe without suction. If unusual resistance and/or unseparable fat is encountered, the more baffled separators can be utilized to ease equalization of the area. Step 3 typically accounts for approximately 20% of the total procedural time. When beginning to use the SAFELipo process, many practitioners find that they spend less time in step 1 but far more time in step 3 in an effort to equalize the remaining tissue bed. As experience grows and the importance of step 1 is fully realized, the 40/40/20 time split is more common. In repeat liposuction procedures, more time is spent trying to equalize remaining hills and valleys, with aggressive molding and contour equalization of the remaining fat bed with the opposite hand while moving the exploded tip instrument back and forth through the uneven tissue bed. This fat equalization step effectively separates some of the remaining fat, eliminating unevenness, and leaving this newly separated fat as a smooth layer of “local” fat grafts that prevent adherence of the dermis down to the deeper fascia or other musculoskeletal structures. This blanket of “local” fat grafts is left in place to create a barrier against scarring, skin adhesions, and resultant contour deformities. Furthermore, this even layer of local fat grafts provides the smooth and natural appearance seen in SAFELipo procedures even when the remaining layer of fat is left very thin. This is in sharp contrast to other forms of liposuction that typically create unsightly contour deformities as the fat layer becomes progressively thinner. As in primary liposuction procedures, the utility of the SAFELipo process in repeat

procedures allows for much more versatility and applicability when faced with uneven, complex, fat-deficient, or severely fibrotic areas. One of the biggest challenges of liposuction is the removal of unwanted fat in an area without creating a dented, lumpy, or wavy surface. SAFELipo has answered that challenge by creating dramatic yet smooth and natural results, and eliminating the traditional “dose–response curve” of liposuction. For primary and repeat cases, the endpoint of the fat equalization step is a smooth rolling pinch test. Using both hands without any instrumentation, the skin is gently pinched and rolled between the fingers and thumbs across the entire area in multiple different directions to assess the smoothness of the skin and underlying fat layer. In areas of persistent unevenness, the exploded cage dissector can be inserted and pushed back and forth through the uneven area while “pinching up” the area with the opposite hand and applying gentle pressure to the uneven area. In repeat cases where the area is still uneven, fat shifting and aggressive manual molding is carried out, along with formal fat grafting if the area is still volume-deficient at that point. Finally, release of any remaining skin adhesions is performed in a conservative and precise fashion at this time. Most plastic surgeons are very familiar with the traditional “spot” approaches that have been widely taught in treating contour deformities. This approach treats “hills” with liposuction and “valleys” with fat grafting (Fig. 25.3.6). This requires extensive preoperative marking and long procedure times. In stark contrast, equalizing an entire area with SAFELipo is technically simpler to perform, with the added benefit of making formal fat grafting unnecessary in many cases. If formal fat grafting is still necessary, the preceding SAFELipo process provides a receptive environment for the fat grafts, unlike the inhospitable recipient bed following thermal methods of liposuction or wide undermining sometimes advocated using a spot approach.

Preventing contour deformities Several techniques facilitate the prevention of contour deformities during liposuction. Suction should cease during the insertion and removal of cannulas at the entry site by pinching the suction tube or turning off power. Angled cannulas are used exclusively. These can be rotated and redirected without needing to retract the cannula back near the entry point. This prevents digging holes and also allows for more complete coverage of an area. Areas closest to the incision should always be treated last, and the fat should be carefully equalized at the access sites at the conclusion of the case. All access sites except the sites used for formal fat grafting are left open to drain, minimizing fluid accumulation, bruising, and persistent swelling. Finally, we avoid suctioning of the mid-buttock area to prevent subsequent contour deformities. Rather than suctioning, we frequently prefer fat grafting this area to achieve an optimal contour postoperatively.

Ancillary procedures The Cellfina cellulite device is useful and effective in releasing tethered areas, or dimples, in a precise and standardized

Results and outcomes

729

Fat grafting to areas of depression Ideal plane

Fascia

Fibrotic area

Muscle

Adipose tissue

fashion in repeat liposuction. The precise, vacuum-assisted release of tethered spots at a controlled depth minimizes bleeding, disruption of the supporting stromal network, and ultimately ensures less disruption of fat that may have been grafted into these areas. Prior to the procedure, areas designated for treatment with Cellfina are photographed and marked. The device is utilized only during the final step of the SAFELipo process, when residual defects are addressed. The Cellfina device obviates the need for traction sutures and large, imprecise cutting cannulas or wires. To optimize results, repeat liposuction may be combined with additional body contouring procedures, including abdominoplasty or breast enhancement procedures. Fat harvesting from repeat liposuction areas for transfer to other body areas is also feasible, although the quality of fat grafts may not be as optimal as in a primary procedure. In this regard, there are few differences between primary and secondary.

Postoperative care Postoperative healing is more complex following repeat liposuction. These patients are prone to prolonged swelling and the development of unevenness, seromas, and contour deformities. Patients are counseled that it will take at least 1 year, and sometimes up to 2 years or longer, for all swelling to resolve and for the skin to soften and resume more normal pliability and elasticity. Furthermore, they are more prone to paresthesias and dysesthesias. Early postoperative recognition and management with Lyrica, desensitization therapy, and massage treatments beginning 2 weeks postoperatively can mitigate this. These patients frequently benefit from prolonged compression to assist in resolution of swelling and discomfort, as well as prevention of contour deformities. Half-inch or 1-inch Reston foam (3 M Inc., St. Paul, MN) is used for uniform compression of smooth, treated areas. One-inch foam with cutouts is used for differential foam compression for large depressions where formal fat grafting has been performed. The foam

Figure 25.3.6  Liposuction of protuberant areas, avoiding areas of depression, while fat grafting the depressed areas – the “spot approach”.

is held in place by a compression garment that is snug, but less compressive or constricting than typical garments used in liposuction. Simple instructions with pictures on how to use the foam will prevent mishaps and irritations: foam is lined on all edges with gauze to prevent blisters; the foam is unstuck the morning after surgery and at 2–3 days postoperatively. Simply unsticking the foam and reapplying it immediately prevents traction blisters from forming and keeps patients more comfortable. The same foam can be used for 2 weeks around the clock, then for 2 weeks during the day only, with nothing on at night. Wearing nothing at night allows the body to get used to handling the edematous areas and also prevents any compression lines. Baby powder can be used under the foam for greater comfort or, if needed, a spandex compression shirt or tight cotton shirt can be worn under the foam if sensitivity develops. With repeated washing, the foam will become softer and more comfortable. Beware of applying new foam postoperatively as it is stiff and sticky and can cut into the patient’s skin causing blisters or ulcerations. Beyond foam and the accompanying compression garment, patients are instructed to avoid skin creases and flexion in susceptible areas (mostly the abdomen). Tight constricting clothes should be avoided for at least 4 months.

Results and outcomes SAFELipo for repeat liposuction improves on traditional, thermal, and other forms of liposuction in several ways. Fat is reduced and redistributed, and areas are augmented to the desired thickness and equalized throughout entire anatomic units, allowing for thorough and aggressive liposuction without increasing the risk of contour deformities. There is some evidence that the fat separation and equalization in SAFELipo promotes angiogenesis and improved oxygen tension in ischemic adipose tissue by activating resident adipose stromal cells. It is likely that this promotes healthy adipose tissue repair and reconstruction.

730

SECTION III

CHAPTER 25.3  • Correction of liposuction deformities with the SAFE liposuction technique

Problems and complications It must be understood that revision and secondary liposuction procedures are associated with less ideal outcomes than other revisionary cosmetic procedures. Patients undergoing extensive repeat liposuction will almost always have some degree of residual deformity from existing contour

irregularities, skin imperfections, or scarring that compromises the overall result. Furthermore, some residual areas of deformity will not be amenable to repair, particularly if the previous procedure involved thermal or avulsive methods. The amount of fibrosis and scarring from these liposuction methods generally reduces the feasibility of successfully treating all residual deformities. (For more examples, see Figs. 25.3.7–25.3.10 .)

Bonus images for this chapter can be found online at Elsevier eBooks+ Fig. 25.3.7 (A,C,E) A 30-year-old female with history of multiple rounds of liposuction, including suction-assisted liposuction and ultrasound-assisted liposuction, was treated with SAFELipo of superficial abdomen, release processes, 60mL fat grafting. (B,D,F) She is seen at 1 year postoperatively. (© 2017 Simeon Wall Jr.) Fig. 25.3.8 (A–C)Stage 1: SAFELipo of circumferential trunk and chest – 4.5 L. (D–F) Stage 2: superficial SAFELipo of abdomen and flanks – 1.3 L. Fig. 25.3.9 A 48-year-old female with history of prior suction-assisted liposuction of circumferential trunk, thighs, and knees elsewhere was treated with SAFELipo of circumferential trunk, circumferential thighs, knees, calves, lower face, jowls, and neck – 6.8 L. Fig. 25.3.10 A 52-year-old female with a history of suction-assisted liposuction of circumferential trunk and thighs ×3, with residual lipodystrophy of the circumferential trunk, was treated with SAFELipo of circumferential trunk with mini-abdominoplasty – 3.3 L.

Problems and complications

A

D

B

E

C

F

730.e1

Figure 25.3.7  (A,C,E) A 30-year-old female with history of multiple rounds of liposuction, including suction-assisted liposuction and ultrasound-assisted liposuction, was treated with SAFELipo of superficial abdomen, release processes, 60 mL fat grafting. (B,D,F) She is seen at 1 year postoperatively. (© 2017 Simeon Wall Jr.)

730.e2

SECTION III

CHAPTER 25.3  • Correction of liposuction deformities with the SAFE liposuction technique

A

B

C

D

E

F

Figure 25.3.8  (A–C) Stage 1: SAFELipo of circumferential trunk and chest – 4.5 L. (D–F) Stage 2: superficial SAFELipo of abdomen and flanks – 1.3 L. (© 2017 Simeon Wall Jr.)

Problems and complications

A

B

C

D

E

F

730.e3

Figure 25.3.9   A 48-year-old female with history of prior suctionassisted liposuction of circumferential trunk, thighs, and knees elsewhere was treated with SAFELipo of circumferential trunk, circumferential thighs, knees, calves, lower face, jowls, and neck – 6.8 L.

730.e4

SECTION III

CHAPTER 25.3  • Correction of liposuction deformities with the SAFE liposuction technique

Figure 25.3.9, cont’d  (A,C,E,G,I) Before SAFELipo; (B,D,F,H,J) after SAFELipo. (© 2017 Simeon Wall Jr.)

G

H

I

J

Problems and complications

A

C

730.e5

B

D

Figure 25.3.10   A 52-year-old female with a history of suction-assisted liposuction of circumferential trunk and thighs ×3, with residual lipodystrophy of the circumferential trunk, was treated with SAFELipo of circumferential trunk with mini-abdominoplasty – 3.3 L. (A,C) Before SAFELipo; (B,D) after SAFELipo. (© 2017 Simeon Wall Jr.)

 

SECTION III •  General Aesthetic Surgery

26 Editors’ perspective: abdominal contouring Alan Matarasso

Until the late 1980s, abdominal contour surgery was one operation limited to a standard full abdominoplasty for all candidates. The introduction of liposuction revolutionized abdominal surgery and indeed all of body contour surgery, as well as many other aspects of plastic surgery. Liposuction surgery has appropriately been designated one of the biggest advances in plastic surgery, in general. In the abdomen, the use of liposuction changed the nature of the procedure and increased the range of available operations, thereby increasing the scope of candidates that could benefit from surgery by fundamentally changing our ability to improve contour. Consequently, abdominal contour surgery is now recognized as a group of procedures from liposuction alone, to limited abdominoplasties, full abdominoplasty, a 270° abdominoplasty or circumferential abdominoplasty; all with and without liposuction of the abdomen and adjacent regions. In addition to the expanded operative choices, surgeons have made other notable advances in abdominal contour surgery by decreasing complication rates such as seromas, stratifying and reducing risk factors, including thromboembolism, made use of more refined wetting solutions and improved liposuction instrumentation. We now have safer pain management methods, enhanced recovery systems and improved pre- and postoperative protocols. Anatomic features such as hip or umbilical asymmetries and their impact on outcomes have been recognized, as well as umbilical aesthetics, rectus muscle variations and their management, and different methods of skin closure have also been reported. Surgeons used

different types of drains, quilting sutures, glue, or combinations to close dead space. The risks associated with the procedures have been quantified by culling numerous databases (CosmetAssure, NSQUIP, AAAASF, ASPS, TOPS, etc.), as well as case series and surveys. Utilizing this information, surgeons have endeavored to improve outcomes and safety. With all plastic surgery procedures, it is a balance between achieving optimal aesthetic results while ensuring safety. In abdominal contour surgery, in addition to reversing the consequences of aging, pregnancies and weight fluctuations, surgeons are concerned with simultaneously reshaping the abdomen as well as when indicated the surrounding flanks, mons pubis, buttocks, thighs, and back rolls to give a more harmonious and uniform appearance. Abdominal sculpting and etching methods, or high-definition liposuction in the closed (liposuction) and open (abdominoplasty) situations can also be incorporated, when indicated to reshape the abdomen. Plastic surgeons have explored the impact of unrelated concomitant aesthetic procedures on overall operative risk; we have studied the use of mesh, combining hysterectomy with abdominoplasty, performing abdominoplasty in conjunction with childbirth, and repairing hernias simultaneously, along with many other technical advances that improve patients’ outcomes and satisfaction. Since the inception of the classic abdominoplasty in our early literature, abdominoplasty has evolved from one operation to fit all patients to a group of operations based on anatomy, sound surgical principles, and patient goals.

 

SECTION III •  General Aesthetic Surgery

27 Abdominoplasty Alan Matarasso

Access video and video lecture content for this chapter online at Elsevier eBooks+

SYNOPSIS

ƒ Abdominolipoplasty is a system of classification and treatment for abdominal contour surgery based on the treatable soft-tissue layers of skin, fat, and muscle of the abdominal wall. ƒ Lipoabdominoplasty is a modification of traditional abdominoplasty that incorporates liposuction of the underlying flap and potentially other areas. The safety of lipoabdominoplasty is based on the manner in which the flap is undermined (inverted “V” style), extent of liposuction, and degree of liposuction, as well as the tension on wound closure. ƒ Complications in abdominoplasty have been reported as local versus systemic, and early or late. Numerous databases for complications exist, and depending upon what they capture, the findings may vary. ƒ Venous thromboembolism occurs more often in abdominoplasty than in other aesthetic procedures. Consequently, screening for high-risk situations, risk modifications, perioperative (pre- and intraoperative) prophylaxis, and postoperative surveillance should be instituted and are essential in these patients. ƒ Depending upon a patient’s goals and anatomy, there are other abdominal contour procedures available. These less-invasive procedures, known as “downstaging,” can be considered, but do not yield the same result as a full abdominoplasty. ƒ Secondary full abdominoplasty means the first operation was different (i.e., liposuction or limited abdominoplasty), or due to age, pregnancies, or unsatisfactory results after a primary abdominoplasty, then the second operation. A revision of a procedure refers to a re-operation by the original surgeon for a complication, unsatisfactory result, or the need for further improvement.

Introduction Abdominal contour surgeries and abdominoplasty are commonly requested procedures for many reasons, including the concerns of an aging population determined to maintain a youthful physique, women intent on restoring their pre-pregnancy appearance, the rise in massive weight loss patients

who are seeking to remove the stigmata of residual excess skin from weight loss, and the enhancement of self-esteem due to the implicit correlation with the appearance of a person’s abdomen and its association with health and fitness. Indeed, for many patients, the appearance and the girth of the abdomen represents a proxy for their health, fitness, and body weight. Abdominal contour surgery constitutes a variety of procedures aimed at the aesthetic improvement of the treatable soft-tissue layers of skin, fat, and muscle (Table 27.1) that impact the patient’s appearance. The goal is a firmer, flatter, more youthful-appearing abdomen through the least conspicuous and most hidden scar feasible. Depending on the anatomic nature of the “disagreeable biologic condition”, these goals can be achieved through a range of procedures referred to as the abdominolipoplasty system of classification and treatment. These procedures include liposuction alone (type I), the limited abdominoplasties – mini-abdominoplasty (type II), modified abdominoplasty (type III), and a full standard abdominoplasty (type IV) with liposuction (lipoabdominoplasty) or without liposuction of the flap (Fig. 27.1).1–5 The indications for abdominoplasty are excess upper or lower abdominal skin with or without lipodystrophy and rectus muscle diastasis. The anatomic boundaries of the abdomen that an abdominoplasty treats generally span from the anterior superior iliac spine to anterior superior iliac spine (ASIS) and from inframammary to pubic area. Abdominoplasty patients may request additional contouring of the flank via liposuction or flank skin excision, known as a 270° lift (or flankplasty), or completely around the entire trunk and posterior aspects, referred to as a circumferential lift or 360° liposuction. Fleur-de-lis abdominoplasty, reverse abdominoplasty, high-definition abdominoplasty, high lateral tension abdominoplasty, and bariatric plastic surgery are among the other abdominal procedures utilized. This chapter will provide a conspectus on abdominal contour surgery and focus on abdominoplasty alone or abdominoplasty

Introduction

733

Table 27.1  Abdominoplasty system of classification and treatment for abdominal contour surgery: based on the treatable soft-tissue layers of the skin, fat, and muscle

Type

Skin

Fat

Musculofacial system

Treatment

I

Minimal laxity

Variable

Minimal diastasis

Suction-assisted lipectomy

II

Mild laxity

Variable

Lower diastasis

Mini-abdominoplasty

III

Moderate laxity

Variable

Lower ± upper diastasis

Modified abdominoplasty

IV

Severe laxity

Variable

Complete upper and lower diastasis

Standard abdominoplasty with or without suction lipectomy

Figure 27.1  The abdominoplasty system of classification and treatment. The common abdominal procedures: type I, liposuction; type II, mini-abdominoplasty; type III, modified abdominoplasty; type IV, full abdominoplasty with liposuction (lipoabdominoplasty) or without liposuction. E, Excision; SAL, suction-assisted lipectomy; U, undermining. (From Matarasso A. Traditional abdominoplasty. Clin Plast Surg. 2010;37(3):415–437, with permission.)

734

SECTION III

CHAPTER 27  • Abdominoplasty

with liposuction (lipoabdominoplasty) (see Table 27.1), as seen in the most frequently encountered scenario of the postpartum patient.

Access the Historical Perspective section online at Elsevier eBooks+

Patient selection and screening The female abdomen undergoes the inevitable changes that all people do as a consequence of aging, weight fluctuations, and sun damage, in addition to the profound and inevitable changes from pregnancy. These issues manifest themselves as loose, damaged, and excess skin, rectus muscle diastasis and stretching, lipodystrophy, widened bony pelvic girth, potentially umbilical hernias and umbilical skin damage, and mons pubic alteration with distortion, widening, and ptosis. A full abdominoplasty is the procedure that most comprehensively addresses these changes. It can be supplemented with flap liposuction, additional skin removal, hernia repair or adjacent liposuction, as well as other unrelated aesthetic procedures. Patients are examined and classified based on their anatomy and assigned to the appropriate abdominolipoplasty classification and treatment type (Fig. 27.1). Their physical characteristics are assessed, and this information is reconciled with their tolerance for incisions, discomfort, healing time, cost, and so forth. They are offered the abdominal contour procedure most suitable to their anatomic needs and preferences. It cannot be overemphasized enough that if they choose a less-invasive or non-surgical procedures, a concept referred to as “downstaging”, although associated with less operative time, faster recovery, and lower costs, those operations do not provide the equivalent outcome of a full abdominoplasty. Anatomic conditions that contribute to a patient’s appearance and are not improved with abdominoplasty, such as intra-abdominal fat, skeletal or spinal disfigurement, uterine malposition, and gastrointestinal dysfunction, such as bloating or distention, should be discussed and clearly conveyed to the patient. Furthermore, the surgeon should consider if the operation proposed addresses the concerns of the patient: that is, do the expectations coincide with the anticipated outcome, and if it can be determined, if the patient will be pleased with the result, “managing the patient’s expectations” is an important component of all aesthetic surgery.

Anatomy Richter has summarized the pertinent anatomy of the anterior abdominal wall.13 Preservation of the vascular anatomy is an important factor in providing protection from skin ischemia, particularly when liposuction is performed. Lymphatic drainage of the abdominal wall infra-umbilically passes in sub-Scarpa’s plane, explaining the rationale for Scarpa’s fascia preservation and its potential reduction in seroma formation. Finally, knowledge of the innervation patterns assists in nerve blocks (i.e., TAP, Exparel [Pacira Pharmaceuticals, Parsippany, NJ], and pain pumps) for pain control and also for avoiding nerve entrapment syndromes (see Complications section below).14–16

Preoperative planning and preparation Preoperative preparation begins from the time of the initial consultation, and is a multidimensional process based on a series of conversations with the physician, the staff, the anesthesiologist, ancillary personnel, and the patient. Patients receive an extensive informational brochure at the time of the consultation. Prior to surgery, they receive another detailed package outlining the preparation for surgery and the postoperative process. This includes a comprehensive list of products that adversely affect coagulation that are to be discontinued, including all non-essential supplements and over-the-counter products. For all abdominal contour surgery procedures, patients are instructed to cease nicotine-containing products and compounds that affect clotting, including hormones, for two to four weeks prior to the procedure. All patients are evaluated by a primary care physician or a specialist when indicated and undergo appropriate diagnostic laboratory tests. A history of non-IVF-related miscarriages can be a marker for these hypercoagulable conditions and that requires evaluation. Consideration is given to obtaining “special” hematology testing for genetic prothrombogenic clotting factors because patients who have these are at a considerable increased risk for blood clots. Friedman et al.17 offer an excellent historical battery for routine screening of hereditary thrombophilias such as protein-C deficiency, protein-S deficiency, factor V Leiden mutation or prothrombin 20210 A mutation (Box 27.1). Furthermore, with the advent of COVID19, patients post convalescence have been noted to be in a hypercoagulable state for many weeks. All patients, including fully vaccinated ones, are PCR tested as close as possible to surgery, and then quarantined before and after surgery to prevent the systemic impact of COVID-19 on a perioperative

BOX 27.1  Risk factors to consider in routine screening for thrombophilia Personal history of VTE (including during pregnancy or while taking oral contraceptives). Unusual site of thrombosis (mesenteric, splenic, portal, hepatic, cerebral) also increases suspicion. Personal history of idiopathic, migratory, or recurrent SVT in the absence of varicose veins. Personal or family history of skin necrosis when receiving warfarin. Warfarin decreases the level of natural anticoagulants, rendering the patient temporarily hypercoaguable. Development of skin necrosis is suggestive of pre-existing protein C or protein S deficiency. Personal history of adverse pregnancy outcomes, including consecutive spontaneous abortions later than 10 weeks of gestation, three non-consecutive spontaneous abortions, severe unexplained intrauterine growth restriction, intrauterine fetal death, placental abruption, or severe preeclampsia. First-degree relative who had a VTE, especially at a young age. First-degree relative with known hereditary coagulopathy. First-degree relative of a neonate with purpura fulminans without sepsis. This suggests a homozygous state of protein C and protein S deficiencies. VTE, Venous thromboembolism; SVT, superficial venous thrombosis. Reproduced from Friedman T, O’Brien Coon D, Michaels JV, et al. Hereditary coagulopathies: practical diagnosis and management for the plastic surgeon. Plast Reconst Surg. 2010;125;1544–1552.

Historical perspective

Historical perspective The modern history of abdominoplasty can be traced back to the late 1960s and the contribution of several surgeons. These procedures have evolved into the present-day abdominal contour surgery owing to the advances in technique (e.g., incision design, muscle treatment), technology (e.g., liposuction

734.e1

techniques), a changing population (e.g., massive weight loss), a better understanding of physiology (e.g., wetting solutions), and anatomy (e.g., the ability to do combined procedures and flap liposuction). Similar to most scientific advances, in abdominoplasty these strides have been incremental. Numerous surgeons have provided contributions to present-day abdominoplasty surgery. Table 27.2 offers a brief and incomplete overview of milestones and abdominoplasty evolution.6–12

Table 27.2  Milestones in the evolution of abdominoplasty and abdominolipoplasty

Time period

Milestone

1960s–1970s

Pitanguy, Regnault, Grazar: Classic abdominoplasty

1982

Illouz: Introduction of SAL

1987

Greminger, Noone, Wilkinson, and Hakme: Mini-abdominoplasty with liposuction

1988

Matarasso, Psilakis: Abdominoplasty system of classification and treatment

1991

Matarasso: Liposuction as an adjunct to full abdominoplasty

1992

Illouz: Abdominoplasty “mesh undermining”, marriage abdominoplasty (Shestak – 1999)

1995

Lockwood: HLT abdominoplasty Matarasso: SA 1–4 zones based on Huger blood supply

2001

Hakme, Avelar, Saldahina, De Souza Pinto, Saltz: Liposuction

2000s

Rise in bariatric plastic surgery

Late 2010s

Persing/others: Validation studies of lipoabdominoplasty and measures to improve safety and recommendation regarding DVT/PE

2012

Pannuci, et al., ASPS VTE Task Force, Eric Swanson, etc. VTE prophylaxis

2017

Janis, Pollack, et al. Seroma prevention, quilting sutures

2020

Hoyos: High-definition liposuction and abdominoplasty

ABD, Abdominoplasties; DVT, deep vein thrombosis; HLT, high lateral tension; PE, pulmonary embolism; SA, suction-assisted; SAL, suction-assisted lipectomy; VTE, venous thromboembolism.

Informed consent

patient. Recommendations are evolving, but currently surgery should be delayed for 6 weeks after vaccines and any SARS-COVID infection, and then D-dimer testing is done to determine the patient’s coagulability prior to surgery. Professional medical photographs of all proposed surgical sites are obtained in black and white and in color.18,19 Patients begin antimicrobial skin washes 3 days preoperatively, extending above and beyond the surgical site, including the umbilicus and perineum. Intranasal antibiotic ointment also begins preoperatively. No shaving of body hair is performed. Broad-spectrum perioperative oral and intravenous antibiotics are employed and may be continued until any drains are removed. However, evidence-based SCIP information (Surgical Care Improvement Project and prevention of postoperative infection, including surgical site infection), which confirms that antibiotics may reduce surgical site infections in abdominoplasty, also suggests that antibiotics be discontinued within 24 hours after completion of surgery. The ERAS (enhanced recovery after surgery) perioperative principles have been advised in complicated inpatient surgeries but not validated for outpatient surgery. They can be instituted for perioperative care programs to improve outcomes after major surgery. Preoperatively, the operating room table is checked to verify that it can reach a maximum beach chair flexed position, which is needed in order to remove the old umbilical site and is necessary for final wound closure (Fig. 27.2). In the operating room, the arms are symmetrically placed on arm boards while avoiding pressure points and secured with Kerlix wraps. The patient should be kept normothermic and fluid status should be monitored. A Foley catheter is inserted for all open abdominal contour procedures and removed when appropriate, which can be before or after discharge. Abdominoplasty is performed as an outpatient procedure and it is the last operation performed in a multi-surgical operation (e.g., breast surgery, liposuction, etc.). Postoperatively, the patient is transferred to a stretcher that can achieve maximum flexion.

Figure 27.2  The Miami beach chair position. Significant operating room bed flexion is often necessary to ensure removal of all the lower abdominal skin including the old umbilical site. (From Matarasso A. Traditional abdominoplasty. Clin Plast Surg. 2010;37(3):415–437, with permission.)

735

Informed consent Informed consent is a spectrum of patient education from the time of the initial contact with the office and until the time of surgery. Informed consent is based on the concepts that patients have the capacity to make a decision and the patient is adequately informed without coercion. Ideally it is obtained in an appropriate stress-free environment. The actual informed consent documents consist of the surgical facility’s form, the surgeon’s consent form, and an anesthesia consent obtained by the anesthesiologist. The patient, staff, and surgeon should discuss the course of treatment, the procedure, including risks, benefits, alternatives, which include not operating, financial policy, and obligations (including the financial burden of additional procedures or cancellation of scheduled surgery for non-medical reasons), and the complications in a manner that the patient understands. All interactions with the patient by telephone, text, emails, photographs, etc., should be dated, documented, HIPPA (Health Insurance Portability and Accountability Act) protected, and entered into the patient’s medical record. While a surgeon may perform the procedure numerous times, patients typically only have it performed once. Consequently, each patient deserves a thorough discussion regarding the procedure. As Nahai has stated, what is acceptable risk for one may not be acceptable risk for another.18a While there are multiple local and systemic complications, untoward sequelae (conditions that resolve on their own or with minimal intervention) and nuisances, the dissatisfied patient can represent a challenging situation. Despite many publications and warning signs, it is not always feasible to know who will be dissatisfied or, conversely, who will be satisfied, until postoperatively. A general rule for aesthetic surgery is to determine preoperatively if the operation coincides with what disturbs the patient, and if, in your interactions with the patient, you believe that they will be satisfied with the outcome prior to operating. It is foolish for the surgeon to believe that they can change most patients’ personality or behavior by performing a good operation or their sincere concern for the welfare of the patient. The threshold for patient dissatisfaction seems to be lower than in years past when the truly aggrieved patient might complain to the office or file a legal action. Currently, patients do not hesitate to air any level of grievance publicly on social media. With the availability of the internet and social media, patients readily vocalize their thoughts, which can create meaningful and potentially egregious damage to the surgeon, their practice, and reputation. Management of social media in general and a dissatisfied patient (the subject of Chapter 1) has spawned an industry dealing with reputation management. A well-regarded aphorism in plastic surgery is that preoperative discussions are considered an explanation, and postoperatively they are considered an excuse. The challenge with a dissatisfied or unhappy patient in aesthetic surgery is the principle that the outcome of surgery is not objectively quantifiable. Rather, it is based on their perception of the result. It might be akin to a baseball batter (patient) deciding if the pitcher’s pitch (surgeon) is a ball or strike and then, if the pitcher complains, they are penalized on social media! The patient’s opinion is influenced by a myriad of factors, such as the perioperative experience and external elements, including what their

736

SECTION III

CHAPTER 27  • Abdominoplasty

significant others feel about the result, friends, monetary issues, personal life happiness, relationships, etc. Therefore, postoperatively, “Talk therapy” management becomes the equivalent in cosmetic surgery to what occupational/physical therapy is to the outcome of hand surgery, an integral part of the surgical rehabilitation outcome. The “ripple effect” refers to how a bad experience in one aspect of the process can taint even other aspects that are essentially normal. It is useful to inform patients that in the event that they should require reconstruction after breast cancer, an abdominoplasty will remove an important source of autologous tissue (Scott Spear, personal communication).

Perioperative management As noted, patients receive a detailed package of both pre-and postoperative instructions prior to the surgery. The staff, the surgeon, and the anesthesiologist call the patient and review the process prior to surgery. A history and physical examination is done with particular attention to medications, allergies, prior surgical and family history, bleeding, or clotting disorders, cardiac and pulmonary status, and scars, as well as any information that can be obtained that will improve the safety, comfort (i.e., nausea and vomiting), and outcome of the patient experience. A report is also generated by the primary care physician and is necessary for preoperative clearance. Routine chest radiographs, an electrocardiogram, and laboratory data are obtained. Any abnormalities are identified and addressed. For example, an elevated PTT (partial thromboplastin time) is most commonly due to a factor XI deficiency (Rosenthal’s syndrome).78 Normotensive blood pressure, less than 130 mm Hg, is necessary since hypertension is often identified as the etiology of hematoma occurrence. We also offer and encourage testing for coagulopathies. Medical consultants are liberally used for patient management. Intraoperatively, a coordinated operating room team is essential to the smooth and safe flow of the operation. After recovery room discharge criteria are met, patients are observed overnight in an apartment-type hotel facility with experienced nurses who are versed in the postoperative management of abdominoplasty patients, including drains, Foley catheters, body movement, ambulation, diet, pain control, and bowel function. The office has regular contact and visits with the patient throughout the immediate postoperative period. Pulmonary thromboembolism is a paramount concern, and the methods described herein are utilized. Any potential findings or symptoms described by the patient for 6 weeks or more postoperatively that are suggestive of blood clots are promptly and thoroughly investigated. Moreover, the patients are encouraged to consider having weekly postoperative venous Doppler tests of the extremities, screening for any blood clots. Multimodal anesthesia for pain management pre-, post-, and intraoperatively is useful.20,21 In particular, setting patient expectations in terms of pain is part of that process. In addition to discomfort, pain can lead to a series of adverse side effects that begins a cascade of events that can lead to significant complications. Pain medications can cause ileus or constipation, which causes straining with bowel movements, or nausea and vomiting, which can also lead to postoperative bleeding. Moreover, pain can also reduce ambulation, which increases the risk of pulmonary thromboembolism. It also

can decrease respiratory function and coughing, which can worsen atelectasis and pulmonary function. Postoperatively, drains and sutures are removed sequentially as indicated. Generally, that is when they reach approximately 30 mL over a 24-hour period per drain, and as the color changes to become more serous in appearance. Patients should then be periodically evaluated when the drains have been removed for the presence of a seroma so that this does not lead to other sequelae, including persistent abdominal disfigurement due to a pseudobursa. We encourage intake of electrolyte-containing fluids. And, we no longer delay resumption of diet until bowel sounds are present.21a A common concern of patients is when they can resume normal exercise. This is variable and not prescriptive. Exercise should begin gradually, and is based upon the type of exercise the patient wishes to engage in. This might begin at postoperative day 15–20, as circumstances dictate, initially recommending less than their normal amount of exercise and then waiting a day to observe their response before their next exercise session, then progressing as tolerated. Another frequently asked question is: how long will healing take? Healing includes the overall appearance, absence of swelling and paresthesias, appearance of the scar, and when they can resume work and activity, among other things. All of these events occur gradually and at different and overlapping rates in each individual, and therefore cannot be accurately pinpointed. These represent a spectrum of events that occur over a period of time. Strong patient support is useful as patients progress through the postoperative period, and can be challenging, particularly with a myriad of sources, information, desire for immediate gratification, and expectations that patients have. In aesthetic surgery, “Talk therapy” is an integral component of managing patients’ results.

Contraindications to abdominoplasty There may be a fine line between absolute contraindications and those that are relative contraindications to abdominoplasty. Most surgeons consider smoking and significant cardiopulmonary disease as contraindications. Complications increase with elevated body mass index (BMI) (100% over 35) and in patients with large vessel disease (which can increase infection or healing issues). Relative contraindications may be determined by the circumstances and adjudicated according to the surgeon’s experience, judgment, and risk tolerance. Age, per se, is not an absolute contraindication but the frailty index can be used to assess each individual situation. Relative contraindications include cardiac, pulmonary, and hematologic issues that impact the safety of the operation, uncontrolled hypertension, and systemic diseases, i.e., adult-onset diabetes mellitus, autoimmune diseases, and inflammatory bowel disorders. Pre-existing scars and upper, non-midline scars, i.e., a chevron/or gallbladder incision that disrupts the crossover blood supply to the distal flap when it is advanced below the umbilicus, are also issues. In these circumstances of non-midline scars, when choosing to proceed, a safety concept can be to perform it only in patients where the abdominoplasty can be closed without undermining beyond the scar or the scar can be incorporated into a vertical excision. Performing a delay of the flap first, has also been reported. The Davison–Caprini risk stratification system for thromboembolism potential is calculated routinely preoperatively

Nuisances, untoward sequelae, and complications

and is used as a validated risk factor modification principle. If the score exceeds 7–8 points and one elects to proceed with surgery, the patients are treated with low-molecular-weight heparin or enoxaparin sodium (Lovenox, Sanofi-Aventis, Bridgewater, NJ). Some surgeons prefer oral anticoagulation. The scale is extrapolated from inpatient general surgery patients and is not wholly transmittable to ambulatory abdominoplasty patients. Furthermore, there are various opinions as to the exact timing of the drug administration (pre-, intra-, or when to begin this postoperatively), the dose, and the duration of therapy. Our preference is to recommend preoperative testing for thrombogenic factors because of the impact positive results have on increasing the risk. Additionally, we do not advise applying the abdominal binder until postoperative day 3 (O. Garcia, personal communication) to diminish abdominal compartment pressure, which can theoretically increase deep vein thrombosis (DVT) formation. There is a paucity of data supporting the benefits of postoperative compression garments on the wound. Ostensibly they are used to decrease fluid collection, improve scar formation, reduce postoperative edema and ecchymosis, or reduce pain. However, binders may affect pulmonary function (such as no effect or decrease), increase venous stasis, or tissue ischemia. However, in circumstances of concomitant adjacent liposuction with the abdominoplasty, the binder is applied that day. Intraoperatively, compression stockings and sequential pneumatic compression devices are always applied, and the patient’s legs are periodically flexed intraoperatively. Postoperatively, ambulation and frequent joint movement exercises are encouraged. Body dysmorphic syndrome (and possibly borderline personality disorder) is an absolute contraindication to surgery. It has certain characteristic features and has been estimated to occur in up to 10% of plastic surgery patients (Mark Constantian, personal communication). These patients are frequently never satisfied with the results of their surgery. Plastic surgeons encounter a myriad of patient personalities and potential psychological disorders (i.e., general anxiety disorder, narcissistic personality) which may not be evident preoperatively in these patients having elective, non-essential, personal choice surgery.22,23 Patients can get pregnant after an abdominoplasty, but some of the benefits of surgery will be lost. Our preference in patients anticipating a relatively imminent pregnancy or if a defined window of time for fertility exists, is to delay a full abdominoplasty. Patients are offered liposuction surgery as an alternative if that can achieve satisfactory results in the interim.22–24 Smoking and nicotine products (i.e., vaping, e-cigarettes,124 etc.) are absolute contraindications to surgery. Our preference is that patients cease their use for a minimum of 2 and up to 4 weeks preoperatively and postoperatively. Female and male hormones (including patches, pills, drug-eluting intrauterine devices, etc.) should be stopped due to the potential for interfering with blood clotting, and preferably for 1-month pre- and postoperatively. All vitamins, nutritional supplements, over-the-counter products, or medications that can safely be stopped, should be discontinued approximately 2–4 weeks prior to surgery. Medications that are deemed necessary should be evaluated on an individual basis by the surgeon, primary care/ clearing physician, and anesthesiologist to determine their continued use. Recommendations are also made about future

737

utilization, including their use on the morning of surgery (i.e., blood pressure and thyroid medications are taken the morning of surgery) and when to resume them postoperatively.

Patient positioning and superwet local anesthesia The operating table must be checked so that it reaches maximal flexed beach chair position required to consistently remove the old umbilical site. The procedure begins with injection of local anesthetic (1 mL of 1 : 100,000 epinephrine and 200 mL of 1% lidocaine in a liter of Ringer’s lactate +10 cc of transexamic acid) in the supine position with the abdomen minimally hyperextended, so that the injection needle stays tangential, thereby avoiding its inadvertent peritoneal cavity penetration. The patient is then turned to the prone position by a coordinated team effort led by the anesthesiologist and surgeon if other planned treatment sites are better accessed in that manner. Those posterior sites are then injected with local anesthetic, prepped, and draped and operated upon. When higher doses of local anesthetic become necessary, sequential injections are performed in order to avoid excessive doses of superwet injectate. For the abdomen itself, we rarely exceed 1 liter of injectate because it is unnecessary, and any excess fluid impedes electrocoagulation. This also allows more injectate to be safely used in other areas.

Nuisances, untoward sequelae, and complications Not all postoperative concerns represent complications. A distinction should be made between a revision, such as the need to correct a complication, unsatisfactory result, or for further improvement that may not have been feasible, recognized, or necessary at the initial operation, and secondary surgery on another surgeon’s patient. For example, dog-ears, despite appropriate planning and wound closure, can be inevitable consequences of the disparity created by upper abdominal dissection that changes the symmetry of the upper and lower excisions, and also the fact that a standard abdominoplasty is only treating 180° of a 360° structure. If dog-ears occur, we endeavor to have the patient agree to wait some months prior to revision so that the wound can contract. Superficial liposuction and steroid injections can sometimes improve minimal excess tissue. Those that do not resolve require revision.25 Untoward sequelae include those things that resolve spontaneously or with minimal intervention over time. These include hypesthesias, paresthesias, feelings of tightness, intermittent episodes of feelings of swelling or enlargement, bruising, edema, mons pubis swelling or scrotal enlargement. Refractory hypesthesias and uncomfortable pruritic itching can be particularly irritating and have been successfully treated with Lyrica (Viatris Inc., Canonsburg, PA). Scars mature over a lengthy period of time, and counseling about the role of scar products (gels, tapes, etc.), the use of energy devices to modify them, triamcinolone acetonide injections, and avoiding sun and smoke exposure are useful as the body undergoes the natural healing process. During periods of

738

SECTION III

CHAPTER 27  • Abdominoplasty

BOX 27.2  Various sources provide databases for complications in abdominoplasty 1. Case series reports of a surgeon. 2. Surveys of groups of plastic surgeons (e.g., American Society of Plastic Surgeons, American Society for Aesthetic Plastic Surgeons, etc.) 3. TOPS (Tracking Operations and Outcomes for Plastic Surgery): National database of plastic surgery procedures and outcomes self-reported by members of American Society of Plastic Surgeons. 4. CosmetAssure: A medical insurance program covering 17 elective cosmetic procedures performed by active or candidate members of the American Society of Plastics Surgeons. Coverage includes complications treated in an emergency room, those requiring hospital admission, or intervention in an accredited surgical center within 30 days of the procedure. It does not include complications treated on an outpatient basis, such as seroma drainage, wound care, or oral antibiotics, which TOPS should include. 5. The Doctors Insurance Company: Data based on claims that the insured physician’s medical malpractice covers. 6. Maintenance of Certification (MOC – now Continuous Certification): Data collected by the American Board of Plastic Surgeons for board certification. 7. American Association for Accreditation of Ambulatory Surgical Facilities (AAAASF): Data collected from outpatient accredited surgery centers. 8. American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) – is risk adjusted and tracks patients for 30 days after their operation.

sunbathing, patients should avoid using dark clothing until full sensation returns, as the diminished skin sensation can result in a burn. No surgeon begins an operation expecting a complication.26 These can be particularly distressing in elective, healthy patients undergoing non-essential cosmetic surgery. In complications that are not resolved quickly (i.e., hematomas), such as wound healing problems (i.e., necrosis) that can take long periods of time to resolve, patients’ access to things like search engines, social media, etc., can be deleterious to the trust that is necessary for the important doctor–patient relationship needed to resolve the problem and thus can exacerbate an already difficult scenario. Awareness and incorporating steps to potentially avoid complications can help reduce, but not eliminate, their occurrence.27 Numerous databases reporting complications exist. These include: the American Society of Plastic Surgeons (ASPS) TOPS registries (Tracking Operations and Outcomes for Plastic Surgeons) and The Doctors Company data (TDC), American College of Surgeons NSQIP (National Surgical Quality Improvement Program), CosmetAssure, American Board of Plastic Surgery (ABPS) tracer data for continuous ­certification, AAAASF (American Association for Accreditation of Ambulatory Surgery Facilities), surveys, and individual surgeon reports. Complications can be subdivided into local versus systemic, early versus late, or by the type of abdominal contouring surgery that is performed (Box 27.2, Tables 27.3–27.6). In the final analysis, it is essential to bear in mind, that because of the way sources capture their data, that the risk factors identified and the complications reported can be different.28–44

Table 27.3  CosmetAssure database of complications based on their insured patients who returned to the operating room within 30 days of their abdominoplastya

Complication

%

Infection

1.63

Hemorrhage

1.17

Fluid overload

0.33

R/O DVT

0.3

Hypoxia

0.24

Pulmonary dysfunction

0.22

R/O PE

0.22

PE

0.19

Severe hypertension

0.16

DVT

0.16

Overall R/O rate of abdominoplasties

4.7

Overal R/O rate of other cosmetic procedures

1.37

b

b

Abbreviations: DVT, deep venous thrombosis; PE, pulmonary embolism; R/O, reportable occurrence. a Abdominoplasty alone 37%; abdominoplasty with multiple procedures 67%. b About half of suspected DVTs were DVTs; almost all suspected PEs were positive.

Traditionally, pulmonary atelectasis or seromas were considered the most common complications reported. However, because of how certain databases draw their information, these may not even be listed. CosmetAssure data reveal that there is an overall 4% complication rate for abdominoplasty (of which 31.5% were hematomas, 27.2% were infections, and 20.2% were suspected or confirmed venous thromboembolism [VTE]) versus 1.4% for all other aesthetic surgery (see Table 27.3). Risk factors include male sex, age greater than 55 years, BMI greater or equal to 30, combined procedures (abdominoplasty alone was 3.1%, with liposuction increased to 3.89%, with breast surgery to 4.3%, with liposuction and breast surgery to 4.6%, with body contour surgery to 6.8%, and highest in abdominoplasty with liposuction and body contour surgery at 10.4%) It was also reported to be higher in a hospital or surgicenter than in an office-based surgery suite. In terms of DVT risk, abdominoplasty was 0.5% and increased to 1.1% in liposuction and abdominoplasty. Perhaps due to the fact that this database looks at complications requiring return to the operating room within 30 days postoperatively, seromas and pulmonary atelectasis are not listed here as a complication and smoking is not included as a risk factor. ASPS–TOPS data report infection being the most common complication (3%–5%). ABPS continuous certification data report infections followed by seromas, and venous thromboembolism as the most frequent.

Infections Infections are often considered the second most common complication of an abdominoplasty, occurring at a rate of 1%–3.8%. Risk factors include obesity, smoking, diabetes, malnutrition,

Nuisances, untoward sequelae, and complications

739

Table 27.4  Local abdominal contour surgery complications

Complications

Liposuction (%)

Limited abdominoplasties (%)

Full abdominoplasties (%)

Contour irregularity

9.2

4.9

5

Major skin necrosis (requiring re-operation)

0

1

1

Minor skin necrosis (healed spontaneously)

0

4

4.4

Scar revision

0.03

2.4

4.9

Hematoma

0.04

0.08

1.4

Wound infection

1

0.02

1.1

Wound dehiscence

0

1

1

Umbilical abnormality (requiring re-operation)

0

0.05

1.2

Dissatisfied patient (unfulfilled expectations)

3.3

2.9

2.2

Need for second surgery

3.5

2.4

3.4

Data from the author national survey of American Society of Plastic Surgeons members on complications in abdominoplasty. Matarasso A, Swift R, Rankin M. Abdominoplasty and abdominal contour surgery: a national plastic surgery survey. Plast Reconstr Surg. 2006;117(6):1797–1808.

Table 27.5  Systemic abdominal contour surgery complications

Complications

Liposuction

Limited abdominoplasties (%)

Full abdominoplasties (%)

Local anesthesia (i.e., wetting solution)

0

0

0

Major anesthesia

0

0

0

Malpractice action

0

0

0.01

Blood transfusion

0

0

0.04

Deep vein thrombophlebitis

0

0.01

0.04

Pulmonary embolism

0

0

0.02

Intra-abdominal perforation

0

0

0

Death

0

0

0

Readmission to hospital

0.01

0.01

0.05

Data from the author national survey of American Society of Plastic Surgeons members on complications in abdominoplasty. Matarasso A, Swift R, Rankin M. Abdominoplasty and abdominal contour surgery: a national plastic surgery survey. Plast Reconstr Surg. 2006;117(6):1797–1808.

and an immunosuppressed state. Signs and symptoms include erythema, inflammation, edema, tenderness, elevated temperature, elevated white blood cell (WBC) count and possibly systemic symptoms. Skin flora account for the majority of infections (but can also include anaerobes and atypical mycobacteria). For prophylaxis, patients are instructed to begin antimicrobial skin washes three days preoperatively and are given intranasal antibiotic ointments and perioperative antibiotics until the drains are removed. The field is widely prepped with alcohol-containing solution, with the perineum cleansed last. The umbilicus is further decontaminated with a betadine-soaked applicator. Intraoperatively, in an effort to reduce infection, the patient is kept normothermic, the surgical field is irrigated with saline prior to closure, and the drains are soaked in a betadine solution before their placement. In the postoperative period, the abdomen is inspected for signs and symptoms of infection. If infection is confirmed, drains should be removed when possible. Depending on the degree of concern about an infection, the wound is explored, copiously irrigated, cultured (including Mycobacterium and

anaerobes), so the appropriate antibiotic coverage can be instituted, beginning with the result of the Gram stain report. Rapidly progressing and erythematous-appearing wounds warrant the consideration that they may represent necrotizing fasciitis and immediate treatment should be instituted.45

Fluid collections Fluid collections include seromas and hematomas or possibly an infection. Seromas represent the most common local complication (although atelectasis can occur more frequently in up to 40% of patients). Abdominoplasty carries a high risk of seroma formation. These are multifaceted in etiology and can range from a trivial nuisance to an untoward sequelae, to the formation of pseudobursas. Various strategies have been suggested to reduce seroma formation, including avoiding flap dissection with electrocautery,46 preserving fibrous tissue on the rectus fascia, preserving Scarpa’s fascia,47,48 not using binders (to prevent shearing of the tissue layers), using tissue sealants, glue,49–54 drains, and/or progressive tension sutures,

740

SECTION III

CHAPTER 27  • Abdominoplasty

Table 27.6  Comparison of results of abdominoplasty complications

Complication

Matarasso et al., 2006

Hester et al., 1989143

Grazer and Goldwyn, 197732

Pitanguy, 1983

Teimourian and Rogers, 198928

No. of procedures

11,016

563

10,490

539

25,562

Necrosis minor

4.4

0.9 (minimal slough)

5.4 (wound dehiscence)

1.4

Necrosis major

1

Local (%) complications

Seroma

0.3 2.5

5.8

Infection

1.1

1.1

Blood loss

35, a group I patient, who underwent a belt lipectomy/ bodylift. Because the abdominal flap at presentation was thick and required thinning, the supraumbilical tissues, shown above the proposed superior marks, were liposuctioned and a limited central flap dissection was performed to maintain the rectus perforators’ blood supply. Note there were two proposed lines of excision marked in the hopes of reaching the more superior one, but if not then the more inferior one would have been utilized. The scar was intentionally kept high in order that a “cinching” at the waist could be accomplished. Posteriorly the inferiorly based buttocks flap was elevated at the level of the underlying muscle fascia, in order to “cinch” around the waist and create a depression above the buttocks proper, which increases the apparent projection of the buttocks. Note that group I, when compared with groups II and III, demonstrates less overall improvement in lower truncal contour.  

Outcomes/prognosis/complications

813

Figure 31.28  Pre- (above) and postoperative photographs (below) of another group I patient who presented in the high BMI range, >35. She previously underwent an unsuccessful “anterior-only” abdominoplasty to treat her circumferential lower truncal excess. A belt lipectomy/bodylift was performed on this patient, which required a complete redo of the abdominal region.

will demonstrate less improvement and more complications than those in group III (Figs. 31.31 & 31.32). This rule holds as long as one compares these patients in groups. Within each of these arbitrarily chosen BMI ranges, patients do not necessarily follow the rule that a lower BMI automatically guarantees better results or lower complication rates because other factors such as fat deposition pattern and the amount of skin laxity also play a role. It is important to explain to patients, prior to surgery, that their contour is improved significantly after bodylift/belt lipectomy but their skin quality is unchanged. Thus, once the swelling associated with surgery is resolved, skin elasticity on palpation is unchanged from its preoperative characteristics, especially in the epigastric region. Both the inexperienced surgeon and the patient may desire more tissue excision, but this will lead to failure. A subject that has not been addressed in the literature is the sensory loss associated with circumferential dermatolipectomy procedures. Traditional abdominoplasty sensory loss is usually located inferior to the neoumbilicus in a triangular

pattern, with the base straddling the midline at the abdominal scar and the apex at the neoumbilicus. Over a 1- to 2-year period, sensation tends to return to this area with the apex descending and the base becoming narrower. What has been observed by the authors is that the area of sensory loss is usually circumferential, with varying and sometimes asymmetric patterns, and that it improves from 6 months to 1 year. It is also important to warn the patients prior to surgery that should they gain significant weight, most or all of their body contour improvement can be reversed.

Complications Circumferential bodylift/belt lipectomy procedures performed on normal weight patients tend to have similar complication profiles to their abdominoplasty counterparts. On the other hand, MWL patients who undergo bodylift/belt lipectomy have significant risk of complications, more so than in any other area of aesthetic surgery. This is especially true if the surgeon chooses to operate on patients presenting in

814

SECTION III

CHAPTER 31  • Belt lipectomy

Figure 31.29  A patient belonging to group II, who presented with a BMI between 30 and 35. The patient is shown prior to surgery (above) and after belt lipectomy/bodylift (below). Patients in this group will generally demonstrate more improvement than group I, but less than group III.

the higher BMI ranges. As a general rule, the higher the BMI, the higher the complication rate.

Wound separation The long incisions in circumferential dermatolipectomy combined with the high-level tension created by the procedure very often lead to small wound separations. Currently this is the most commonly encountered complication by the authors. Most often these small separations will heal without much difficulty or negative sequelae, but they can be bothersome to the patient. Thus, it is best to warn patients about them prior to surgery. Treatment is usually conservative, allowing secondary intention healing to occur.

Seromas Previously, the most common complication of bodylift/belt lipectomy was seroma (Algorithm 31.2). However, since the

authors incorporated closure of dead space, the avoidance of the use of drains, and the use of low dose diuretic for 30 days, the frequency has considerably decreased. It is still true that the higher the BMI the more likely that one encounters a seroma but the measures described here have dramatically decreased the rate even in that patient population. When a seroma is encountered, the authors serially aspirate it every 2–3 days, and if that is not successful, they will inject the pocket with a sclerosing agent, doxycycline, in the hopes of closing down the pocket, again every 2–3 days. Lastly, if the seroma still persists, a small opening of the original scar is opened, and the pocket is entered. A Penrose drain is placed into the pocket and sewn in place. The pocket will eventually close around the Penrose drain, sometimes requiring 4–6 weeks, at which point it can be simply removed. Using this graduated regimen of seroma treatment, the authors have not had to operate on a seroma in over 22 years. It has also become apparent that the presence of a seroma capsule is not an indication for operating on a seroma, as is

Outcomes/prognosis/complications

815

Figure 31.30  Group II patient, BMI 30–35, before (above) and after belt lipectomy/bodylift (below). Note the patient subsequently also underwent an upper bodylift.

traditionally believed. The authors will often encounter capsules that are empty when performing revisions. This is an old dictum that must be exposed for its fallacy.

Dehiscence A dehiscence is defined as a wound separation at the superficial fascial system level or deeper. Circumferential procedures are more prone to dehiscence because of the competing tensions. Fortunately, dehiscences are fairly rare if a number of issues are addressed. Dehiscence may occur within the immediate postoperative period or a few weeks after surgery when the patient has presumably healed. Three strategies will help reduce the risk of dehiscing in the early postoperative period. First, the extent of the back midline resection is preoperatively marked with the patient in the flexed waist position attained after the anterior resection is completed. Second, the sign placed on the patient’s bed that warns all healthcare personnel to avoid manipulating the patient until they are awake and alert is essential because “an awake patient can

sense tension and protect themselves”. Third, preoperatively, patients and nursing staff are coached on how a patient is to be “rolled out of bed” with the aid of the patient “sensing tension” and avoiding body positions that strain the closures. It is important to advise patients that all their movements, for the first 3 months after surgery, should be slow and deliberate, which will lead to a sense of tension before the tension reaches the level required to dehisce.

Infection The most common cause of infections after a bodylift/belt lipectomy is undetected seromas. It is wise to see these patients for at least a year after surgery to make sure that there are no undetected seromas. The authors do not treat small non-expanding fluid collections but they do keep a close watch on them in case they become infected. Occasionally a patient will develop a skin cellulitis, which is unrelated to a seroma. Those are treated as in any other cellulitis encountered after a surgical procedure, usually with appropriate antibiotic coverage.

816

SECTION III

CHAPTER 31  • Belt lipectomy

Figure 31.31  Group III patient, BMI 6 months

Staged procedure

Wait 3–6 months

Abdominoplasty

Wait approximately 6 months

Buttock lift

Decision tree, patients group 1.

Patients have to be informed about the intraoperative procedures including any change of position with the risks of postoperative complications, antithrombotic precautions, Foley catheter, drains and garment placement, as well as patient-controlled analgesia. Moreover, they have to be instructed about the postoperative course regarding thromboembolism prevention, respiratory exercises, early mobilization, avoidance of high abdominal pressure, the estimated time point for drain and suture removal, as well as the minimum time required off work and away from exercise. Patients should avoid any skin irritation or inflammation in the area of the abdominal fold and umbilicus. An inspection of these areas during consultation as well as immediately prior to the operation is strongly advisable. Prophylaxis for pulmonary embolism and deep vein thrombosis is an essential consideration, especially in smokers and patients taking

birth control medications or hormone replacement therapy.15 We initialize heparin therapy in all patients the evening before surgery or at latest 2 h prior to the surgical procedure, Fragmin 5000 I.U. SC 1× day. We inform patients that this specific risk will be decreased if hormonal therapy is discontinued 3–4 weeks prior to surgery. In cases of a pre-existing diastasis or hernia, the reconstruction of the fascia results in an additional increase of intra-abdominal pressure, which may be a source of respiratory difficulties. Therefore, we advise preoperative breathing exercises (utilizing an incentive spirometer) and the wearing of a compression girdle beginning 1–2 weeks prior to the surgery. A cold, dry cough, or any kind of respiratory infection, should lead to postponement of surgery, since fits of coughing may provoke a rupture of the fascial sutures with consequent secondary bleeding.9,12,16

824

SECTION III

CHAPTER 32  • Circumferential approaches to truncal contouring: the lower lipo-bodylift

Algorithm 32.2 Patients Group 2

Normal size buttocks with ptosis and skin redundancy

Focus on gluteal projection

Yes

No

Lipo-bodylift with fat-preservation & autoaugmentation

Standard lipo-bodylift

More projection wanted

Additional fat-grafting

Decision tree, patients group 2.

Algorithm 32.3 Patients Group 3

Flattened, hypoplastic buttocks

Bodylift with tissue preservation & autoaugmentation

Residual fat available

Yes

No

Additional fat grafting

If more volume desired

Gluteal implants

Decision tree, patients group 3.

Markings

825

Markings

Superficial lobular fat Deep lamellar fat

Fascia superficialis

Figure 32.3  Superficial lobular fat separated by the superficial fascia from the deep lamellar fat.

A

B

C

E

Figure 32.4 Bodylift markings showing the future scar line in red.  

We recommend starting the markings in a standing position (Fig. 32.4). The patient should be asked to bring their favorite underwear so the borders can be marked and the future scar line can be adjusted to the patient’s favored underwear. This means, ideally, that the future scar can be hidden. As the next step, the tissue should be pinched out to get an estimation of the mobility and quality of the excess tissue. The future scar line should be marked in red to get a better idea of where to plan the upper incision line. It is very important to discuss with the patient their desired result and preferences. The main aim of the lower bodylift is that the scar can be completely hidden by underwear. This approach is different from the belt lipectomy, where the main goal is to achieve the best possible waistline. After marking the future scar line in red, we start the markings on the back with the very top of the intergluteal fold. Then the excess tissue should be pulled down at the midaxillary line to estimate the laxity from cranial of the future scar line, so that, at the end of the surgery, the scar will end up within the borders of the underwear. In most patients, the laxity from above the scar line is about 3–4 finger-breadths. This point should be marked symmetrically on both sides. Now the point on top of the intergluteal fold is connected with the point in the midaxillary line following the natural contour in an arcuate manner. In such a manner, the upper back incision line is finalized.

D

826

SECTION III

CHAPTER 32  • Circumferential approaches to truncal contouring: the lower lipo-bodylift

As a next step, the lower incision line is marked. The excess skin should be pinched by pulling the tissue upwards at the level of the midaxillary line while stabilizing the upper incision line with the index finger. Quite commonly, this point of the lower incision line relates to the lateral zones of adherence. Depending on the type of deformity of the buttock, the excess tissue is pinched again and either a curved or straight line is drawn from the midaxillary line back to the intergluteal fold. If gluteal augmentation is required – such as in deflated buttocks – the lower incision line should be drawn a little more cranially, since more tissue will be required to cover the augmented area. Over-resection of skin should be strictly avoided. In the area of the rima ani, the incision line should end in a pointed angle, because a straight incision line across the intergluteal fold leads to an elongated intergluteal fold and an enlarged buttock. Now the front markings can be started. Most commonly in MWL patients, an additional relaxation of the mons pubis is found and should be included in the surgical plan. First, the patient should be asked to lift up the excess tissue of the abdomen so the vulva commissure or the root of the penis is exposed. Then a distance of 7–8 cm is measured and marked cranially from the vulva commissure/root of the penis. This is the lower border of your incision line. Now the line can be drawn laterally connecting the ventral with the dorsal markings. The ventral incision line should be planned a little bit below the natural tissue fold, since the tissue quality within the folds is normally quite low. To make sure that the angle of the incision is correct, make the patient sit and double-check that your markings on the abdomen relate to the natural folds. To estimate the upper incision line, the patient should lay down and bend the hips in about a 45° angle. After that, the excess tissue is pinched and the upper incision line is marked above the umbilicus if it allows a tension-free closure. Then a line is drawn between the point above the umbilicus and the midaxillary line to connect the upper incision line of the back with the upper incision line of the front. To be safe, double-check your drawings by pinching the tissue circumferentially. Experience has shown us that the resection above the future scar line can be estimated about a quarter of the excess tissue, and the resection below the future scar line makes up about three-quarters of the excess tissue, in general. In the front, the excess tissue and amount of resection varies a lot. After finalizing your drawings in the front, the posterior vectors should be marked (Fig. 32.5) to get better waist contouring. The idea is to rotate the tissue inwards to get a rounder and fuller projection of the buttock and a more defined waistline. If additional liposuction is required, we recommend marking the areas in a different color in concentric circles while the patient is standing up.

Patient positioning After orotracheal intubation and bladder catheterization, the patient is transferred to the operating room in the supine position. Here the patient is turned into the prone position, ideally from the first operating table to a second. It is advisable to use prepared soft cushions for a secure, pressure-reduced, and symmetrical positioning. We drape the entire region of the

lower back, the hips, the gluteal, and the dorsal thigh region with a sterile covering, ensuring a total overview of the gluteal and the surrounding regions, including the gluteal fold. After final closure of the gluteal region, the lateral skin excess is temporarily closed with staples, and a sterile dressing is applied (Fig. 32.6). The primary covering is then removed, and the patient is turned to a second operating table back in the supine position and then transferred back to the original table using a sterile cover. In this way, a change of tables is avoidable. Dressings and staples are removed after symmetrical positioning, and the patient is draped and covered sterile. Posterior drains may now be connected. Further, the anterior part of resection is now continued, using either the standard horizontal or fleur-de-lis excision pattern.9,12

Procedural approach The lower bodylift is routinely performed by two surgeons and optionally with one or two medical assistants. The leading surgeon performs the initial markings and their intraoperative verification and has to supervise the entire procedure. Tissue preparation, dissection, and wound closure are performed simultaneously on both sides. After surgical scrub and consequent draping, the area of resection and undermining is infiltrated moderately with tumescent solution (1 L Ringer solution including 1 mg epinephrine) until the desired turgor is achieved. The solution is introduced in the entire surgical field and the neighboring regions. It should be ensured that the liquid is introduced only in the preparation plane in order to cause a cooling effect and a hydrodissection. An excessive swelling of the tissue and an associated hyperhydration should be avoided.

Type 1 In type 1 patients where a lipo-bodylift is planned, we start with the liposuction of the area that is going to be resected (Fig. 32.7). We reduce the volume below and above Scarpa’s fascia and go very superficially until the tissue to be resected gets paper-thin. Then the lower incision line is infiltrated with local anesthetic to reduce postoperative pain and the consecutive risk of blood pressure increase. The dissection goes easy and dry through the empty network of tissue due to the liposuction until the lower incision line.

Types 2 and 3 The initial skin incision (utilizing a cold blade or, alternatively, the Colorado microdissection needle) is made along the superior marking line and is continued down to the level of the underlying superficial fascia, which separates the superficial lobular from the subfascial lamellar fat. Next, the dissection is continued caudally just above the robust white superficial fascia. The preservation of fascia to the deep gluteal fat as the “gluteal SMAS” is conceptually similar to the “facial SMAS” used in facelifts or abdominal “Scarpa fascia”. In all types of patients, the lateral gluteal half of the superficial fascia is then incised at the height of the inferior resection line before flap mobilization is continued caudally bluntly

Procedural approach

827

A

B

C

Figure 32.5  Marking of the posterior vectors is necessary to avoid a “tent-like” appearance of the back after the bodylift. Schematic (A) and intraoperative (B) demonstration of posterior vector lines. Intraoperative lateral view after incision of vectors (C). (From Rubin P, Jewell M, Richter DF et al., eds. Body Contouring and Liposuction. St. Louis: Elsevier Saunders; 2012:389–390.)

Figure 32.6  Temporary dressing of the lateral wounds with Opsite film allows an easy turnover of the patient from prone to supine position.

Figure 32.7  Liposuction should only be performed within the area of resection to avoid compromised blood supply.

828

SECTION III

CHAPTER 32  • Circumferential approaches to truncal contouring: the lower lipo-bodylift

on an epimuscular level down to the gluteal fold. The preservation of superficial fascia to the inferior skin flap allows a reconstruction of the fascial continuity upon wound closure. For this maneuver, it is essential to maximally release the lateral gluteal tissue adhesions to the gluteal skin flap as far anterior to the anterior axillary line and caudally to height of the gluteal fold. Further dissection is then continued to the lateral thigh, where the preparation level is above the aponeurosis of the tensor fascia lata muscle. An extended distal mobilization of the lateral thigh may be carried out bluntly utilizing the Lockwood underminer or by additional liposuction with low pressure. The mobilization of the superior wound edges should be avoided or, if necessary for wound closure, should be performed cautiously, preserving any emerging perforators. With completion of dissection, the waist and gluteal adipose tissue should be widely mobilized and ideally covered by a stable superficial fascia. For the purpose of autologous gluteal augmentation, three 1-0 non-absorbable braided threads are sutured from lateral to medial before knotting, ideally grasping stable fascia and consequently displacing the gluteal and waist adipose tissue medially. For cranial repositioning, another three to four 1-0 threads are sutured from caudal to cranial at the medial to central aspect of the buttocks (Fig. 32.8). Hereby, it is crucial to avoid strangulation of adipose tissue during fascial suturing in terms of avoidance of tissue necrosis. By transpositioning and tightening of the gluteal adipose tissue, the gluteal region is lifted cranially with a consequent final skin closure under reduced tension. Further, this maneuver is able to improve the shape of the waist by mobilization of the waist adipose tissue and its medial transpositioning.9,12 In severe or secondary cases of gluteal ptosis, it may be advisable to strengthen the gluteal tissue reconstruction with an additional mesh, either resorbable, semi-resorbable, or non-resorbable. Studies with acellular dermis are under conduction. The stage of resection should always be supervised by the “leading” surgeon to assure a symmetrical resection. We advise the utilization of bullet forceps (“sweet lip clamps”) for determination of the amount of resection. The marked vector lines are incised from medial to lateral and incised under maximal tension. The medial, central, and lateral gluteal flaps arising in this way are measured precisely under tension for symmetrical resection, which is subsequently carried out between the clamps. Following the vector lines, a moderate inward rotation is achieved, and a temporary wound closure of the gluteal area is performed with bullet forceps, followed by reconstruction of the superficial fascia system (SFS) with absorbable stable 2-0 monofilament or braided sutures. A subcuticular multilayer wound closure is performed with absorbable 2-0 and 3-0 monofilament suture in an everting manner prior to intracuticular suturing. Because of the wound length and resulting tissue tension, absorbable 2-0 monofilament suture is advisable. Finally, Steri-Strips are applied in perpendicular direction for the initial 3 weeks postoperatively. Alternatively, wound closure at all levels may be performed with a single absorbable barbed suture (2-0) in running manner; this saves a lot of time and provides stable results. Skin closure may alternatively be performed with a two-component skin closure system.17 Two suction drains are placed in each gluteal and lateral thigh

region if necessary. Before patients are turned into supine position, we perform a temporary closure of the lateral skin excess utilizing a stapler and an occlusive dressing.

Anterior preparation The inferior incision is checked and remarked, adjusting the initial inferior line to the laterally final ending gluteal incision line. It always has to be ensured that the umbilical stalk is thoroughly cleaned. Initially, the whole area of direct and indirect undermining is infiltrated with the standard tumescent solution, and a deep liposuction is performed in accordance to the lipoabdominoplasty. This enables more flap mobility and thins out the fatty tissue, especially in type 1 patients with local fat deposits. Then the lower incision line is infiltrated with local anesthetics to reduce postoperative pain and the consecutive risk of blood pressure increase as in the back. After incision of the lower incision line, preparation is performed down to Scarpa’s fascia after ligation of any superficial epigastric vessels (Fig. 32.9). For adequate preparation of Scarpa’s fascia, we recommend the use of the Colorado MicroNeedle and to ensure a sufficient upward pull of the abdominal flap. By preservation of Scarpa’s fascia, the subjacent lymphatic vessels are preserved. In general, we found a thin fat layer below Scarpa’s fascia. The dissection level is performed above Scarpa’s fascia entailing a number of key advantages: long-lasting swellings can be prevented because the underlying lymphatic vessels are preserved and the tightening of the SFS craniomedially provides an additional “inner traction” on the deep penetrating fascial system of the thigh (Colles’ fascia).18 Approximately three finger-breadths below the umbilicus, Scarpa’s fascia is dissected and further mobilization of the abdominal flap is performed cranially above the anterior rectus fascia. At the height of the umbilicus, the abdominal flap is incised in the midline and the umbilical stalk is transected square-shaped or circularly and completely mobilized from the abdominal flap without any remaining periumbilical fat tissue. Especially in patients after MWL, the umbilical stalk has to be shortened and fixated to the anterior rectus fascia at the height of the stalk’s basis, preferably with stronger absorbable sutures at 3, 6, and 9 o’clock positions. Further, dissection continues superior above the anterior rectus fascia up to the xiphoid. The linea alba can easily be identified as it is distinctively connected to Scarpa’s fascia. Usually it is sufficient to dissect the tissue up to the lateral border of the rectus muscles. In the area of the costal margin, it is essential to restore the lateral perforators for sufficient flap perfusion. At this time point, after finalization of the abdominal flap mobilization, in cases of concomitant rectus diastasis, the plication of the anterior rectus fascia from the xiphoid to the symphysis is accomplished using non-absorbable or absorbable suture material in preferred crosswise technique (Fig. 32.10). This takes care of the vertical and horizontal excess of the muscle relaxation. In cases of lower abdominal diastasis, Scarpa’s fascia and underlying tissue may be bluntly mobilized to allow for further midline fascial plication. For cases of an asymmetrically located umbilical stalk or for further accentuation of the waist with further waist tightening, an additional paramedian plication of the anterior rectus sheath may be facilitated. Since

Procedural approach

A

829

B

C

Figure 32.8  Schematic (above) and intraoperative (below) presentation of the gluteal autoaugmentation (transposition-gluteoplasty), which includes subfascial gluteal adipose tissue preservation and entire epifascial mobilization (A), two-dimensional fascial and adipose tissue transpositioning utilizing non-resorbable sutures in single-knot technique (B), and maximization of tissue accumulation at the upper gluteal third (C). (From Rubin P, Jewell M, Richter DF et al., eds. Body Contouring and Liposuction. St. Louis: Elsevier Saunders; 2012:397.)

lateral dissection is avoided up to the costal arch for preservation of the lateral perforators, a discontinuous separation of lateral adhesions using the Lockwood underminer or more liposuction may enable a further flap mobilization.

Now, the patient is placed in the beach-chair position and several progressive tension sutures with 2-0 Vicryl are placed in the midline from cranial to caudal to seal the dead space and to shift the tension caudally (also see Chapters 27 and 28).

SECTION III

830

CHAPTER 32  • Circumferential approaches to truncal contouring: the lower lipo-bodylift

Afterwards, Scarpa’s fascia is gripped below the umbilicus with a powerful 1 Ethibond thread (Ethicon Inc., Somerville, NJ, US) and pulled upward (Fig. 32.11). Due to this so-called Scarpa lift, moderate tightening effects can be achieved in the

Figure 32.9  Preparation above Scarpa’s fascia on lower abdomen to preserve lymphatic vessels.

Figure 32.10  Rectus plication in a crosswise technique treating vertical and horizontal muscle relaxation.

A

area of the inner thigh and the pubic area. In addition, you achieve stability of the lower scar line to control the subsequent scar position. If an infraumbilical rectus diastasis is found, either a fingertip dissection or a direct excision of the overlying fat should be performed to allow a fascia plication in that area. Occasionally the fatty tissue below Scarpa’s fascia is so strong that it should be thinned with additional liposuction. This is rarely necessary, since the rotation and spreading of the tissue leads to a flattening of the tissue. Now the new position of the umbilicus is defined and a V-shaped incision performed. Another quilting suture is made from the tip of the V-incision down to the deep muscle fascia superior to the umbilicus stalk. This gives a nice definition of the midline and creates, in conjunction with the other progressive tension sutures, a mild central groove. The umbilicus is then pulled through and sutured to the skin with 6 × 0 Prolene. More progressive tension sutures are then applied so the cavity is closed completely and the tension is taken from the wound edge. You can now start the resection. During tissue resection, bullet forceps or a Pitanguy tissue demarcator can support the estimation of the upper resection line. Further evaluation of the amount of resection may be facilitated by additional vertical flap incisions and temporary wound closure utilizing bullet forceps. The upper incision line is then marked and the resection is performed oblique to the wound edge in a 45° angle to enable a more precise adaptation of varyingly thick layers. In selected patients with a pronounced abdominal fat layer, the fatty tissue beneath Scarpa’s fascia should be resected in the entire mobilized area. This may avoid postoperative complications due to superinfected fat necrosis. In general, it is safely practicable to excise the sub-Scarpa fat plane from the abdominal flap, especially in the midline region for abdominal contour accentuation. After meticulous coagulation, the wound is closed temporarily. Temporary wound closure is performed with bullet forceps, starting laterally to medial. In patients with MWL and extensive circular tissue excess in the thigh region, we recommend maximally shifting the entire tissue medially. This tissue excess can be pleated at the medial aspect of the proximal thigh and removed at the time of the inner thigh lift if planned. After the placement of 2–3 drains in the abdominal region, the final wound closure is performed for all layers as described

B

Figure 32.11 The Scarpa lift: this can add extra contouring on the anterior and lateral thigh when Scarpa’s fascia is strong enough and well preserved.  

Postoperative care

above. Again, for time reduction in wound closure, the use of absorbable barbed sutures and a two-component skin closure system is routinely advisable.17 After a final antiseptic wound cleaning, Steri-Strips are applied as described before. These supportive dressings should remain for 3 weeks postoperatively. Finally, a sterile wound dressing is applied and an adjustable compression girdle is applied.

Mons pubis reconstruction Primarily, female patients ask for a reconstruction of the mons pubis region. A tissue surplus in this region can be maximally reduced by aligning the lower incision line at 7 cm above the vulvar commissure. In severe cases, a central wedge excision can be performed to reduce the horizontal tissue surplus.

Adjuvant liposuction Adipose tissue surplus in the back or upper flank region, which may be detected superior to the resulting scar line, can be reduced by liposuction after wound closure. This adjuvant procedure allows improvements of the gluteal and overall body contour from different perspectives.

Male “love handles” Male patients frequently present with local adipose tissue in the posterior flank region, which may be reduced by liposuction after gluteal wound closure or superiorly excised in toto during posterior preparation. We recommend cautious hemostasis of this localized fat pad during extirpation, since blood supply is ensured by 2–3 perforating vessels.10

Potential complications and management General symptoms after lower bodylift procedures include postoperative pain or soreness, numbness of the skin flaps, bruising, general fatigue, and discomfort due to increased skin tension for a few weeks postoperatively. Local complications in all regions include hematoma, seroma, wound infection, fat necrosis, wound dehiscence, paresthesias, and persisting numbness. Seromas are a very common problem in the abdominal region and usually handled with serial punctures and drainage. Persistent seromas may require a secondary surgical procedure. In general, seromas should be detected in time and treated by simple aspiration to avoid a superinfection or any consequent wound separation. Minor wound dehiscences are common and mostly self-limiting. In the intergluteal cleft region, patients frequently have to deal with wound healing disorders and their consequent conservative treatments. Wound closure in this specific region is strengthened with non-resorbable, simple, interrupted sutures to avoid wound separation due to shearing forces. Due to the use of absorbable sutures for wound closure, we regularly see single or multiple local wound-healing disorders throughout the entire wound; however, this splitting occurs more often in the gluteal region. Since tension in this region cannot be reduced as effectively as in the abdominal region, a consequent wound separation in this area is of higher risk. To improve

831

wound healing, we routinely perform wound closure in an everting manner, which reduces wound healing disorders due to a reduced interference by suture material on skin level. Significant dehiscences may be caused by increased tension or wound-edge necrosis. Appropriate treatment of wound necrosis is initial conservative wound care, until the area of necrosis has demarcated for surgical revision. Additional flap advancement may allow optimal secondary wound closure. Any impairment of the umbilical perfusion should be treated conservatively, as long as the umbilical stalk is adapted on skin level. Further local complications include dog-ears, hypertrophic or malpositioned scars, and in the abdominal region cosmetic problems related to the umbilicus. Most of these issues can be avoided with good preoperative planning and attention to surgical detail. Systemic complications include deep vein thrombosis, pulmonary embolism, fat embolism, respiratory compromise due to increased intra-abdominal pressure in abdominal cases with fascial tightening, and systemic infections including toxic shock syndrome. All of these complications may be potentially lethal. In general, abdominal tightening procedures have a higher systemic complication rate than any other type of routine cosmetic surgical procedure.9,10,12,13,19,20 However, the senior author has experienced only one lethal complication after more than 3000 procedures in MWL patients within the last 15 years due to pulmonary embolism (to clear the reason of death). Uni- or bilateral soft-tissue relaxation or rupture of the reconstructive gluteal sutures may be revised by a secondary procedure, alternatively with the use of a mesh for tissue support. In cases of general fascial deficiency, it may be a future option to apply a mesh support during primary gluteal autoaugmentation.

Postoperative care Every patient with a lower bodylift procedure receives single-shot antibiotic therapy at induction; in a few cases with pre-existing risk factors, we extend the antibiotic therapy to 5 days. For safety reasons, patients with lower bodylift are monitored for the initial 24 h postoperatively on an intensive or intermediate care unit. In order to ensure an optimal tissue perfusion and appropriate microcirculation, 2500 mL/24 h of Ringer’s solution is provided for the initial 48 h postoperatively. Dressings during this time include compression girdles surrounding fluid-collecting compresses. Furthermore, laboratory checks for electrolytes and hemoglobin are performed repeatedly during the initial 48 h and urinary output is monitored. Patients are positioned in beach-chair position, if available on a soft mattress, with electronically adjustable positions. Low molecular weight heparin and compression stockings are administered for thrombosis prophylaxis. Immediately postoperative, patients are instructed to move their feet consistently without crossing legs, followed by early mobilization on the first postoperative day; instructions for deep-breathing exercises for prevention of pneumonia are given. All patients receive pain treatment during the initial 48 h utilizing an individualized patient-controlled analgesia (PCA) pump. Drains are removed when drainage is less than 30 mL per 24 h. The urinary catheter is removed 2–3 days postoperatively. In cases of reimbursement by a statutory or private health insurance, the average duration of hospitalization after lower bodylift in our institution is 6 days. If the procedure is privately

832

SECTION III

CHAPTER 32  • Circumferential approaches to truncal contouring: the lower lipo-bodylift

financed by the patient, the hospital stay lasts an average 3–4 days. This time is generally required for a full patient mobilization and removal of all drains. Immediate postoperative compression therapy is intended to reduce shearing forces for support of the adhesion between different reconstructed tissue layers. In this context, drains are kept for a minimum of 4 days postoperatively to address negative intracavitary pressure. Before patients are discharged, we individually adapt a compression garment for 8 weeks postoperatively. For reduction of superficial wound tension, Steri-Strips are applied perpendicular on the wound for the initial 3 weeks postoperatively. Any suture or wound closure material is removed at the latest 3 weeks postoperatively. For at least 3 months postoperatively we recommend that our patients cover their entire scars with silicon sheets or apply various available scar-reducing skin lotions for improved scar formation.9,12 Sporting activities should be omitted for 8 weeks postoperatively. Patients should be advised to avoid saunas and tanning beds.

Outcomes In male patients, the postoperative results regarding scar course and appearance, as well as body contour enhancement, are usually promising, with stable results after years. Salient points are a very low scar course from the anterior and posterior view, a maximal reduction of the abdominal tissue surplus, favorably avoiding the vertical midline scar from fleur-de-lis, and a maximal reduction of the localized adipose tissue of the lateral and posterior flank region (“love handles”). Thus, in patients after MWL, the vertical midline scar may not be avoidable. In general, we have observed a stronger skin quality in male patients after weight loss with a lower rate of secondary relaxation. This probably is due to the fact that the rate of patients with conservative weight reduction is higher in the male population (unpublished data). Female patients, especially after weight loss, have their main focus on the improvement of the abdominal region, including the mons pubis. In this regard, we have observed a high patient satisfaction after fleur-de-lis tightening of the abdominal region, since this procedure enables a tissue reduction to a maximal amount. Since the subcutaneous fat tissue layer in the central upper abdomen is completely excised, the remaining abdominal subcutaneous tissue is maximally thinned out, consequently with maximal aesthetic improvement of the abdominal and waist contour. To avoid a tissue mismatch of the mons pubis region in relation to the abdomen, a sufficient reduction is advisable, either by liposuction, direct excision, or a wedge excision pattern. The second main focus of female patients is on gluteal reshaping. Since every patient presents with different preoperative conditions, individual therapy has to be selected. Since most patients present with sufficient gluteal fat tissue, the reconstruction by transpositioning of the tissues enables a stable reshaping of the buttocks.

postoperatively. A surplus of adipose tissue in the area of the lateral and dorsal thigh region may negatively affect the gluteal contour, since any additional downward traction may impair the gluteal projection. Therefore, we recommend an extensive reduction of this specific redundant adipose tissue through liposuction as a staged procedure prior to or during the gluteal procedure. The harvested fat tissue may be prepared and used for additional fat grafting in the gluteal region.

Scar appearance We favor performing an arch-shaped scar course that commences at the superior end of the intergluteal cleft and proceeds to the upper lateral gluteal border. The central back region is characterized by a strong midline zone of adherence, which consequently disables any significant skin and soft-tissue sagging. This has to be taken into account, since a more superior scar ending in the dorsal midline may result in a prolonged intergluteal cleft with aesthetic limitations. Further, the arch-shaped scar course accentuates a round-shaped buttock and respects the borders of the gluteal aesthetic unit (Fig. 32.12).

Transition vectors Due to a larger body circumference at the height of the inferior compared with the superior incision line, more tissue has to be moved medially in the lower gluteal area. This fact becomes more apparent when a fleur-de-lis abdominoplasty is performed in the anterior part with reduction of the superior circumference. For this reason, we symmetrically mark three vectors per side, enabling a medial transposition of the lower gluteal tissue with tissue accumulation at the medial buttock, which may further accentuate the gluteal projection.9,12 Further, this maneuver may induce a slender waist and improve the entire gluteal shape. In cases of extensive tissue surplus in the lateral and anterior thigh region, we recommend shifting the entire skin and soft-tissue envelope medially, resulting in a skin congestion in the medial thigh and groin region. This tissue surplus may then be excised during the second-stage inner thigh lift.

Maximal point of gluteal projection During the first postoperative weeks, patients usually present with a maximal gluteal projection at the upper third of the buttocks. This intentional overcorrection of gluteal projection at this height will be compromised during the first 6–8 weeks

A

B

Figure 32.12  Comparison of a straight scar (A) to an arch-shaped scar (B) on the backside, showing the optical elongation of the infragluteal fold when using a straight back incision.

Conclusions

1A

1B

1C

1D

2A

2B

2C

2D

3A

3B

3C

3D

833

Figure 32.13  Results. (1A–D) 34-year-old patient after 66-kg weight loss due to sleeve gastrectomy, before and 3 months after the lower bodylift with fleur-de-lis. (2A–D) 31-year-old patient after 46-kg weight loss due to diet and exercise, before and 3 months after the lower bodylift. (3A–D) 34-year-old patient after 87-kg weight loss due to bypass surgery, before and 3 months after the lower body- and thigh lift.

Conclusions The lower lipo-bodylift presents an extremely effective procedure for body rejuvenation and body contouring. Besides the advantages and enhancements attainable in the abdominal region, the overall body and gluteal shape can be significantly improved. The gluteal autoaugmentation (transposition-gluteoplasty) presents an effective and reliable method for gluteal augmentation in terms of

Access the reference list online at 

 

Elsevier eBooks+

transpositioning of the subfascial lateral gluteal, lateral thigh, and hip adipose tissue. It can be integrated into every bodylift procedure, without any considerable amount of time extension or additional expenditure. If clinical routine is ensured, the lower lipo-bodylift can be safely performed with reduced operating time and consequently fewer complications in total, with high patient satisfaction and optimized aesthetic outcomes (Fig. 32.13). However, these expectations are dependent on the patients’ preoperative conditions and tissue characteristics.

References

References 1. Roberts 3rd TL, Weinfeld AB, Bruner TW, et al. “Universal” and ethnic ideals of beautiful buttocks are best obtained by autologous micro fat grafting and liposuction. Clin Plast Surg. 2006;33:371–394. 2. Roberts 3rd TL, de la Pena JA, Cardenas JC, et al. Cosmetic surgery of the buttocks region. Aesthet Surg J. 2003;23:381–387. 3. Lockwood TE. Superficial fascial system (SFS) of the trunk and extremities: a new concept. Plast Reconstr Surg. 1991;87:1009–1018. 4. Lockwood TE. Lower body lift with superficial fascial system suspension. Plast Reconstr Surg. 1993;92:1112–1122. 5. Lockwood TE. The role of excisional lifting in body contour surgery. Clin Plast Surg. 1996;23:695–712. 6. Lockwood TE. Maximizing aesthetics in lateral-tension abdominoplasty and body lifts. Clin Plast Surg. 2004;31:523–537. 7. Sozer SO, Agullo FJ, Wolf C. Autoprosthesis buttock augmentation during lower body lift. Aesthetic Plast Surg. 2005;29:133–137, discussion 138–140. 8. Sozer SO, Agullo FJ, Palladino H. Split gluteal muscle flap for autoprosthesis buttock augmentation. Plast Reconstr Surg. 2012;129: 766–776. 9. Richter DF, Stoff A. Lower body lift. In: Rubin P, Jewell M, Richter DF, eds. Body Contouring and Liposuction. St. Louis, MO: Elsevier Saunders; 2012. 10. Stoff A, Richter DF. Abdominoplasty and body contouring. In: Farhadieh RD, Bulstrode NW, Cugno S, eds. Plastic and Reconstructive Surgery Approaches and Techniques. Hoboken, NJ: Wiley; 2015.

833.e1

11. Song AY, Jean RD, Hurwitz DJ, et al. A classification of contour deformities after bariatric weight loss: the Pittsburgh Rating Scale. Plast Reconstr Surg. 2006;116:1535–1544. 12. Richter DF, Stoff A, Velasco FJ, et al. Circumferential lower truncal dermatolipectomy. Clin Plast Surg. 2008;35:53–71. 13. Hunstad JP, Repta R. Atlas of Abdominoplasty. Philadelphia, PA: Saunders Elsevier; 2009. 14. Orpheu SC, Coltro PS, Scopel GP, et al. Collagen and elastic content of abdominal skin after surgical weight loss. Obes Surg. 2010;20: 480–486. 15. Krueger JK, Rohrich RJ. Clearing the smoke: the scientific rationale for tobacco abstention with plastic surgery. Plast Reconstr Surg. 2001;108:1063–1073, discussion 1074–1077. 16. Rubin JP, Nguyen V, Schwentker A. Perioperative management of the post-gastric-bypass patient presenting for body contour surgery. Clin Plast Surg. 2004;31:601–610. 17. Richter DF, Stoff A, Ramakrishnan V, et al. A comparison of a new skin closure device and intradermal sutures in the closure of full-thickness surgical incisions. Plast Reconstr Surg. 2012;130: 843–850. 18. Richter DF, Stoff A. The Scarpa lift – a novel technique for minimal invasive medial thigh lifts. Obes Surg. 2011;21:1975–1980. 19. Richter DF, Stoff A. Abdominoplasty procedures. In: Neligan PC, ed. Plastic Surgery. 3rd ed. St. Louis, MO: Elsevier Saunders; 2012. 20. Aly AS. Body Contouring after Massive Weight Loss. St. Louis, MO: Quality Medical Publishing; 2006.

 

SECTION III •  General Aesthetic Surgery

33

Circumferential approaches to truncal contouring: autologous buttocks augmentation with purse-string gluteoplasty Joseph P. Hunstad and Nicholas A. Flugstad

Access video lecture content for this chapter online at Elsevier eBooks+

SYNOPSIS

ƒ Previous methods of buttock autoaugmentation have employed rotational flaps that are prone to complications due to poor vascularity. Purse-string gluteoplasty was developed as a unique method of buttock autoaugmentation that does not require any undermining or rotation of flaps, thus adding to its simplicity and safety. ƒ Key elements of the procedure are buttock lifting combined with autoaugmentation, no undermining of autoaugmentation tissue, and use of a purse-string suture to enhance projection of autoaugmentation tissue. ƒ Other options in these patients include buttock fat grafting, but this does not correct skin laxity, and fat is usually not present in sufficient quantities to harvest from massive weight loss patients. Traditional buttock lifting is an option, but lack of volume will not be well corrected. Lastly, buttock autoaugmentation with rotational flaps is effective, but this requires additional dissection, and flaps may not be reliable in terms of vascularity. ƒ The ideal patient for purse-string gluteoplasty has buttock deflation and ptosis and wishes to improve projection. Patients should be healthy enough for elective surgery and, as in any body contouring, must be accepting of the proposed scar. ƒ Buttock ptosis and atrophy are very common after weight loss or even normal aging. Purse-string gluteoplasty is a safe and effective technique to correct both of these problems.

buttocks in conjunction with buttock lifting. Autologous buttock augmentation has been described by several authors.2–7 Previous methods typically involve undermining, rotational flaps, or flaps with a narrow base that are based on named perforator vessels. The purse-string gluteoplasty was developed as a safe and straightforward method of autologous buttock augmentation. No undermining or rotation of the augmentation tissue is required, therefore the safety and simplicity of the procedure are high.5,8 This method provides complete vascular preservation. In addition, the purse-string suture lends shape and additional projection (3–5 cm) to the buttocks. The procedure can be done as an isolated buttock reshaping surgery, or in conjunction with circumferential abdominoplasty/ bodylift. Body contouring secondary to massive weight loss is experiencing ever-increasing demand worldwide. This is secondary to increasing obesity and increasing success of weight loss surgery.9 This patient population has been shown to have significant psychological distress due to the deformities of massive weight loss.10 It has also been suggested that buttock autoaugmentation during buttock lifting leads to higher patient satisfaction than buttock lift without autoaugmentation.8 These patients will continue to demand ever-improving and aesthetically pleasing body contouring results, as may be provided by offering the purse-string gluteoplasty.

Introduction

Patient selection

Buttock atrophy and ptosis after massive weight loss or as part of normal aging is a common complaint of many patients. The purse-string gluteoplasty was first described in 20091 as an alternative to existing methods where rotation flaps had random vascularity of the tips and were fraught with tip loss. It is a method of autologous buttock augmentation, which uses the patient’s own redundant soft tissues to augment the atrophic

The ideal candidate is a patient with redundant skin and soft tissues of the lower back and gluteal region. This can be determined using bimanual pinch and palpation. Many of these patients have experienced significant weight loss, but this procedure is not exclusive to the weight loss population. Patients with buttock atrophy and ptosis also benefit from this procedure.

Surgical technique

Patients should be medically healthy enough for body contouring surgery and have adequate cardiopulmonary status to tolerate the prone position during surgery. Since the procedure involves moderate tension on the skin, smoking cessation is imperative for at least 6 weeks prior to surgery and until complete healing has occurred. Caution should be used in those with diabetes or vascular disease. The surgeon should also be aware of the patient’s coagulation status and hemoglobin preoperatively, although blood loss is typically minimal. In consultation, patients will often demonstrate their desire for buttocks augmentation and lifting by pulling up on their buttocks and thigh tissue, demonstrating their desired result. Patients may wish to discuss other options such as buttock fat grafting or buttock implants. In the typical massive weight loss patient, it is important to remember that skin removal will almost always be required to achieve satisfactory lifting of the ptotic and deflated buttock. In addition, patients with “complete weight loss” will not have adequate fat on their body to harvest via liposuction for buttock fat grafting.11 Prosthetic buttock implants come in a limited size range and are not recommended for use in conjunction with buttock lifting. Autologous tissue is plentiful, natural feeling, and redundant in virtually all massive weight loss patients.

Figure 33.1  The desired level of the scar is marked at the level of the gluteal apex.

Surgical technique The markings are made in a fashion similar to the posterior component of a circumferential abdominoplasty.12 The position of the final scar is marked somewhat more caudal than a typical buttock lift, so that the central tissue mound will be in a better location for buttock augmentation. The ideal line of maximum buttock projection is from the coccyx to the greater trochanter of the femur.13 During patient marking, the planned scar line is drawn oriented horizontally, at or just below the level of the gluteal apex from the greater trochanter to the coccyx (Fig. 33.1). An estimate of the amount of tissue to be incorporated into the autologous buttocks augmentation is made using strong bimanual palpation (Fig. 33.2). This technique is used to draw the extent of the resection superior and inferior to the planned scar position. On each buttock, the tissue intended for augmentation is marked within the resection pattern (Fig. 33.3). The lateral extent of the augmentation mounds corresponds to the lateral contour of the buttocks. Vertical realignment marks are placed to facilitate accurate soft-tissue closure, with the final markings shown in Fig. 33.4. As a safety measure, once the bimanual palpation lines are drawn, we frequently come in 1 cm from the superior and 1 cm from the inferior markings to ensure closure without undue tension. The patient is brought to the operating room and placed in the prone position under general anesthesia. Appropriate padding and sequential compression pumps on the lower extremities are used. Penetrating towel clamps are used to check that the markings are correct and that closure can be performed without undue tension (Fig. 33.5). The realignment marks are then tattooed with methylene blue using a tuberculin syringe with a 27-gauge needle, which ensures they will not be washed off. Dilute lidocaine-containing epinephrine is infiltrated into the incision lines and under the

835

Figure 33.2  Bimanual pinch is used to estimate and mark the extent of skin resection.

Figure 33.3  The area of intended augmentation is marked within the resection pattern, and in this case labeled “purse-string gluteoplasty”.

836

SECTION III

CHAPTER 33  • Circumferential approaches to truncal contouring: autologous buttocks augmentation

Figure 33.4  The complete markings are shown, with realignment marks drawn in blue.

Figure 33.5  In the operating room, towel clamps are used to check the markings and estimate the amount of tension required.

skin overlying the gluteal mound to facilitate hemostasis. This is done prior to full prepping and draping to allow the epinephrine to take maximum effect before the procedure begins. The incisions are made with a No.10 scalpel partially through the dermis. The augmentation mounds are then de-epithelialized. Electrocautery is used to complete the incisions, controlling bleeding throughout the procedure, and continue the dissection through the subcutaneous tissue down to the deep muscular fascia (Fig. 33.6). The dissection plane should be straight and not beveled, such that no undermining of the gluteoplasty mounds is done. The purse-string suture is then placed around each mound at the level of the superficial fascia system. Placement at this level is important, as placement too superficially or at the edge of the de-epithelialized skin will create undesirable invagination of the soft tissue, as opposed to increased projection. A No. 1 braided polyester suture is used to perform the purse-string component of the procedure in running fashion around each mound,

Figure 33.6  The gluteoplasty mounds are de-epithelialized, and dissection around the mounds is performed straight down to the deep fascia, taking care not to bevel or undermine the augmentation mounds.

Figure 33.7  The purse-string suture is placed in the superficial fascial system in running fashion and tightened, narrowing the base of the gluteoplasty mound, imparting shape and projection to the soft tissue.

taking equal but substantial bites along the way. When placed, the suture must glide and never be locked. When the suture is tightened, it narrows the base and increases the projection of the gluteal mound (Fig. 33.7). The purse-string creates a beautiful, round shape and imparts impressive projection. The dermis of the augmentation mounds is then sutured to the midline at the level of the superficial fascia to prevent lateral displacement of the mound (Fig. 33.8). Undermining of the buttock soft tissue inferiorly is performed as needed to allow the autologous tissue to fit properly and allow adequate tissue recruitment for closure (Fig. 33.9). Suction drains are placed and coiled laterally for final placement at the end of the procedure. Towel clamps are used to approximate the closure, and a temporary V–Y closure with No. 1 Prolene (Ethicon) is done laterally on each side (Fig. 33.10); otherwise the incision can end usually at the anterior axillary line when an isolated buttocks augmentation and lift is being performed. Incision line closure is performed in three

Surgical technique

837

Figure 33.8  The gluteoplasty mounds are secured to a central remnant of superficial fascia tissue to keep the mounds from migrating laterally.

Figure 33.10  Temporary towel clips are used to align the skin edges during closure. The superficial fascial system layer is closed with 1 Vicryl. Laterally, a temporary V–Y closure is done, to be finalized when the patient is turned supine.

Figure 33.9  Undermining of the buttock soft tissue is done inferiorly to create a pocket for the gluteoplasty mound to fit in and allow proper soft-tissue recruitment to facilitate closure.

Figure 33.11  Final closure in the operating room.

layers. The superficial fascia is closed with 0 or 1 Vicryl (Ethicon), usually one per centimeter of incision length. The deep dermis is closed with buried interrupted 2-0 Vicryl, and the final intradermal closure is performed with 4-0 Monocryl (Ethicon) (Fig. 33.11). After completion of the prone portion, the patient is turned supine. If the purse-string gluteoplasty is being performed in isolation, the Prolene suture is removed, followed by lateral dog-ear excision and closure. If the purse-string gluteoplasty is being performed as part of a circumferential abdominoplasty, the latter portion of the procedure is then completed. The surgeon must remember that re-flexing the patient during the abdominoplasty increases tension and pressure on the purse-string gluteoplasty. The immediate result of this procedure is dramatically improved buttock laxity and soft-tissue projection. A certain amount of relaxation will undoubtedly occur, but this technique has been reliable in achieving and maintaining buttocks volume and projection (Figs. 33.12–33.14).

Hints and tips • Checking your marks with towel clamps will help ensure that excessive tension or inability to close the skin over the gluteoplasty mounds does not occur. Avoid over-resection when performing this procedure by marking 1 cm inside the lines of the bimanual palpation. • Tattooing the realignment marks with methylene blue before prepping ensures they will not be washed off. • The most tension can often occur laterally. When marking the lateral aspect, instruct the patient to lean slightly away from you to avoid over-resecting that area. • Engaging the superficial fascial system (SFS) with your deepest layer of sutures allows for the majority of the tension to be placed on the SFS layer and not the skin. This allows the skin to heal with minimal tension, improving the final scar outcome.

838

SECTION III

CHAPTER 33  • Circumferential approaches to truncal contouring: autologous buttocks augmentation

A

B

C

D

Figure 33.12  (A,B) A 60-year-old female who has experienced buttock ptosis and deflation with aging. She is not a weight loss patient. (C,D) At 3 months postoperatively from buttock lift with purse-string gluteoplasty.

Postoperative care Our typical dressing is 1-inch paper tape over the incisions, with cuts in the tape every 5 cm to allow for swelling. The tape allows reinforcement of the closure and protection from shearing for the first 2–3 weeks and should be changed every 5–7 days. Due to difficulty with placement and replacement, no compression garments are used following this procedure. In recovery, patients who have isolated purse-string gluteoplasty may be placed flat and in a lateral decubitus position while recovering. If concurrent circumferential abdominoplasty is performed, the patient will remain supine and in a beach-chair position. Upon discharge, routine narcotic pain medication as well as prophylactic antibiotics are taken. During the healing period, patients are asked to sit very gently on a pillow or cushion as opposed to a hard surface, and are asked to limit time sitting if possible. Periodic ambulation ensures pressure relief on the buttocks as well as reducing the likelihood of deep vein thrombosis (DVT). Frequent follow-up is performed within a few days to make sure healing is progressing as expected, as well as to answer any questions that may arise. Drains are removed when the drainage amount decreases to less than 25 mL per 24-h period. When complete

healing has occurred at approximately 4 weeks, the patient is released from activity restrictions.

Outcomes and complications Long-term buttock projection with the purse-string gluteoplasty is excellent. The overlying skin may relax to some degree over time, but the underlying gluteoplasty mounds are living tissue – therefore long-lasting and natural. The suture maintains the shape and projection of the autologous augmentation and is quite durable. Adequate preparation and informed consent of the patient prior to surgery is an essential component. Patients must be prepared for scars from this procedure as the trade-off for skin removal and ptosis correction. Patients must also be prepared for potential widened or unfavorable scarring. Patient satisfaction with this procedure is consistently high in our experience. The most frequent complications are focal areas of wound dehiscence and superficial infection. Areas of dehiscence are treated with wet to dry dressings until healed. Small areas of incisional opening can often be treated with removal of suture material that is extruded. Localized infections are treated with broad-spectrum oral antibiotics

Outcomes and complications

A

B

C

D

839

Figure 33.13  (A,B) A 47-year-old female with weight loss and complaints of buttock ptosis. (C,D) At 1 year and 3 months after circumferential abdominoplasty with pursestring gluteoplasty. She went on to have a scar revision.

such as amoxicillin/clavulanate or clindamycin, keeping in mind that the incisions are in close proximity to the anus. We have not experienced any infection or delayed healing secondary to necrosis of the gluteoplasty mounds. The gluteoplasty mounds are durable and reliable in this technique. In addition, as in any dissection with large potential space, seroma or hematoma is possible but have been rarely encountered. Hematoma should be treated with immediate evacuation. Seroma is treated with serial aspiration until resolution. Finally, in the long term, inferior migration of

the lateral scar onto the upper thigh is occasionally seen. This has been treated in two patients with scar revision and release of the lateral thigh zones of adherence inferior to the scar. Patients who wish to undergo buttock lifting and improve their buttock shape and projection may choose to undergo purse-string gluteoplasty. It is reflected in the literature that body contouring produces physical and psychological benefits for the patient. With careful planning and preparation, fantastic and predictable results are possible.

840

SECTION III

CHAPTER 33  • Circumferential approaches to truncal contouring: autologous buttocks augmentation

A

B

C

D

Figure 33.14  (A,B) A 34-year-old female with complaints of loose skin and flat buttocks. (C,D) At 18 months following buttock lift with purse-string gluteoplasty. Her buttock shape and projection are improved.

Access the reference list online at   Elsevier eBooks+

References

References 1. Hunstad JP, Repta R. Purse string gluteoplasty. Plast Reconstr Surg. 2009;123:123e–125e. 2. Centeno RF. Autologous gluteal augmentation. Clin Plastic Surg. 2006;33:479–496. 3. Balague N, Combescure C, Huber O. Plastic surgery improves long-term weight control after bariatric surgery. Plast Reconstr Surg. 2013;132:826–833. 4. van der Beek ES, Geenen R, de Heer F. Quality of life long-term following bariatric surgery: sustained improvement after 7 years. Plast Reconstr Surg. 2012;130:1133–1139. 5. Rohde C, Gerut Z. Augmentation buttock-pexy using autologous tissue following massive weight loss. Aesthet Surg J. 2005;25:576–581. 6. Raposo-Amaral CE, Cetrulo CL, de Campos Guidi M. Bilateral lumbar hip dermal fat rotation flaps: a novel technique for autologous augmentation gluteoplasty. Plast Reconstr Surg. 2006;117:1781–1788.

840.e1

7. Sozer SO, Francisco JA, Wolf C. Autoprosthesis buttock augmentation during lower body lift. Aesthetic Plast Surg. 2006;29:133–137. 8. Srivastava U, Rubin JP, Gusenoff JA. Lower body lift after massive weight loss: autoaugmentation versus no augmentation. Plast Reconstr Surg. 2015;135:762–772. 9. Kitzinger HB, Aayev S, Pittermann A. The prevalence of body contouring surgery after gastric bypass surgery. Obes Surg. 2012;22:8–12. 10. Azin A, Zhou C, Jackson T, et al. Body contouring surgery after bariatric surgery: a study of cost as a barrier and impact on psychological well-being. Plast Reconstr Surg. 2014;133:776e–782e. 11. Hunstad JP, Aiken ME. Circumferential body contouring. In: Aly A, ed. Body Contouring after Massive Weight Loss. Boca Raton, FL: CRC Press; 2006:183–212. 12. Hunstad JP, Deos M, Repta R. Circumferential abdominoplasty. In: Hunstad JP, Repta R, eds. Atlas of Abdominoplasty. Philadelphia, PA: Saunders Elsevier; 2009:89–114. 13. Centeno RF, Mendieta CG, Young VL. Gluteal contouring surgery in the massive weight loss patient. Clin Plast Surg. 2008;35:73–91.

 

SECTION III •  General Aesthetic Surgery

34 Circumferential approaches to truncal contouring: Lower bodylift with autologous gluteal flaps for augmentation and preservation of gluteal contour Robert F. Centeno and Jazmina M. Gonzalez Access video lecture content for this chapter online at Elsevier eBooks+ 

SYNOPSIS

ƒ There has been a dramatic rise in popularity of aesthetic gluteal contouring in both weight loss and non-weight loss patients. ƒ While most procedures performed today are autologous fat transfer and implant procedures, some gluteal deformities including skin excess or buttock ptosis demand alternative body contouring solutions. ƒ Several techniques for autologous gluteal autoaugmentation with circumferential bodylift and excisional buttock lifts are used. ƒ Three categories of autologous flaps are described in this chapter: island flaps, what the senior author describes as incremental flaps, and transpositional flaps.

Introduction The ongoing demand for bariatric surgery procedures and its effect on massive weight loss (MWL) patients presenting with severe body contour deformities has unexpectedly driven demand for gluteal contouring procedures. Changing sociocultural gluteal aesthetic norms and exposure in popular culture media channels has also increased demand for aesthetic gluteal contouring procedures across the US.1 While most procedures performed today are autologous fat transfer and implant procedures, the MWL patient can present with unique gluteal deformities demanding alternative body-contouring solutions. The dramatic rise in popularity of aesthetic gluteal contouring has also increased the demand for circumferential bodylifts and excisional buttock lifts with autoaugmentation in weight loss patients and non-weight loss patients with significant skin laxity or hypoplasia. Several techniques for autologous gluteal autoaugmentation (AGA) with circumferential bodylift (CBL) and excisional buttock lifts (EBL) have been posited as a solution to this problem. Three general categories of autologous flaps are described in this chapter: island flaps, what the senior author describes as incremental flaps,

and transpositional flaps. Experience and knowledge of the variety of techniques will allow expanded application to the aesthetic patient presenting with gluteal hypoplasia in addition to the MWL population. Indications, technical variations, surgical planning, results, complications, and postoperative management are discussed.

Gluteal hypoplasia in the massive weight loss and aesthetic patient As one ages, anatomic changes that occur in the torso and gluteal region contribute to decreased gluteal projection and aesthetics. Accumulation of subcutaneous fat in areas surrounding the gluteal region detracts from the aesthetic appearance of the buttock. The accumulation of intra-abdominal fat in women that accompanies perimenopausal changes coupled with rectus diastasis negatively affects the contour of the torso. Age-related skin laxity and ptosis of the subcutaneous fat also decreases projection of the gluteal region. Dramatic loss of adipose volume in the buttock of weight loss patients uniquely contributes to decreased projection and ptosis. The average female patient gets wider at the hips and the infragluteal crease lengthens with age.2–4 Many of these findings prompt aesthetic patients to seek consultation for body contouring procedures. The circumferential bodylift has proven to be a very effective procedure in addressing many of these concerns and is often recommended. Unfortunately, significant flattening of the buttock can occur with aggressive lifting posteriorly (Fig. 34.1). Pre-existing platypygia is also worsened by the procedure and is of concern to many aesthetic patients. The massive weight loss patient represents another end of the spectrum. Weight loss secondary to exercise or bariatric procedures often occurs in a variable manner. There is data to suggest that certain areas of adipose tissue on the body are more resistant to weight loss than others. The

SECTION III

842

CHAPTER 34  • Circumferential approaches to truncal contouring: Lower bodylift with autologous gluteal flaps

A

B

C

D

E

F

Figure 34.1  (A–F) Circumferential bodylift/excisional buttock lift and buttock flattening.

A

B

C

Figure 34.2  (A–C) Skeletal changes after massive weight loss.

genetic programming of the resistant adipocytes differ from more responsive areas, suggesting a genetic role of different somatotypes. Some somatotypes such as “apples” seem to have less adipose tissue in the gluteal region. “Pears” tend to retain more tissue in the gluteal region. These somatotypes can also affect the shape of the pelvis and buttock shape.

Final post-weight loss body mass index (BMI) has a significant impact on these findings, irrespective of body shape. Many MWL patients tend to lose some volume in the gluteal region.4,5 The MWL patient also develops skeletal changes that may contribute to platypygia (Fig. 34.2). Morbid obesity is a

Development of techniques

restrictive lung disease with an obstructive component that is more pronounced in the supine position. Expiratory flow limitation in the supine position may lead to pulmonary hyperinflation and intrinsic positive end-expiratory pressure (PEEP). This is thought to play a role in positional orthopnea reported by obese patients.6,7 Over time, obese patients are hypothesized to develop thoracic skeletal expansion to accommodate this increased need for functional reserve capacity and to accommodate hyperinflation. Thoracic kyphosis or scoliosis secondary to thoracic spine compression and anterior inclination of the pelvis also occurs.8 Inadequately treated post-bypass hypocalcemia, vitamin D malabsorption, secondary hypoparathyroidism, and independent negative bone remodeling modulated by either sex hormones or serum telopeptides may also worsen these weight-related skeletal changes.9 These skeletal changes are permanent and worsen pre-existing primary or secondary platypygia caused by loss of adipose tissue in the gluteal region. The skeletal findings also contribute significantly to asymmetry that is resistant to body contouring.

Development of techniques As demand for gluteal enhancement and the collective experience with the various forms of alloplastic and autologous gluteal augmentation have grown, a consensus has emerged that limitations in gluteal implant design have limited the success and widespread acceptance of alloplastic gluteal augmentation in the US. Nevertheless, these techniques are still applicable in certain subsets of well-informed patients. Alloplastic techniques are very successful in enhancing the gluteal aesthetic but have limited applicability because of their significant long-term complication rates. The “aesthetic success” of these alloplastic procedures has inspired the authors and others to continue to refine several autologous flap techniques for gluteal augmentation.10–13 Furthermore, the impact of implant position on buttock projection and aesthetics has significantly influenced autologous augmentation techniques. Submuscular implants have the highest point of maximum projection in comparison to the ideal at the level of the mons pubis. Intramuscular implants lower the point of maximum projection, but they are still higher than ideal. Subfascial implants lower the point of maximum projection closest to the ideal at the level of the mons pubis (Fig. 34.3). The MWL patient with significant skin excess and buttock ptosis is not the ideal candidate for either alloplastic augmentation in any of the three accepted planes: subfascial, intramuscular, submuscular; nor autologous fat transfer. The combination of an excisional procedure (CBL/EBL) characterized by a higher than average minor complication rate, with alloplastic augmentation procedures where infection would be catastrophic, seems imprudent.14,15 Recently, several authors have reported their experiences with “hybrid” procedures which combine smaller alloplastic implants with autologous fat transfer in both the aesthetic and MWL populations. This approach seeks to address the known complications of larger implants with supplemental augmentation and lateral filling to address the aesthetic limitations of the smaller implants.16,17 De-epithelialized flaps have been used in gluteal contouring for some time.18–20 Published references

843

Figure 34.3  Implant position and gluteal point of maximal projection.

to the use of autologous tissue in preventing gluteal deformities with CBL were also reported but lacked significant detail and did not substantiate their potential for augmentation.21,22 The description of the superior gluteal artery, inferior gluteal artery, and transverse lumbosacral back flaps and their vascular supplies also bolstered the clinical viability of this approach.23 More recent anatomic studies have further refined our knowledge of the vascular anatomy of the gluteal region.24,25 The island AGA flap, one of the earliest techniques, simulated the round, non-anatomic design of submuscular gluteal implants. This flap is based on perforators from the superior gluteal artery, which are preserved by restricting undermining of the flaps. Hunstad has reported a variation of the island flap, an imbrication flap, which utilizes a purse-string suture to enhance the projection of the flap. Colwell described a variation of the island flap based on a superior gluteal artery perforator (SGAP) flap design (Fig. 34.4). Pascal, RaposaAmaral, and Kohler all proposed variations of the SGAP island flap with incremental recruitment of additional surrounding tissue to enhance outcomes (Fig. 34.5). While projection is enhanced significantly with these incremental flaps, the point of maximum projection remains high compared to alternative flap designs. Flap dissection that limits undermining and mobilization of the flap from the original donor site in order to preserve vascularity is the main limiting factor. Long-term augmentation results with these approaches have been disappointing in the author’s experience. Higher than ideal gluteal projection and lack of inferior pole projection continue to plague the aesthetic outcomes of these techniques. These shortcomings led to the development of the author’s preferred technique, the moustache autologous gluteal augmentation (AGA) flap (Fig. 34.6), which is one variation of a transpositional flap. The moustache AGA flap utilizes the back and lateral flank tissue as a partial island and partial transposition flap based on perforators from the superior gluteal artery and lumbar perforators.26,27 Inferomedial transposition of the “handle-bar” part of the moustache AGA flap allows recruitment of additional tissue for augmentation purposes as well as lowers the point of maximum projection to the level of the mons pubis, which is more aesthetically harmonious. Loose imbrication of the flap with sutures allows for the formation of an “anatomically” shaped autologous implant reminiscent of the alloplastic procedures. The central area of the flap tissue is typically divided to allow for easier closure and turned inferolaterally to be incorporated into the flap. Rohde

SECTION III

844

CHAPTER 34  • Circumferential approaches to truncal contouring: Lower bodylift with autologous gluteal flaps

also proposed a partial transposition flap to lower the point of maximum projection of the autologous flaps to enhance outcomes.28 Sozer, in multiple reports, proposed a gluteus maximus muscle turnover flap based on partial dissection of the gluteus maximus muscle to enhance projection and reach of the flap to the mid to lower pole of the buttock with pleasing results.29–32 Based on the published results and a critical assessment of aesthetic outcomes, the Centeno–moustache transposition flap, or one of the other iterations as described by Rohde or Sozer et al., likely represent the procedures of choice where

A

significant, long-lasting aesthetic augmentation is desired and a lower point of maximum projection is critical for a harmonious outcome (see Fig. 34.6).

Aesthetic analysis Selection of a technique for gluteal contouring in the MWL or aesthetic patient begins with a careful aesthetic analysis of the nature and causes of the gluteal deformity. The status

B

C

D

E

F

Figure 34.4 Island gluteal flaps: (A–D) Centeno – island flap; (E,F) Hunstad – purse-string flap;  

BMI and procedural indications

G

H

845

I

J

Figure 34.4, cont’d (G–J)  Colwell–Borud – SGAP (superior gluteal artery perforator) flap.

of the subcutaneous adipose tissue in the gluteal region as well as the surrounding gluteal aesthetic units of the torso and lower extremities is the first step of the analysis (Fig. 34.7).33 Volume excess or paucity is precise enough for technique selection purposes. The buttock shape as described by Mendieta is then determined (Fig. 34.8). V-shaped buttocks are the most difficult to correct and require the largest volume of tissue in the lower pole and lateral aspect of the buttocks. Muscle and bony skeletal height and width is then identified to determine if the buttock needs apparent shortening or lengthening and the final location of the point of maximum projection determined (Fig. 34.9).34 This analysis is important to incision height placement as it relates to flap selection and final incision location. High-riding CBL/EBL incisions can enhance waist definition while lengthening the buttocks favorably in shorter-buttock patients and unfavorably in longer-buttock patients (Fig. 34.10). Shorter buttocks characterized by short gluteus maximus muscle and pelvic height can be favorably treated more efficiently with shorter flaps such as the island or incremental flaps. Buttocks characterized by longer muscle, bony, and visual length, as well as V-shaped buttocks, are more appropriately treated with a transposition flap. The transposition flaps recruit additional tissue to fill the lower third of the buttock, the lower lateral aspect of V-shaped buttock, and lower the point of maximum projection closer to the ideal. Finally, the quality and laxity of the skin of the abdomen, flanks, hip, back,

buttock, anterior thigh, lateral thigh, and posterior thigh are noted. The results of this analysis are then used to guide the surgeon through a “gluteal contouring algorithm” for body contouring (Algorithm 34.1). Once the decision is made that gluteal augmentation is desirable and that an excisional procedure is indicated due to posterior skin laxity, then CBL or EBL is considered. If CBL or EBL are indicated, then autologous augmentation with a vascularized gluteal flap becomes the procedure of choice in patients with BMI under 30. The gluteal augmentation algorithm indicates preferred choices for gluteal augmentation under various conditions. Over time, the use of autologous tissues either as a flap or in fat transfer have become the procedures of choice in the author’s practice. The moustache flap and other transpositional flaps have made supplemental procedures such as staged fat transfer or alloplastic implants less necessary due to the significant augmentation achieved. The high complication rates experienced with the various forms of implant augmentation have also relegated these procedures to last-resort procedures in only the most well-informed and compliant patients.

BMI and procedural indications Obese patients with a BMI over 30 have been shown to be at higher risk for perioperative complications in aesthetic and

846

CHAPTER 34  • Circumferential approaches to truncal contouring: Lower bodylift with autologous gluteal flaps

SECTION III

1

2

A

B

C

Figure 34.5  Incremental gluteal flaps: (A) Pascal; (B) Raposa–Amaral; (C) Koller.

MWL body contouring. Wound-healing dehiscence, delayed healing, seromas, infection, and deep venous thrombosis are some of the common complications observed in obese patients. These patients are far from the generally agreed upon ideal aesthetic goals and should be managed more conservatively. Less risky approaches such as staged liposuction and excisional procedures and limited dissection can reduce morbidity in this group. AGA with CBL/EBL is not recommended in this group.

Mid-range BMI patients (BMI 25–30) also benefit from excisional procedures, adjunctive liposuction, and the addition of autologous fat transfer for further shaping. Younger patients without comorbidities in the lower part of this range can benefit from AGA with CBL/EBL. Which procedures are combined and how they are staged is determined by combining aesthetic judgment, preoperative medical status, age, BMI, physical findings, and patient desires.

Gluteal flap selection

A

D

B

847

C

E

F

G

H

Figure 34.6  Transpositional gluteal flaps: (A–E) Centeno – moustache flap; (F) Sozer – split gluteal turnover flap; (G,H) Rohde.

Low-range BMI patients (BMI