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Core Procedures in Plastic Surgery
This page intentionally left blank
Core Procedures in
Plastic Surgery

Peter C. Neligan MB, FRCS(I),

Professor of Surgery
Department of Surgery, Division of Plastic Surgery
University of Washington
Seattle, WA, USA

Donald W. Buck II MD
Assistant Professor of Surgery
Division of Plastic & Reconstructive Surgery
Washington University School of Medicine
St. Louis, MO, USA

For additional online content visit

Edinburgh London New York Oxford Philadelphia St Louis Sydney 2020

© 2020, Elsevier Inc. All rights reserved.

First edition 2014

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
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Center and the Copyright Licensing Agency, can be found at our website:

This book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).

The following authors retain copyright of the following content:

Video clip 1.1 Periorbital Rejuvenation © Julius Few Jr.

Video clip 2.6 The High SMAS Technique with Septal Reset © Fritz E. Barton Jr.
Video clip 6.3 Post Bariatric Reconstruction-Bodylift © J. Peter Rubin.
Video clip 21.4 DIEP flap breast reconstruction © Philip N. Blondeel.


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,
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or ideas contained in the material herein.

Library of Congress Control Number: 2018963267

ISBN: 978-0-323-54697-3

Ebook ISBN: 978-0-323-54773-4

Inkling ISBN: 978-0-323-54774-1

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Printed in China

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


Preface vi 14 Chest reconstruction 250

List of Contributors vii 15 Back reconstruction 262
Acknowledgments xii
16 Abdominal wall reconstruction 277
Video Contents xiii
Video Contributors xv 17 Breast augmentation 291
18 Mastopexy and augmentation mastopexy 303
1 Blepharoplasty 1 19 Reduction mammaplasty and gynecomastia 324
2 Facelift 23 20 Implant-based breast reconstruction 333
3 Forehead rejuvenation 46 21 Autologous breast reconstruction using
4 Rhinoplasty 60 abdominal flaps 350
5 Otoplasty 85 22 Essential anatomy of the upper extremity 381
6 Abdominoplasty and lipoabdominoplasty 93 23 Examination of the upper extremity 414
7 Body contouring 106 24 Flexor tendon injury and reconstruction 430
8 Liposuction and fat grafting 139 25 Nerve transfers (ONLINE) e1
9 Facial injuries 157 26 Tendon transfers in the upper extremity (ONLINE) e18
10 Local flaps for facial coverage 175 27 Extensor tendon injuries 446
11 Cleft lip repair 199
12 Cleft palate 221 Index 459
13 Lower extremity reconstruction 231


When putting together the first edition of Core Procedures in In this new edition, we have compiled 27 chapters in both
Plastic Surgery, our goal was to provide a quick reference aesthetic and reconstructive plastic surgery. In addition to the
resource for some of the most common plastic surgery pro- updated original 24 chapters from the first edition, we have
cedures performed in day-to-day practice. Recognizing the added new chapters focusing on forehead rejuvenation, body
challenge of having “enough” time – time to balance work contouring, liposuction, and fat grafting. Again, reference is
and life activities, time to read encyclopedic textbooks – we made to the chapters in Plastic Surgery 4th Edition from which
felt that this text would be useful as an adjunct to its more the content is extracted. Each chapter follows a template,
exhaustive counterparts. When Elsevier contacted us about so the text is presented in a consistent and concise manner.
putting together a second edition for this book, it further Within each topic, the chapters are littered with bulleted pearls
solidified the notion that busy surgeons just want important of wisdom highlighting key concepts of anatomy, operative
facts, the key information, and technical detail that is easily technique, complications and outcomes, and preoperative and
accessible and will help them day to day. We are humbled and postoperative considerations. There is generous use of illus-
grateful for the opportunity to produce this second edition of trations, schematic diagrams, photographs, as well as videos
Core Procedures in Plastic Surgery. Since our first edition, there extracted from the fourth edition text. A short annotated
have been some new developments within plastic surgery, bibliography is at the end of each chapter. An icon appears
including new techniques, which we have tried to capture in beside the text or illustration to indicate video content.
this edition. In keeping with our original goal, we have kept the We are honored to produce this second edition of Core
focus of this edition on highlighting some of the most common Procedures and hope you will find this edition as useful as
plastic surgery procedures. Likewise, as the companion to the the first and a great addition to your plastic surgery library.
six-volume Plastic Surgery 4th Edition text, we have combed We have tried to design it to be intuitive and user-friendly,
through the various topics and condensed the appropriate and we hope that you will appreciate the condensed format
chapters into our bulleted, highly focused, high-yield chapters that makes for quick review in the OR or clinic.
containing only the most pertinent information along with
high-quality images and video. Peter C. Neligan
Donald W. Buck II

List of Contributors

The editor(s) would like to acknowledge Jonathan Bank, MD Charles E. Butler, MD, FACS
and offer grateful thanks for the input Resident, Section of Plastic and Reconstructive Professor and Chairman
of all previous editions’ contributors, Surgery Department of Plastic Surgery
without whom this new edition would Department of Surgery Charles B. Barker Endowed Chair in Surgery
not have been possible. Pritzker School of Medicine The University of Texas M. D. Anderson Cancer
University of Chicago Medical Center Center
Jamil Ahmad, MD, FRCSC Chicago, IL, USA Houston, TX, USA
Staff Plastic Surgeon
The Plastic Surgery Clinic Fritz E. Barton Jr, MD M. Bradley Calobrace, MD, FACS
Mississauga, ON, Canada Clinical Professor Plastic Surgeon
Department of Plastic Surgery Calobrace and Mizuguchi Plastic Surgery
Robert J. Allen, MD University of Texas Southwestern Medical Center
Clinical Professor of Plastic Surgery Center Departments of Surgery, Divisions of Plastic
Department of Plastic Surgery Dallas, TX, USA Surgery
New York University Medical Center Clinical Faculty, University of Louisville and
Charleston, SC, USA Brett Beber, BA, MD, FRCSC University of Kentucky
Plastic and Reconstructive Surgeon Louisville, KY, USA
Al S. Aly, MD Lecturer, Department of Surgery
Professor of Plastic Surgery University of Toronto Andrés F. Cánchica, MD
Aesthetic and Plastic Surgery Institute Toronto, ON, Canada Chief Resident of Plastic Surgery
University of California Irvine Plastic Surgery Service Dr. Osvaldo Saldanha
Orange, CA, USA Miles G. Berry, MS, FRCS(Plast) São Paulo, Brazil
Consultant Plastic and Aesthetic Surgeon
Khalid Al-Zahrani, MD, SSC-PLAST Institute of Cosmetic and Reconstructive Joseph F. Capella, MD
Assistant Professor Surgery Chief Post-bariatric Body Contouring
Consultant Plastic Surgeon London, UK Division of Plastic Surgery
King Khalid University Hospital Hackensack University Medical Center
King Saud University Phillip N. Blondeel, MD, PhD, FCCP Hackensack, NJ, USA
Riyadh, Saudi Arabia Professor of Plastic Surgery
Department of Plastic and Reconstructive Giuseppe Catanuto, MD, PhD
Ryan E. Austin, MD, FRCSC Surgery Research Fellow
Plastic Surgeon University Hospital Gent The School of Oncological Reconstructive
The Plastic Surgery Clinic Gent, Belgium Surgery
Mississauga, ON, Canada Milan, Italy
Kirsty U. Boyd, MD, FRCSC
Sérgio Fernando Dantas de Azevedo, MD Clinical Fellow – Hand Surgery Robert F. Centeno, MD, MBA
Member Department of Surgery – Division of Plastic Medical Director
Brazilian Society of Plastic Surgery Surgery St. Croix Plastic Surgery and MediSpa;
Volunteer Professor of Plastic Surgery Washington University School of Medicine Chief Medical Quality Officer
Department of Plastic Surgery Saint Louis, MO, USA Governor Juan F. Luis Hospital and Medical
Federal University of Pernambuco Center
Pernambuco, Brazil Mitchell H. Brown, MD, MEd, FRCSC Christiansted, Saint Croix
Plastic and Reconstructive Surgeon United States Virgin Islands
Daniel C. Baker, MD Associate Professor, Department of Surgery
Professor of Surgery University of Toronto James Chang, MD
Institute of Reconstructive Plastic Surgery Toronto, ON, Canada Professor and Chief
New York University Medical Center Division of Plastic and Reconstructive Surgery
Department of Plastic Surgery Donald W. Buck II, MD Stanford University Medical Center
New York, NY, USA Assistant Professor of Surgery Stanford, CA, USA
Division of Plastic & Reconstructive Surgery
Washington University School of Medicine Robert A. Chase, MD
St. Louis, MO, USA Holman Professor of Surgery – Emeritus
Stanford University Medical Center
Stanford, CA, USA

viii List of Contributors

Philip Kuo-Ting Chen, MD Jorge I. de la Torre, MD Joshua Fosnot, MD

Director Professor and Chief Resident
Department of Plastic and Reconstructive Division of Plastic Surgery Division of Plastic Surgery
Surgery University of Alabama at Birmingham The University of Pennsylvania Health System
Chang Gung Memorial Hospital and Chang Birmingham, AL, USA Philadelphia, PA, USA
Gung University
Taipei, Taiwan, The People’s Republic of China Amir H. Dorafshar, MBChB Ida K. Fox, MD
Assistant Professor Assistant Professor of Plastic Surgery
Mark W. Clemens II, MD Department of Plastic and Reconstructive Department of Surgery
Assistant Professor Surgery Washington University School of Medicine
Department of Plastic Surgery John Hopkins Medical Institute Saint Louis, MO, USA
Anderson Cancer Center University of Texas John Hopkins Outpatient Center
Houston, TX, USA Baltimore, MD, USA Allen Gabriel, MD
Assistant Professor
Robert Cohen, MD, FACS Gregory A. Dumanian, MD, FACS Department of Plastic Surgery
Medical Director Chief of Plastic Surgery Loma Linda University Medical Center
Plastic Surgery Division of Plastic Surgery, Department of Chief of Plastic Surgery
Scottsdale Center for Plastic Surgery Surgery Southwest Washington Medical Center
Paradise Valley, AZ, and Northwestern Feinberg School of Medicine Vancouver, WA, USA
Santa Monica, CA, USA Chicago, IL, USA
Michael S. Gart, MD
Amy S. Colwell, MD L. Franklyn Elliott, MD Resident Physician
Associate Professor Assistant Clinical Professor Division of Plastic Surgery
Harvard Medical School Emory Section of Plastic Surgery Northwestern University Feinberg School of
Massachusetts General Hospital Emory University Medicine
Boston, MA, USA Atlanta, GA, USA Chicago, IL, USA

Mark B. Constantian, MD, FACS Marco F. Ellis, MD Günter Germann, MD, PhD
Active Staff Chief Resident Professor of Plastic Surgery
Saint Joseph Hospital Division of Plastic Surgery Clinic for Plastic and Reconstructive Surgery
Nashua, NH (private practice) Northwestern Memorial Hospital Heidelberg University Hospital
Assistant Clinical Professor of Plastic Surgery Northwestern University, Feinberg School of Heidelberg, Germany
Division of Plastic Surgery Medicine
Department of Surgery Chicago, IL, USA Jazmina M. Gonzalez, MD
University of Wisconsin Bitar Cosmetic Surgery Institute
Madison, WI, USA Julius W. Few Jr, MD Fairfax, VA, USA
Albert Cram, MD The Few Institute for Aesthetic Plastic Surgery Lawrence J. Gottlieb, MD
Professor Emeritus Clinical Associate Professor of Surgery
University of Iowa Division of Plastic Surgery Department of Surgery
Iowa City Plastic Surgery University of Chicago Section of Plastic and Reconstructive Surgery
Coralville, IO, USA Chicago, IL, USA University of Chicago
Chicago, IL, USA
Phillip Dauwe, MD Neil A Fine, MD
Department of Plastic Surgery Associate Professor of Clinical Surgery Barry H. Grayson, DDS
University of Texas Southwestern Medical Department of Surgery Associate Professor of Surgery (Craniofacial
School Northwestern University Orthodontics)
Dallas, TX, USA Chicago, IL, USA New York University Langone Medical Center
Institute of Reconstructive Plastic Surgery
Dai M. Davies, FRCS David M. Fisher, MB, BCh, FRCSC, FACS New York, NY, USA
Consultant and Institute Director Medical Director, Cleft Lip and Palate Program
Institute of Cosmetic and Reconstructive Division of Plastic and Reconstructive Surgery James C. Grotting, MD, FACS
Surgery The Hospital for Sick Children Clinical Professor of Plastic Surgery
London, UK Toronto, ON, Canada University of Alabama at Birmingham;
The University of Wisconsin, Madison, WI;
Michael R. Davis, MD, FACS, LtCol, Jack Fisher, MD Grotting and Cohn Plastic Surgery
USAF, MC Department of Plastic Surgery Birmingham, AL, USA
Chief Vanderbilt University
Reconstructive Surgery and Regenerative Nashville, TN, USA
Plastic and Reconstructive Surgeon Nicholas A. Flugstad, MD
San Antonio Military Medical Center Flugstad Plastic Surgery
Houston, TX, USA Bellevue, WA, USA
List of Contributors ix

Dennis C. Hammond, MD Neil F. Jones, MD, FRCS Charles M. Malata, BSc(HB), MB ChB,
Clinical Assistant Professor Chief of Hand Surgery LRCP, MRCS, FRCS(Glasg), FRCS(Plast)
Department of Surgery University of California Medical Center Professor of Academic Plastic Surgery
Michigan State University College of Human Professor of Orthopedic Surgery Postgraduate Medical Institute
Medicine Professor of Plastic and Reconstructive Surgery Faculty of Health Sciences
East Lansing University of California Irvine Anglia Ruskin University
Associate Program Director Irvine, CA, USA Cambridge and Chelmsford, UK;
Plastic and Reconstructive Surgery Consultant Plastic and Reconstructive Surgeon
Grand Rapids Medical Education and Ryosuke Kakinoki, MD, PhD Department of Plastic and Reconstructive
Research Associate Professor Surgery
Center for Health Professions Chief of the Hand Surgery and Microsurgery Cambridge Breast Unit at Addenbrooke’s
Grand Rapids, MI, USA Unit Hospital
Department of Orthopedic Surgery and Cambridge University Hospitals NHS
Emily C. Hartmann, MD, MS Rehabilitation Medicine Foundation Trust
Aesthetic Surgery Fellow Graduate School of Medicine Cambridge, UK
Plastic and Reconstructive Surgery Kyoto University
University of Southern California Kyoto, Japan Paul N. Manson, MD
Los Angeles, CA, USA Professor of Plastic Surgery
Alex Kane, MD University of Maryland Shock Trauma Unit
Vincent R. Hentz, MD Associate Professor of Surgery University of Maryland and Johns Hopkins
Emeritus Professor of Surgery and Orthopedic Washington University School of Medicine School of Medicine
Surgery (by courtesy) Saint Louis, WO, USA Baltimore, MD, USA
Stanford University
Stanford, CA, USA Jeffrey Kenkel, MD David W. Mathes, MD
Professor and Chairman Professor and Chief of the Division of Plastic
Kent K. Higdon, MD Department of Plastic Surgery and Reconstructive Surgery
Former Aesthetic Fellow UT Southwestern Medical Center University of Colorado
Grotting and Cohn Plastic Surgery; Dallas, TX, USA Aurora, CO, USA
Current Assistant Professor
Vanderbilt University Marwan R. Khalifeh, MD G. Patrick Maxwell, MD, FACS
Nashville, TN, USA Instructor of Plastic Surgery Clinical Professor of Surgery
Department of Plastic Surgery Department of Plastic Surgery
William Y. Hoffman, MD Johns Hopkins University School of Medicine Loma Linda University Medical Center
Professor and Chief Washington, DC, USA Loma Linda, CA, USA
Division of Plastic and Reconstructive Surgery
University of California, San Francisco John Y.S. Kim, MD Kai Megerle, MD
San Francisco, CA, USA Professor and Clinical Director Research Fellow
Department of Surgery Division of Plastic and Reconstructive Surgery
Joon Pio Hong, MD, PhD, MMM Division of Plastic Surgery Stanford Medical Center
Chief and Associate Professor Northwestern University Feinberg School of Stanford, CA, USA
Department of Plastic Surgery Medicine
Asian Medical Center University of Ulsan Chicago, IL, USA Roberto N. Miranda, MD
School of Medicine Professor
Seoul, Korea Steven M. Levine, MD Department of Hematopathology
Assistant Professor of Surgery (Plastic) Division of Pathology and Laboratory Medicine
Joseph P. Hunstad, MD, FACS Hofstra Medical School, Northwell Health MD Anderson Cancer Center
Associate Consulting Professor New York, NY, USA Houston, TX, USA
Division of Plastic Surgery
The University of North Carolina at Chapel Hill; Frank Lista, MD, FRCSC Luis Humberto Uribe Morelli, MD
Private Practice Medical Director Resident of Plastic Surgery
Huntersville/Charlotte, NC, USA The Plastic Surgery Clinic Unisanta Plastic Surgery Department
Mississauga, ON, Canada; Sao Paulo, Brazil
Ian T. Jackson, MD, DSc(Hon), FRCS, Assistant Professor Surgery
FACS, FRACS (Hon) University of Toronto Colin M. Morrison, MSc (Hons), FRCSI
Emeritus Surgeon Toronto, ON, Canada (Plast)
Surgical Services Administration Consultant Plastic Surgeon
William Beaumont Hospitals Alyssa Lolofie Department of Plastic and Reconstructive
Royal Oak, MI, USA University of Utah Surgery
Salt Lake City, UT, USA Saint Vincent’s University Hospital
Mark Laurence Jewell, MD Dublin, Ireland
Assistant Clinical Professor of Plastic Surgery Susan E. Mackinnon, MD
Oregon Health Science University Sydney M. Shoenberg, Jr and Robert H. Hunter R. Moyer, MD
Jewell Plastic Surgery Center Shoenberg Professor Fellow
Eugene, OR, USA Department of Surgery, Division of Plastic and Department of Plastic and Reconstructive
Reconstructive Surgery Surgery
Washington University School of Medicine Emory University, Atlanta, GA, USA
Saint Louis, MO, USA
x List of Contributors

John B. Mulliken, MD Karl-Josef Prommersberger, MD, PhD Osvaldo Ribeiro Saldanha, MD

Director, Craniofacial Centre Chair, Professor of Orthopedic Surgery Chairman of Plastic Surgery Unisanta Santos
Department of Plastic and Oral Surgery Clinic for Hand Surgery Past President of the Brazilian Society of Plastic
Children’s Hospital Bad Neustadt/Saale Surgery (SBCP) International Associate
Boston, MA, USA Germany Editor of Plastic and Reconstructive Surgery
São Paulo, Brazil
Maurice Y. Nahabedian, MD, FACS Oscar M. Ramirez, MD, FACS
Professor and Chief Adjunct Clinical Faculty Osvaldo Ribeiro Saldanha Filho, MD
Section of Plastic Surgery Plastic Surgery Division São Paulo, Brazil
MedStar Washington Hospital Center Cleveland Clinic Florida
Washington DC, USA; Boca Raton, FL, USA Renato Saltz, MD, FACS
Vice Chairman Saltz Plastic Surgery
Department of Plastic Surgery Vinay Rawlani, MD President
MedStar Georgetown University Hospital Division of Plastic Surgery International Society of Aesthetic Plastic
Washington DC, USA Northwestern Feinberg School of Medicine Surgery
Chicago, IL, USA Adjunct Professor of Surgery
Maurizio B. Nava, MD University of Utah
Chief of Plastic Surgery Unit Dirk F. Richter, MD, PhD Past-President, American Society for Aesthetic
Istituto Nazionale dei Tumori Clinical Director Plastic Surgery
Milano, Italy Department of Plastic Surgery Salt Lake City and Park City, UT, USA
Dreifaltigkeits-Hospital Wesseling
Peter C. Neligan, MB, FRCS(I), FRCSC, Wesseling, Germany Paulo Rodamilans Sanjuan, MD
FACS Chief Resident of Plastic Surgery
Professor of Surgery Eduardo D. Rodriguez, MD, DDS Plastic Surgery Service Dr. Ewaldo Boliar de
Department of Surgery, Division of Plastic Chief, Plastic Reconstructive and Maxillofacial Souza Pinto
Surgery Surgery, R Adams Cowley Shock Trauma São Paulo, Brazil
University of Washington Center
Seattle, WA, USA Professor of Surgery Nina Schwaiger, MD
University of Maryland School of Medicine Senior Specialist in Plastic and Aesthetic
Jonas A. Nelson, MD Baltimore, MD, USA Surgery
Integrated General/Plastic Surgery Resident Department of Plastic Surgery
Department of Surgery Rod J. Rohrich, MD, FACS Dreifaltigkeits-Hospital Wesseling
Division of Plastic Surgery Professor and Chairman Crystal Charity Ball Wesseling, Germany
Perelman School of Medicine Distinguished Chair in Plastic Surgery
University of Pennsylvania Department of Plastic Surgery; Jeremiah Un Chang See, MD
Philadelphia, PA, USA Professor and Chairman Betty and Plastic Surgeon
Warren Woodward Chair in Plastic and Department of Plastic and Reconstructive
M. Samuel Noordhoff, MD, FACS Reconstructive Surgery Surgery
Emeritus Superintendent University of Texas Southwestern Medical Penang General Hospital
Chang Gung Memorial Hospitals Center at Dallas Georgetown, Penang, Malaysia
Taipei, Taiwan, Dallas, TX, USA
The People’s Republic of China Joseph M. Serletti, MD, FACS
Michelle C. Roughton, MD Henry Royster-William Maul Measey
Sabina Aparecida Alvarez de Paiva, MD Chief Resident Professor of Surgery; Chief
Resident of Plastic Surgery Section of Plastic and Reconstructive Surgery Division of Plastic Surgery
Plastic Surgery Service Dr. Ewaldo Bolivar de University of Chicago Medical Center Vice Chair (Finance)
Souza Pinto Chicago, IL, USA Department of Surgery
São Paulo, Brazil University of Pennsylvania
J. Peter Rubin, MD, FACS Philadelphia, PA, USA
Angela Pennati, MD Chief of Plastic Surgery
Assistant Plastic Surgeon Director, Life After Weight Loss Body Kenneth C. Shestak, MD
Unit of Plastic Surgery Contouring Program Professor of Plastic Surgery
Istituto Nazionale dei Tumori University of Pittsburgh Division of Plastic Surgery
Milano, Italy Pittsburgh, PA, USA University of Pittsburgh
Pittsburgh, PA, USA
Jason Pomerantz, MD Michel Saint-Cyr, MD, FRCSC
Assistant Professor Associate Professor Plastic Surgery Navin K. Singh, MD, MSc
Surgery Department of Plastic Surgery Assistant Professor of Plastic Surgery
University of California San Francisco University of Texas Southwestern Medical Department of Plastic Surgery
Surgical Director Center Johns Hopkins University School of Medicine
Craniofacial Center Dallas, TX, USA Washington, DC, USA
University of California San Francisco
San Francisco, CA, USA Cristianna Bonneto Saldanha, MD Wesley N. Sivak, MD, PhD
Resident General Surgery Department Resident in Plastic Surgery
Santa Casa of Santos Hospital Department of Plastic Surgery
São Paulo, Brazil University of Pittsburgh
Pittsburgh, PA, USA
List of Contributors xi

Ron B. Somogyi, MD, MSc FRCSC John D. Symbas, MD Richard J. Warren, MD, FRCSC
Plastic and Reconstructive Surgeon Plastic and Reconstructive Surgeon Clinical Professor
Assistant Professor, Department of Surgery Private Practice Division of Plastic Surgery
University of Toronto Marietta Plastic Surgery University of British Columbia
Toronto, ON, Canada Marietta, GA, USA Vancouver, BC, Canada

David H. Song, MD, MBA, FACS Jin Bo Tang, MD Henry Wilson, MD, FACS
Cynthia Chow Professor of Surgery Professor and Chair Attending Plastic Surgeon
Chief, Section of Plastic and Reconstructive Department of Hand Surgery; Private Practice
Surgery Chair Plastic Surgery Associates
Vice-Chairman, Department of Surgery The Hand Surgery Research Center Lynchburg, VA, USA
The University of Chicago Medicine & Affiliated Hospital of Nantong University
Biological Sciences Nantong, The People’s Republic of China Scott Woehrle, MS BS
Chicago, IL, USA Physician Assistant
Charles H. Thorne, MD Department of Plastic Surgery
Andrea Spano, MD Associate Professor of Plastic Surgery Jospeh Capella Plastic Surgery
Senior Assistant Plastic Surgeon Department of Plastic Surgery Ramsey, NJ, USA
Unit of Plastic Surgery NYU School of Medicine
Istituto Nazionale dei Tumori New York, NY, USA Kai Yuen Wong, MA, MB BChir, MRCS,
Milano, Italy FHEA, FRSPH
Patrick L. Tonnard, MD Specialist Registrar in Plastic Surgery
Scott L. Spear, MD, FACS Coupure Centrum Voor Plastische Chirurgie Department of Plastic and Reconstructive
Professor and Chairman Ghent, Belgium Surgery
Department of Plastic Surgery Cambridge University Hospitals NHS
Georgetown University Hospital Matthew J. Trovato, MD Foundation Trust
Georgetown, WA, USA Dallas Plastic Surgery Institute Cambridge, UK
Dallas, TX, USA
Michelle A. Spring, MD, FACS Alan Yan, MD
Program Director Francisco Valero-Cuevas, PhD Former Fellow
Glacier View Plastic Surgery Director Adult Reconstructive and Aesthetic
Kalispell Regional Medical Center Brain-Body Dynamics Laboratory Craniomaxillofacial Surgery
Kalispell, MT, USA Professor of Biomedical Engineering Division of Plastic and Reconstructive Surgery
Professor of Biokinesiology and Physical Massachusetts General Hospital
Phillip J. Stephan, MD Therapy Boston, MA, USA
Clinical Faculty By Courtesy, Professor of Computer Science
Plastic Surgery and Aerospace and Mechanical Engineering Michael J. Yaremchuk, MD
UT Southwestern Medical School; The University of Southern California Chief of Craniofacial Surgery
Plastic Surgeon Los Angeles, CA, USA Massachusetts General Hospital;
Texoma Plastic Surgery Clinical Professor of Surgery
Wichita Falls, TX, USA Allen L. Van Beek, MD, FACS Harvard Medical School;
Adjunct Professor Program Director
W. Grant Stevens, MD, FACS University Minnesota School of Medicine Harvard Plastic Surgery Residency Program
Clinical Professor of Surgery Division of Plastic Surgery Boston, MA, USA
Marina Plastic Surgery Associates; Minneapolis, MN, USA
Keck School of Medicine of USC
Los Angeles, CA, USA Valentina Visintini Cividin, MD
Assistant Plastic Surgeon
Alexander Stoff, MD, PhD Unit of Plastic Surgery
Senior Fellow Istituto Nazionale dei Tumori
Department of Plastic Surgery Milano, Italy
Dreifaltigkeits-Hospital Wesseling
Wesseling, Germany

Donnie Buck came up with the idea for the first edition procedure concept in 2011, I couldn’t have imagined that 7
of this book and followed through with spearheading this years later I’d be putting the finishing touches on another
second edition. The Elsevier editorial team who helped me edition. I must again thank Peter Neligan for believing in
put together the 4th edition of Plastic Surgery fleshed out the my idea and collaborating with me to make it a reality all
details and oversaw the production. The team, led by Belinda those years ago. Working on this title with Elsevier and Dr.
Kuhn consisted of Louise Cook, Alexandra Mortimer and Sam Neligan has been a tremendous honor, and I cannot thank
Crowe, worked to help make this a reality. Donnie extracted them enough for their support and guidance throughout the
the content from chapters in the big book and re-formatted process. Specifically, I owe a debt of gratitude to the wonderful
the information in a condensed form, often combining more team at Elsevier, especially Belinda Kuhn and Nani Clansey,
than one chapter. The feedback from the first edition was very who have kept me on target and are responsible for making
positive and I hope you will find this second edition equally this book a reality. I would also like to thank the authors, all
useful. I am indebted to everyone who helped bring this about. masters of their craft, for contributing the wonderful text,
As always, Gabrielle Kane, my wife has supported every part illustrations, photographs, and videos that comprise this book.
of this project and without her, none of this would happen. Finally, none of this would be possible without the love and
support of my incredible family. Thank you to Benjamin and
PCN Brooke for continuing to inspire me daily, and to my beautiful
wife Jennifer for her unwavering love and encouragement.
I am incredibly honored for the opportunity to produce
this second edition of Core Procedures in Plastic Surgery. When DWB
I first approached the folks at Elsevier with my original core

Video Contents
Chapter 1: Blepharoplasty Chapter 8: Liposuction and fat grafting
1.1  Periorbital rejuvenation 8.1   Structural fat grafting
Julius Few Jr. and Marco Ellis Sydney R. Coleman and Alesia P. Saboeiro

Chapter 2: Facelift Chapter 10: Local flaps for facial coverage

2.1  Anterior incision 10.1  Facial artery perforator flap
2.2  Posterior incision 10.2  Local flaps for facial coverage
2.3  Facelift skin flap Peter C. Neligan
Richard J. Warren
Chapter 11: Cleft lip repair
2.4  Platysma SMAS plication
Dai M. Davies and Miles G. Berry 11.1  Repair of unilateral cleft lip
Philip Kuo-Ting Chen and Samuel M. Noordhoff
2.5  Loop sutures MACS facelift
Patrick L. Tonnard 11.2  Unilateral cleft lip repair – anatomic subunit
From Aesthetic Plastic Surgery, Aston 2009, approximation technique
with permission from Elsevier David M. Fisher
11.3  Repair of bilateral cleft lip
2.6  The high SMAS technique with septal reset
Barry H. Grayson
Fritz E. Barton, Jr.
2.7  Facelift – Subperiosteal mid facelift Chapter 13: Lower extremity reconstruction
endoscopic temporo-midface
13.1  Alternative flap harvest
Oscar M. Ramirez
Michel Saint-Cyr
2.8  Facelift – Subperiosteal midface lift
Alan Yan and Michael J. Yaremchuk Chapter 16: Abdominal wall reconstruction

Chapter 4: Rhinoplasty 16.1  Component separation innovation

Peter C. Neligan
4.1  Open technique rhinoplasty
Allen L. Van Beek Chapter 17: Breast augmentation

Chapter 6: Abdominoplasty 17.1  Endoscopic transaxillary breast

6.1 Abdominoplasty
17.2  Endoscopic approaches to the breast
Dirk F. Richter and Alexander Stoff
Neil A. Fine
6.2  Lipoabdominoplasty (including
secondary lipo) Chapter 18: Mastopexy
Osvaldo Ribeiro Saldanha,
18.1  Circum areola mastopexy
Sérgio Fernando Dantas de Azevedo,
Kenneth C. Shestak
Osvaldo Ribeiro Saldanha Filho,
Cristianna Bonneto Saldanha, and 18.2  Preoperative markings for a single-stage
Luis Humberto Uribe Morelli augmentation mastopexy
W. Grant Stevens
6.3  Post bariatric reconstruction – bodylift
Chapter 19: Reduction mammaplasty
J. Peter Rubin
19.1  Spair technique
Chapter 7: Body contouring 19.2  Marking the SPAIR mammaplasty
7.1  Post-bariatric reconstruction: bodylift Dennis C. Hammond
procedure 19.3  Breast reduction surgery
J. Peter Rubin and Jonathan W. Toy James C. Grotting

xiv Video Contents

19.4   Ultrasound-assisted liposuction 23.5   Test for assessing thenar muscle function
Charles M. Malata 23.6   The “cross fingers” sign
23.7   Static two point discrimination test
Chapter 20: Implant-based breast reconstruction
(s-2PD test)
20.1   Mastectomy and expander insertion:
23.8   Moving 2PD test (m-2PD test) performed
first stage
on the radial or ulnar aspect of the finger
20.2   Mastectomy and expander insertion:
23.9   Semmes-Weinstein monofilament test
second stage
Maurizio B. Nava, Guiseppe Catanuto, 23.10  Allen’s test in a normal person
Angela Pennati, Valentina Visitini Cividin, 23.11  Digital Allen’s test
and Andrea Spano 23.12  Scaphoid shift test
20.3   Acellular dermal matrix 23.13  Dynamic tenodesis effect in a normal hand
20.4   Pectoralis muscle elevation
23.14  The milking test of the fingers and thumb
20.5  Sizer
in a normal hand
Amy S. Colwell
23.15  Eichhoff test
20.6   Latissimus dorsi flap technique
Scott L. Spear 23.16  Adson test
20.7  Markings 23.17  Roos test
20.8   Intraoperative skin paddles Ryosuke Kakinoki
20.9   Tendon division
20.10  Transposition and skin paddles Chapter 24: Flexor tendon injury and reconstruction
20.11  Inset and better skin paddle explanation 24.1   Zone II flexor tendon repair
Neil A. Fine and Michael Gart Jin Bo Tang
24.2   Incision and feed tendon forward
Chapter 21: Autologous breast reconstruction using
24.3   Distal tendon exposure
abdominal flaps
24.4   Six-strand M-tang repair
21.1   Pedicle TRAM breast reconstruction 24.5   Extension-flexion test – wide awake
L. Franklyn Elliot and John D. Symbas
21.2   The muscle sparing free TRAM flap Chapter 25: Nerve transfers
Joshua Fosnot, Joseph M. Serletti,
25.1   Scratch collapse test of ulnar nerve
and Jonas A. Nelson
Susan E. Mackinnon and Ida K. Fox
21.3  SIEA
Peter C. Neligan Chapter 26: Tendon transfers in the upper extremity
21.4   DIEP flap breast reconstruction 26.1   EIP to EPL tendon transfer
Philip N. Blondeel and Robert J. Allan
Neil F. Jones, Gustavo Machado, and Surak Eo

Chapter 23: Examination of the upper extremity

Chapter 27: Extensor tendon injuries
23.1   Flexor profundus test in a normal long
finger 27.1   Sagittal band reconstruction
27.2   Setting the tension in extensor indicis
23.2   Flexor sublimis test in a normal long finger transfer
23.3   Extensor pollicis longus test in a normal Kai Megerle
23.4   Test for the extensor digitorum communis
(EDC) muscle in a normal hand
Video Contributors

Robert J. Allen Sr., MD Amy S. Colwell, MD Joshua Fosnot, MD

Clinical Professor of Plastic Surgery Associate Professor Assistant Professor of Surgery
Department of Plastic Surgery Harvard Medical School Division of Plastic Surgery
New York University Medical Center Massachusetts General Hospital The Perelman School of Medicine
Charleston, NC, USA Boston, MA, USA University of Pennsylvania Health System
Philadelphia, PA, USA
Sergio Fernando Dantas de Azevedo, MD Dai M. Davies, FRCS
Member Consultant and Institute Director Ida K. Fox, MD
Brazilian Society of Plastic Surgery Institute of Cosmetic and Reconstructive Assistant Professor of Plastic Surgery
Volunteer Professor of Plastic Surgery Surgery Department of Surgery
Department of Plastic Surgery London, UK Division of Plastic and Reconstructive Surgery
Federal University of Pernambuco Washington University School of Medicine
Pernambuco, Brazil L. Franklyn Elliot, MD St. Louis, MO, USA
Assistant Clinical Professor
Fritz E. Barton Jr., MD Emory Section of Plastic Surgery Michael S. Gart, MD
Clinical Professor Emory University Resident Physician
Department of Plastic Surgery Atlanta, GA, USA Division of Plastic Surgery
UT Southwestern Medical Center Northwestern University Feinberg School of
Dallas, TX, USA Marco Ellis, MD Medicine
Director of Craniofacial Surgery Chicago, IL, USA
Miles G. Berry, MS, FRCS(Plast) Northwestern Specialists in Plastic Surgery;
Consultant Plastic and Aesthetic Surgeon Adjunct Assistant Professor Barry H. Grayson, DDS
Institute of Cosmetic and Reconstructive Surgery University of Illinois Chicago Medical Center Associate Professor of Surgery (Craniofacial
London, UK Chicago, IL, USA Orthodontics)
New York University Langone Medical Centre
Philip N. Blondeel, MD Surak Eo, MD, PhD Institute of Reconstructive Plastic Surgery
Professor of Plastic Surgery Chief, Professor New York, NY, USA
Department of Plastic Surgery Department of Plastic and Reconstructive
University Hospital Ghent Surgery James C. Grotting, MD, FACS
Ghent, Belgium Dongguk University Medical Center Clinical Professor of Plastic Surgery
Gyeonggi-do, South Korea University of Alabama at Birmingham;
Guiseppe Catanuto, MD, PhD The University of Wisconsin, Madison, WI;
Research Fellow Julius Few Jr., MD Grotting and Cohn Plastic Surgey
The School of Oncological Reconstructive Surgery Director Birmingham, AL, USA
Milan, Italy The Few Institute for Aesthetic Plastic Surgery;
Clinical Professor Dennis C. Hammond, MD
Philip Kuo-Ting Chen, MD Plastic Surgery Clinical Assistant Professor
Professor University of Chicago Pritzker School of Department of Surgery
Craniofacial Center Medicine Michigan State University College of Human
Chang Gung Memorial Hospital Chicago, IL, USA Medicine
Taoyuan City, Taiwan, The People’s Republic East Lansing
of China Neil A. Fine, MD Associate Program Director
President Plastic and Reconstructive Surgery
Valentina Visintini Cividin, MD Northwestern Specialists in Plastic Surgery; Grand Rapids Medical Education and
Assistant Plastic Surgeon Associate Professor (Clinical) Surgery/Plastics Research
Unit of Plastic Surgery Northwestern University Fienberg School of Center for Health Professions
Istituto Nazionale dei Tumori Medicine Grand Rapids, MI, USA
Milano, Italy Chicago, IL, USA
Neil F. Jones, MD, FRCS
Sydney R. Coleman, MD David M. Fisher, MB, BCh, FRCSC, FACS Professor and Chief of Hand Surgery
Assistant Clinical Professor Medical Director Cleft Lip and Palate Program University of California Medical Center;
Plastic Surgery Plastic Surgery Professor of Orthopedic Surgery;
New York University Medical Center Hospital for Sick Children; Professor of Plastic and Reconstructive Surgery
New York; Associate Professor University of California Irvine
Assistant Clinical Professor Surgery Irvine, CA, USA
Plastic Surgery University of Toronto
University of Pittsburgh Medical Center Toronto, ON, Canada
Pittsburgh, PA, USA
xvi Video Contributors

Ryosuke Kakinoki, MD, PhD Oscar M. Ramirez, MD, FACS Scott L. Spear, MD (deceased)
Professor of Hand Surgery and Microsurgery, Adjunct Clinical Faculty Formerly Professor of Plastic Surgery
Reconstructive, and Orthopedic Surgery Plastic Surgery Division Division of Plastic Surgery
Department of Orthopedic Surgery Cleveland Clinic Florida Georgetown University
Faculty of Medicine Boca Raton, FL, USA Washington, MD, USA
Kindai University
Osakasayama, Osaka, Japan Dirk F. Richter, MD, PhD W. Grant Stevens, MD, FACS
Clinical Professor of Plastic Surgery Clinical Professor of Surgery
Gustavo Machado, MD University of Bonn Marina Plastic Surgery Associates;
Prairie Orthopaedic & Plastic Surgery Director and Chief Keck School of Medicine of USC
Lincoln, NE, USA Dreifaltigkeits-Hospital Los Angeles, CA, USA
Wesseling, Germany
Susan E. Mackinnon, MD Alexander Stoff, MD, PhD
Sydney M. Shoenberg Jr. and Robert H. J. Peter Rubin, MD, FACS Senior Fellow
Shoenberg Professor Chief Department of Plastic Surgery
Department of Surgery, Division of Plastic and Plastic and Reconstructive Surgery Dreifaltigkeits-Hospital Wesseling
Reconstructive Surgery University of Pittsburgh Medical Center Wesseling, Germany
Washington University School of Medicine Associate Professor
St. Louis, MO, USA Department of Surgery John D. Symbas, MD
University of Pittsburgh Plastic and Reconstructive Surgeon
Charles M. Malata, BSc(HB), MB ChB, Pittsburgh, PA, USA Private Practice
LRCP, MRCS, FRCS(Glasg), FRCS(Plast) Marietta Plastic Surgery
Professor of Academic Plastic Surgery Alesia P. Saboeiro, MD Marietta, GA, USA
Postgraduate Medical Institute Attending Physician
Faculty of Health Sciences Private Practice Jin Bo Tang, MD
Anglia Ruskin University New York, NY, USA Professor and Chair
Cambridge and Chelmsford, UK; Department of Hand Surgery;
Consultant Plastic and Reconstructive Surgeon Michel Saint-Cyr, MD, FRSC(C) Chair, The Hand Surgery Research Center
Department of Plastic and Reconstructive Surgery Professor Affiliated Hospital of Nantong University
Cambridge Breast Unit at Addenbrooke’s Plastic Surgery Nantong, The People’s Republic of China
Hospital Mayo Clinic
Cambridge University Hospitals NHS Rochester, MN, USA Patrick L. Tonnard, MD
Foundation Trust Coupure Centrum Voor Plastische Chirurgie
Cambridge, UK Cristianna Bonnetto Saldanha, MD Ghent, Belgium
Plastic Surgery Service Dr. Osvaldo Saldanha
Luis Humbert Uribe Morelli, MD São Paulo, Brazil Jonathan W. Toy, MD, FRCSC
Resident of Plastic Surgery Program Director, Plastic Surgery Residency
Unisanta Plastic Surgery Department Osvaldo Saldanha, MD, PhD Program Assistant Clinical Professor
Sao Paulo, Brazil Director of Plastic Surgery Service Dr. Osvaldo University of Alberta
Saldanha; Edmonton, AB, Canada
Maurizio B. Nava, MD Professor of Plastic Surgery Department
Chief of Plastic Surgery Unit Universidade Metropolitana de Santos Allen L. Van Beek, MD, FACS
Instituto Nazionale dei Tumori – UNIMES Adjunct Professor
Milano, Italy São Paulo, Brazil University Minnesota School of Medicine
Division of Plastic Surgery
Peter C. Neligan, MB, FRCS(I), FRCSC, FACS Osvaldo Ribeiro Saldanha Filho, MD Minneapolis, MN, USA
Professor of Surgery Professor of Plastic Surgery
Department of Surgery, Division of Plastic Surgery Plastic Surgery Service Dr. Osvaldo Saldanha Richard J. Warren, MD, FRCSC
University of Washington São Paulo, Brazil Clinical Professor
Seattle, WA, USA Division of Plastic Surgery
Joseph M. Serletti, MD, FACS University of British Columbia
Jonas A. Nelson, MD The Henry Royster–William Maul Measey Vancouver, BC, Canada
Integrated General/Plastic Surgery Resident Professor of Surgery and Chief
Department of Surgery Division of Plastic Surgery Alan Yan, MD
Division of Plastic Surgery University of Pennsylvania Health System Former Fellow
Perelman School of Medicine Philadelphia, PA, USA Adult Reconstructive and Aesthetic
University of Pennsylvania Craniomaxillofacial Surgery
Philadelphia, PA, USA Kenneth C. Shestak, MD Division of Plastic and Reconstructive Surgery
Professor, Department of Plastic Surgery Massachusetts General Hospital
Samuel M. Noordhoff, MD, FACS University of Pittsburgh Medical Center Boston, MA, USA
Emeritus Professor in Surgery Pittsburgh, PA, USA
Chang Gung University Michael J. Yaremchuk, MD
Taoyuan City, Taiwan, The People’s Republic Andrea Spano, MD Chief of Craniofacial Surgery
of China Senior Assitant Plastic Surgeon Massachusetts General Hospital;
Unit of Plastic Surgery Clinical Professor of Surgery
Angela Pennati, MD Istituto Nazionale dei Tumori Harvard Medical School;
Assistant Plastic Surgeon Milano, Italy Program Director
Unit of Plastic Surgery Harvard Plastic Surgery Residency Program
Istituto Nazionale dei Tumori Boston, MA, USA
Milano, Italy
This chapter was created using content from Neligan & Rubin, Plastic Surgery
3rd edition, Volume 2, Aesthetic, Chapter 9, Blepharoplasty, Julius W. Few Jr. and
Marco F. Ellis

Anatomical pearls
Blepharoplasty is a vital part of facial rejuvenation. The traditional
Osteology and periorbita

removal of tissue may or may not be the preferred approach when

assessed in relation to modern cosmetic goals.
■ A thorough understanding of orbital and eyelid anatomy is necessary
■ The orbits are pyramids formed by the frontal, sphenoid,
to understand aging in the periorbital region and to devise appropriate maxillary, zygomatic, lacrimal, palatine, and ethmoid
surgical strategies. bones (Fig. 1.1).
■ The periosteal covering or periorbita is most firmly
■ Preoperative assessment includes a review of the patient’s perceptions,

assessment of the patient’s anatomy, and an appropriate medical and attached at the suture lines and the circumferential
ophthalmologic examination. anterior orbital rim.
■ Surgical techniques in blepharoplasty are numerous and should ■ The investing orbital septum in turn attaches to the

be tailored to the patient’s own unique anatomy and aesthetic periorbita of the orbital rim, forming a thickened
diagnosis. perimeter known as the arcus marginalis.
■ Interrelated anatomic structures, including the brow and the infraorbital ■ This structure reduces the perimeter and diameter of the

rim, may need to be surgically addressed for an optimal outcome. orbital aperture and is thickest in the superior and lateral
aspects of the orbital rim.
■ Certain structures must be avoided during upper lid

Brief introduction surgery.

• The lacrimal gland, located in the superolateral orbit
■ The eyelids are vital, irreplaceable structures that serve deep to its anterior rim, often descends beneath the
to protect the globes. Their shutter-like mechanism is orbital rim, prolapsing into the postseptal upper lid in
essential to clean, lubricate, and protect the cornea. many persons.
Any disruption or restriction of eyelid closure will • The trochlea is located 5 mm posterior to the
have significant consequences for both the patient superonasal orbital rim and is attached to the
and the surgeon. periorbita. Disruption of this structure can cause
■ Instead of the common practice of excising precious motility problems.
upper and, to a somewhat lesser degree, lower eyelid
tissue, it is preferable to focus on restoration of Lateral retinaculum
attractive, youthful anatomy.
■ One should first conceptualize the desired outcome, then ■ Anchored to the lateral orbit is a labyrinth of connective
select and execute procedures accurately designed to tissues, known as the lateral retinaculum, that are crucial
achieve those specific goals. to maintenance of the integrity, position, and function of
■ Several important principles are advocated (Box 1.1). the globe and periorbital.

2 1 Blepharoplasty

Medial canthal tendon

BOX 1.1  Principles for restoration of youthful eyes Medial check retinaculum Orbicularis
Fossa for lacrimal sac Lateral canthal tendon
• Control of periorbital aesthetics by proper brow positioning, Lateral check retinaculum
corrugator muscle removal, and lid fold invagination when
• 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. Tenon’s capsule
• Preservation of maximal lid skin and muscle (so essential to
lid function and aesthetics) as well as orbital fat. Medial rectus and sheath
• Lifting of the midface through reinforced canthopexy,
Lateral rectus and sheath
preferably enhanced by composite malar advancement. Periorbita
• 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.
Figure 1.2  Horizontal section of the orbit showing the lateral retinaculum formed
• Removal of only that tissue (skin, muscle, fat) that is truly by the lateral horn of the levator, lateral canthal tendon, tarsal strap, the Lockwood
excessive on the upper and lower lids, sometimes resorting to suspensory ligament, and lateral rectus check ligaments.
unconventional excision patterns.
• Modification of skin to remove prominent wrinkling and
excision of small growths and blemishes.
Orbicularis fascia
Lateral orbital thickening
Zygomatic bone
Lateral canthal tendon
Supraorbital fissure Frontal bone Supraorbital foramen
Superior orbital ridge

Frontal bone

Optic foramen
Greater wing
of sphenoid Ethmoid
Zygomatic Lacrimal bone
Infraorbital and fossa
fissure Maxilla

Coronoid process of mandible Maxilla bone Tarsal plates

Figure 1.3  Lateral canthal tendon has separate superficial and deep components.
The deep component attaches inside the orbital rim at Whitnall tubercle. The
superficial component passes from the tarsal plates to the periosteum of the lateral
Infraorbital foramen orbital rim and lateral orbital thickening. Both components are continuous with
Zygomaticofacial foramen both superior and inferior lid tarsal plates. (Adapted from 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(3):873–884.)
Figure 1.1  Orbital bones. Frontal view of the orbit with foramina.

rim and deep temporal fascia by means of the lateral

■ These structures coalesce at the lateral orbit and support orbital thickening.
the globe and eyelids like a hammock (Fig. 1.2). ■ A deep component connects directly to the Whitnall
■ The lateral retinaculum consists of the lateral canthal tubercle and is classically known as the lateral canthal
tendon, tarsal strap, lateral horn of the levator tendon (Fig. 1.3).
aponeurosis, the Lockwood suspensory ligament, ■ The tarsal strap is a distinct anatomic structure that
Whitnall ligament, and check ligaments of the lateral inserts into the tarsus medial and inferior to the lateral
rectus muscle. canthal tendon.
■ They converge and insert securely into the thickened ■ The tarsal strap attaches approximately 3 mm inferiorly
periosteum overlying the Whitnall tubercle. and 1 mm posteriorly to the deep lateral canthal tendon,
■ Controversy exists surrounding the naming of the approximately 4–5 mm from the anterior orbital rim.
components of the lateral canthal tendon. ■ It shortens in response to lid laxity, benefiting from
■ A superficial component is continuous with the release during surgery to help achieve a long-lasting
orbicularis oculi fascia and attaches to the lateral orbital restoration or elevation canthopexy (Fig. 1.4).
Anatomical pearls 3

Posterior limb, medial canthal tendon

Superior limb, medial canthal tendon

Anterior limb, medial canthal tendon

Whitnall tubercle Lacrimal fossa

Lateral canthal tendon Anterior and posterior lacrimal crests
‘Tarsal strap’

Figure 1.5  The medial canthal tendon envelops the lacrimal sac. It is tripartite,
with anterior, posterior, and superior limbs. Like the lateral canthal tendon, its
Orbital septum
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. (Adapted from Spinelli HM. Atlas of Aesthetic Eyelid and
Periocular Surgery. Philadelphia: Saunders; 2004:13.)


Figure 1.4  The lateral canthal tendon inserts securely into the thickened
periosteum overlying Whitnall tubercle. The tarsal strap is a distinct anatomic Superciliary corrugator
structure that suspends the tarsus medial and inferior to the lateral canthal tendon
Frontalis Procerus
to lateral orbital wall, approximately 4–5 mm from the orbital rim.

■ Adequate release of the tarsal strap permits a tension-

free canthopexy, minimizing the downward-tethering Orbicularis oculi
force of this fibrous condensation. Pretarsal
■ This release, along with a superior reattachment of the
lateral canthal tendon, is key to a successful canthopexy.

Medial orbital vault Preseptal

■ 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 ligament, and check ligaments of
the medial rectus. Figure 1.6  Facial muscles of the orbital region. Note that the preseptal and
■ The medial canthal tendon, like the lateral canthal pretarsal orbicularis muscles fuse with the medial and lateral canthal tendons.
tendon, has separate limbs that attach the tarsal plates to
the ethmoid and lacrimal bones.
■ 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. 1.5). frontalis will give the appearance of deep horizontal
creases in the forehead (Fig. 1.8).
Forehead and temporal region ■ The vertically oriented procerus is a medial muscle, often

continuous with the frontalis, arising from the nasal

■ The forehead and brow consist of four layers: skin, bones and inserting into the subcutaneous tissue of the
subcutaneous tissue, muscle, and galea. glabellar region. It pulls the medial brow inferiorly and
■ There are four distinct brow muscles: frontalis, procerus, contributes to the horizontal wrinkles at the root of the
corrugator superciliaris, and orbicularis oculi (Fig. 1.6). nose. More commonly, these wrinkles result from brow
■ The frontalis muscle inserts predominately into the ptosis and correct spontaneously with brow elevation.
medial half or two-thirds of the eyebrow (Fig. 1.7), ■ The obliquely oriented corrugators muscle arises from

allowing the lateral brow to drop hopelessly ptotic from the frontal bone and inserts into the brow tissue laterally,
aging, while the medial brow responds to frontalis with some extensions into orbicularis and frontalis
activation and elevates, often excessively, in its drive to musculature, forming vertical glabellar furrows during
clear the lateral overhand. Constant contraction of the contraction.
4 1 Blepharoplasty

Levator palpebrae
Superior rectus

Orbicularis oculi
Müller muscle

Upper tarsal plate

Capsulopalpebral fascia
Lockwood’s ligament

Inferior rectus

Figure 1.9  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.

Figure 1.7  The frontalis muscle inserts predominantly into the medial half or
two-thirds of the eyebrow. The medial brow responds to frontalis activation and
elevates, often excessively, in its drive to clear lateral overhang.
■ The orbicularis muscle, which acts as a sphincter for the
eyelids, consists of orbital, preseptal, and pretarsal
Diagonal lines segments.
■ The pretarsal muscle segment fuses with the lateral

canthal tendon and attaches laterally to Whitnall

tubercle. Medially it forms two heads, which insert into
the anterior and posterior lacrimal crests (see Fig. 1.6).

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 ligament. The aponeurosis fans out medially
and laterally to attach to the orbital retinacula. The
Figure 1.8  Frontalis action. The frontalis muscle inserts into the medial two- aponeurosis fuses with the orbital septum above the
thirds of the brow. Exaggerated medial brow elevation is required to clear the superior border of the tarsus and at the caudal extent of
lateral overhang and to eliminate visual obstruction. Constant contraction of the the sling, sending fibrous strands to the dermis to form
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- the lid crease. Extensions of the aponeurosis finally insert
elevated and distorted medial brow drops profoundly. 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
Eyelids attachments while the lid margin drops.
■ Müller muscle, or the supratarsal muscle, originates on

■ There is much similarity between upper and lower the deep surface of the levator near the point where
eyelid anatomy. Each consists of an anterior lamella of the muscle becomes aponeurotic and inserts into the
skin and orbicularis muscle and a posterior lamella of superior tarsus. Dehiscence of the attachment of the
tarsus and conjunctiva (Fig. 1.9). levator aponeurosis to the tarsus results in an acquired
Anatomical pearls 5

ptosis only after the Müller muscle attenuates and loses orbital retaining ligament directly attaches the orbicularis
its integrity. at the junction of its orbital and preseptal components to
■ In the Asian eyelid, fusion of the levator and septum the periosteum of the orbital rim and, consequently,
commonly occurs at a lower level, allowing the sling and separates the prezygomatic space from the preseptal
fat to descend farther into the lid. This lower descent of space. This ligament is continuous with the lateral orbital
fat creates the characteristic fullness of their upper thickening, which inserts onto the lateral orbital rim and
eyelid. In addition, the aponeurotic fibers form a weaker deep temporal fascia. It also has attachments to the
attachment to the dermis, resulting in a less distinct lid superficial lateral canthal tendon (see Figs. 1.3, 1.12, 1.13).
fold (Fig. 1.10). Attenuation of these ligaments permits descent of orbital
fat onto the cheek. A midfacelift must release these
Septal extension ligaments to achieve a supported, lasting lift.

■ The orbital septum has an adhesion to the levator Blood supply

aponeurosis above the tarsus. The septum continues
beyond this adhesion and extends to the ciliary margin. ■ The internal and external carotid arteries supply blood to
It is superficial to the preaponeurotic fat found at the the orbit and eyelids (Fig. 1.14).
supratarsal crease. The septal extension is a dynamic ■ The ophthalmic artery is the first intracranial branch of

component to the motor apparatus, as traction on this the internal carotid; its branches supply the globe,
fibrous sheet reproducibly alters ciliary margin position extraocular muscles, lacrimal gland, ethmoid, upper
(Fig. 1.11). The septal extension serves as an adjunct to, eyelids, and forehead.
and does not operate independent of, levator function, ■ The external carotid artery branches into the superficial

as mistaking the septal extension for levator apparatus temporal and maxillary arteries. The infraorbital artery is
and plicating this layer solely results in failed ptosis a continuation of the maxillary artery and exits 8 mm
correction. below the inferomedial orbital rim to supply the lower
Lower eyelid ■ The arcade of the superior and inferior palpebral arteries

gives a rich blood supply to the eyelids. The superior

■ The anatomy of the lower eyelid is somewhat analogous palpebral artery consists of a peripheral arcade located
to that of the upper eyelid. at the superior tarsal border – the area where surgical
■ The retractors of the lower lid, the capsulopalpebral dissection occurs to correct lid ptosis and to define lid
fascia, correspond to the levator above. folds. Damage to a vessel within this network commonly
■ The capsulopalpebral head splits to surround and fuse results in a hematoma of Müller muscle, causing lid
with the sheath of the inferior oblique muscle. The two ptosis for 2–8 weeks postoperatively. Likewise, on the
heads fuse to form the Lockwood suspensory ligament, lower lid, the inferior palpebral artery lies at the inferior
which is analogous to Whitnall ligament. border of the inferior tarsus.
■ It fuses with the orbital septum 5 mm below the tarsal ■ The supratrochlear, dorsal nasal, and medial palpebral

border and then inserts into the anterior and inferior arteries all traverse the orbit medially. Severing these
surface of the tarsus. arteries during fat removal, without adequately
■ The inferior tarsal muscle is analogous to Müller muscle providing hemostasis, may lead to a retrobulbar
of the upper eyelid and also arises from the sheath of hematoma, a vision-threatening complication of
the inferior rectus muscle. It runs anteriorly above the blepharoplasty.
inferior oblique muscle and also attaches to the inferior
tarsal border. Innervation: trigeminal nerve and facial nerve
■ The combination of the orbital septum, orbicularis, and

skin of the lower lid acts as the anterior barrier of the ■ The trigeminal nerve, along with its branches, provides
orbital fat. As these connective tissue properties relax, sensory innervations to the periorbital region (Fig. 1.15).
the orbital fat is allowed to herniate forward, forming an ■ A well-placed supraorbital block will anesthetize most of

unpleasing, full lower eyelid. This relative loss of orbital the upper lid and the central precoronal scalp.
volume leads to a commensurate, progressive hollowing ■ The maxillary division exits the orbit through one to

of the upper lid as upper eyelid fat recesses. three infraorbital foramina. It provides sensation to the
■ The capsulopalpebral fascia and its overlying conjunctiva skin of the nose, the lower eyelids, and the upper lid.
form the posterior border of the lower orbital fat. ■ The facial nerve supplies motor function to the lids

Transection of the capsulopalpebral fascia during lower (Fig. 1.16).

lid procedures, particularly transconjunctival ■ Innervation of facial muscles occurs on their deep

blepharoplasty, releases the retractors of the lower eyelid, surfaces.

which can reduce downward traction and allow the ■ Interruption of the branches to the orbicularis muscle

position of the lower lid margin to rise. from the periorbital surgery or facial surgery may result
in atonicity due to partial denervation of the orbicularis
Retaining ligaments with loss of lid tone or anomalous reinnervation and
possibly undesirable eyelid twitching.
■ A network of ligaments serves as a scaffold for the skin ■ The frontal branch of the facial nerve courses

and subcutaneous tissue surrounding the orbit. The immediately above and is attached to the periosteum of

Deep set
(levator dehiscence)

Baggy eyelid 0 to minimum

0 to minimum

Figure 1.10  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) The normal youthful Asian 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. (C) In the aging eyelid, the septum becomes attenuated and stretches. The septal extension loosens, and this 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. (Adapted from
Spinelli HM. Atlas of Aesthetic Eyelid and Periocular Surgery. Philadelphia: Saunders; 2004:59.).
Anatomical pearls 7



Septum orbitale
septum Orbitomalar ligament

Müller muscle Prezygomatic space

Orbicularis oculi
Septal Figure 1.13  The orbital retaining ligament (ORL) directly attaches the orbicularis
extension oris (OO) at the junction of its pars palpebrarum and pars orbitalis to the
periosteum of the orbital rim and, consequently, separates the prezygomatic space
Tarsus from the preseptal space. (Adapted from 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(3):873–884.)

Medial palpebral artery (superior)

Figure 1.11  The orbital septum has an adhesion to the levator aponeurosis above 1. Peripheral arcade
the tarsus. The septal extension begins at the adhesion of the orbital septum to Supraorbital artery 2. Marginal arcade
the levator and extends to the ciliary margin. It is superficial to the preaponeurotic
fat found at the supratarsal crease. (Adapted from Reid RR, Said HK, Yu M, Superficial temporal Supratrochlear artery
et al. Revisiting upper eyelid anatomy: introduction of the septal extension. Plast artery
Reconstr Surg. 2006;117(1):65–70.) Lacrimal artery Dorsal nasal artery

Angular artery
Medial palpebral artery
Lateral nasal artery
Zygomaticofacial artery
Orbicularis retaining ligament Inferior palpebral artery
Corrugator supercilii Maxilla bone Transverse facial artery
Orbicularis oculi
Frontal bone Nasal bone
Infraorbital artery Facial artery

Figure 1.14  Arterial supply to the periorbital region.

Lacrimal nerve Supraorbital nerve

Supratrochlear nerve

Zygomaticotemporal Infratrochlear nerve


Lateral orbital thickening Zygomatic bone Orbicularis retaining

ligament Zygomaticofacial
Figure 1.12  The orbicularis muscle fascia attaches to the skeleton along the Infraorbital nerve
orbital rim by the lateral orbital thickening (LOT) in continuity with the orbicularis
retaining ligament (ORL). (Adapted 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(3):994–1001.). Figure 1.15  Sensory nerves of the eyelids.
8 1 Blepharoplasty

Temporal branches (facial nerve VIII)


Zygomatic branches (facial nerve VIII)

Figure 1.17  On relaxed forward gaze, the ideal upper lid should rest
Figure 1.16  Anatomy of the brow and temporal region. The light-green opaque approximately 2 mm below the upper limbus. The lower lid ideally covers 0.5 mm
area denotes the deep temporal fascia and the periosteum where sutures may of the lower limbus. The ratio of distance from the lower edge of the eyebrow to
be used to suspend soft tissue. Wide undermining, soft tissue suspension, and the open lid margin to the pretarsal skin ratio should be greater than 3.
canthopexy are safely performed here.

the zygomatic bone. It then courses medially ■ Patients of Indo-European and African decent show 1 to
approximately 2 cm above the superior orbital rim to 2 mm lower than European ethnicities.
innervate the frontalis, corrugators, and procerus ■ The ratio of distance from the lower edge of the eyebrow

muscles from their deep surface. (at the center of the globe) to the open lid margin to the
■ A separate branch travels along the inferior border of the visualized pretarsal skin should never be less than 3 : 1
zygoma to innervate the inferior component of (see Fig. 1.1), preferably more.
orbicularis oculi. ■ Scleral show is the appearance of white sclera below the

lower border of the cornea and above the lower eyelid

margin. In general, sclera show is contradictory to
Youthful, beautiful eyes optimal aesthetics and may be perceived as a sign of
aging, previous blepharoplasty, or orbital disease (e.g.,
■ The characteristics of youthful, beautiful eyes differ from thyroid disease).
one population to another, but generalizations are ■ More than 0.5 mm of sclera show beneath the cornea on

possible and provide a needed reference to judge the direct, forward gaze begins to confer a sad or
success of various surgical maneuvers. melancholy aura to one’s appearance.
■ Attractive, youthful eyes have globes framed in ■ The intercanthal axis is normally tilted slightly upward

generously sized horizontal apertures (from medial and (from medial to lateral) in most populations.
lateral), often accentuated by a slight upward tilt of the ■ Exaggerated tilts are encountered in some Asian,

intercanthal axis (Fig. 1.17). Indo-European, and African-American populations.

■ The aperture length should span most of the distance

between the orbital rims.

■ In a relaxed forward gaze, the vertical height of the Preoperative considerations
aperture should expose at least three-quarters of the
cornea, with the upper lid extending down at least ■ A thorough history and physical examination should be
1.5 mm below the upper limbus (the upper margin obtained – including an ophthalmic history (see Box 1.2).
of the cornea) but no more than 3 mm. The lower lid ■ Physical exam should include evaluation for symmetry;

ideally covers 0.5 mm of the lower limbus but no more globe shape, position, and appearance; signs of aging; lid
than 1.5 mm. appearance; lid function; and relative laxity.
■ In the upper lid, there should be a well-defined lid ■ In the upper lid, excessive skin due to loss of elasticity

crease lying above the lid margin with lid skin under and sun damage is one of the major causes of an aged
slight stretch, slightly wider laterally. appearance in the periorbital area.
■ Ideally, the actual pretarsal skin visualized on relaxed ■ In addition to relaxed skin changes, excessive fat

forward gaze ranges from 3 to 6 mm in European herniation can cause bulging, resulting in a heavy
ethnicities. appearance to the upper lid area.
■ The Asian lid crease is generally 2–3 mm lower, with the ■ Aging changes in the lower lid include relaxation of the

distance from lid margin diminishing as the crease tarsal margin with scleral show, rhytides of the lower lid,
moves toward the inner canthus. herniated fat pads resulting in bulging in one or all of
Preoperative considerations 9

BOX 1.2  Important information to obtain during history and BOX 1.3  Recommended photographic views
physical examination
• Full face, upright (at rest) frontal, oblique, and lateral views.
• Medication use: particularly anticoagulants, anti-inflammatory • Full face, upright, and smiling.
and cardiovascular drugs, and vitamins (especially vitamin E). • Direct periorbital views in upward gaze and downward gaze
• Herbal supplement use: herbs represent risks to anesthesia and with eyes gently closed.
and surgery, particularly those affecting blood pressure, blood • A view with a finger slightly elevating the brows with the eyes
coagulation, the cardiovascular system, and healing. open and another with the eyes closed.
• 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. ■ The margin reflex distance (MRD), measured from the
• Bleeding disorders or blood clots. light reflex on the center of the cornea to the upper
• Psychiatric disease. eyelid margin, ranges from 3 to 5 mm.
• Alcohol and smoking history. ■ True blepharoptosis is defined by the degree of upper lid
• Recreational drug use, which may interact with anesthesia.
• Exposure to human immunodeficiency virus and hepatitis infringement upon the iris and pupil.
■ As the MRD decreases toward zero, the severity of
• Any history of facial herpes zoster or simplex. 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.
the three fat pocket areas, and hollowing of the nasojugal ■ If ptosis exists, the type of repair depends upon the

groove and lateral orbital rim areas. severity of the ptosis and the reliability of the levator to

■ Hollowing of the nasojugal groove area appears as dark recreate smooth upper lid elevation.
circles under the eyes, mostly because of lighting and the ■ Pseudoptosis occurs when excess upper lid skin covers

shadowing that result from this defect. the eyelid, depressing the eyelashes, forming hooding,

■ Contact lens wear poses particular risks when eyelid and simulating ptosis.
surgery is performed. ■ Photographic evidence of this is often necessary for

■ Long-term contact lens wearing hastens the process of insurance purposes when a levator aponeurosis repair or
drying out the eyes. an excisional blepharoplasty is planned.

■ Traditional blepharoplasty techniques consistently ■ Brow ptosis is a common aspect of facial aging. It adds

produce vertical dystopia with increased scleral weight and volume to the upper eyelid to develop, or
exposure, making the lens wear difficult if not exacerbate, eyelid ptosis.
dangerous. ■ The ability to differentiate the causes of droopy eyelids

■ Ptosis and canthopexy surgery may alter the corneal – brow ptosis (brow weight resting on the eyelids),
curvature and require that contacts be refitted. dermatochalasis (excess skin), and blepharoptosis

■ The patient should discontinue contact lens wear in the (levator attenuation or dehiscence) – will enable the
perioperative period to allow healing without the need surgeon to select the proper correction.
to manipulate the eyelids. ■ There is a normal 10–12 mm projection of the globe seen

■ Dry, irritated eyes before surgery will lead to irritated in a lateral, as measured from the lateral orbital rim at
eyes after surgery, and the surgeon may be blamed. the level of the canthal tendon to the pupil.

■ Treatment options include artificial tears, ointment, ■ Proptosis and enophthalmos are relative anterior and

anti-inflammatory drops, and punctal plugs or punctal posterior displacement of the globe, respectively. Hertel
closure. exophthalmometry can be used to quantitate the degree

■ Exophthalmos, unilaterally or bilaterally, associated of relative projection for documentation purposes.
with a thyroid disorder, should be completely stabilized ■ Assessment of tear production is a necessary but

for approximately 6 months before elective aesthetic unreliable task.

surgery. ■ The Schirmer test:

■ Eyelid measurements are documented for use during • Placing filter paper strips in the lateral third of the
ptosis surgery and, if necessary, for insurance lower eyelid.
purposes. • After 5 min, normal tear production should be greater

■ In the typical person with the brow in an aesthetically than 15 mm; 5–10 mm indicates borderline tear
pleasing position, 20 mm of upper lid skin must remain secretion, and below 5 mm is hyposecretion.
between the bottom of the central eyebrow and the ■ No other area of cosmetic surgery is more dependent

upper lid margin to allow adequate lid closure during on accurate photography than the periorbital region
sleep, a well-defined lid crease, and an effective and (Box 1.3).
complete blink. ■ Before surgical planning, one must have a meaningful

■ In the eyelid of the white individual, the aperture conceptualization of the desired result. Only then can
(distance between the upper and lower eyelids) average the surgical maneuvers required be organized in a
is 10–12 mm. meaningful way (Box 1.4).
10 1 Blepharoplasty

• A 1–2 mm sliver of orbicularis must be removed in

BOX 1.4  Preoperative periorbital plan proportion to the amount of skin removed.
• A small pretarsal skin and muscle flap are dissected
The preoperative periorbital plan should include the following:
from the aponeurosis and septum adhesion.
• The patient’s specific concerns and desires for improvement.
• Brow position.
• After sharply disinserting the aponeurosis from the
• Lower eyelid tonicity. tarsus, pretarsal fatty tissue can be removed to debulk
• Eyelid ptosis, retraction, or levator dehiscence. the pretarsal skin.
• Exophthalmos or enophthalmos. • Mattressed anchor sutures are placed connecting the
• Supraorbital rim prominence or hypoplasia. tarsus to the aponeurosis and pretarsal skin (Fig. 1.20).
• Suborbital malar and tear trough deformities. • Finally, a running suture approximates the preseptal
• Excision of necessary skin, muscle, and fat – only if 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

Operative techniques (Video 1.1) skin excision into each fat compartment in which
conservative resection of redundant fat has been
Simple skin blepharoplasty planned.
■ The fat is teased out bluntly and resected using pinpoint

■ When skin-only excision is elected, it should occur above cautery.

the supratarsal fold or crease, leaving that structure ■ This fat usually includes the medial or nasal

intact – this retains most of the definition of an existing compartment, which contains white fat.
lid fold. ■ Yellow fat in the central compartment is usually more

■ The supratarsal fold is located approximately 7–8 mm superficial and lateral.

above the ciliary margin in women and 6–7 mm in men. ■ Gentle pressure on the patient’s globe can reproduce the

■ The upper marking must be at least 10 mm from the degree of excess while the patient lies recumbent on the
lower edge of the brow and should not include any thick operating room table (Fig. 1.21).
brow skin. ■ Overall, undercorrection is preferred to prevent

■ The use of a pinch test for redraping the skin is helpful. hollowing, which can be dramatic and recognized as an
■ The shape of the skin resection is lenticular in younger A-frame abnormality.
patients and more trapezoid shaped laterally in older ■ The attenuated orbital septum may be addressed by

patients. using selective diathermy along the exposed caudal

■ The incision may need to be extended laterally with a septum.
larger extension, but extension lateral to the orbital rim ■ Inflammation-mediated tightening can enhance septal

should be avoided if possible to prevent a prominent integrity.

scar (Fig. 1.18). ■ Septal plication aid is unnecessary and may induce a

■ Similarly, the medial markings should not be extended brisk, restrictive inflammatory response.
medial to the medial canthus because extensions onto
the nasal side wall result in webbing. Blepharoptosis
■ At the conclusion of the case, the patient should have

approximately 1–2 mm of lagophthalmos bilaterally. ■ During upper blepharoplasty, with the septum open and
Fig. 1.19 displays the predictable, restorative outcomes the aponeurosis and superior tarsus exposed, there is an
that can be achieved with skin excision alone. ideal opportunity to adjust the level of the aperture.
■ Inappropriate aperture opening can be due to upper lid

Anchor (or invagination blepharoplasty) ptosis or upper lid retraction.

■ True ptosis repair involves reattachment of the levator

■ Anchor blepharoplasty involves the creation of an upper aponeurosis to the tarsus, with or without shortening of
eyelid crease by attaching pretarsal skin to the applicable structures (e.g. aponeurosis, Müller muscle,
underlying aponeurosis. and tarsus).
■ Advantages of an anchor blepharoplasty are a crisp, ■ There are a variety of techniques to address

precise, and well-defined eyelid crease that persists blepharoptosis, but they are outside the scope of this
indefinitely. chapter. There is a significant learning curve to
■ Disadvantages are that it is more time-consuming, performing a ptosis repair, and even then, the ability to
requires greater surgical skills and expertise, and get perfect symmetry is elusive.
encourages greater frontalis relaxation as a result ■ In the setting of mild upper eyelid ptosis (~1 mm),

of more effective correction of the overhanging where the decision has been made to avoid a formal lid
pseudoptotic skin. ptosis procedure, selective myectomy of the upper eyelid
■ Key components of the anchor blepharoplasty include: orbicularis can be performed to widen the lid aperture.
• Minimal skin excision (2–3 mm) extending cephalad ■ The amount of muscle to be resected depends on a host

from the tarsus. of factors, including the severity of relative lid ptosis,
Operative techniques 11

Levator aponeurosis


Orbital septum


Skin and orbicularis muscle resection

Central fat pad (preaponeurotic)

on levator aponeurosis

Pressure on globe causes

medial fat pad bulge

Figure 1.18  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. (Adapted from Spinelli HM. Atlas of Aesthetic Eyelid and Periocular Surgery. Philadelphia:
Saunders; 2004:64.)

brow position, and fold disparity (Fig. 1.22) and is ■ Leaving a small cuff of filmy connective tissue (~1 mm)
titrated depending on the amount of effect desired. on the tarsus will minimize bleeding from the richly
■ For 1 mm or less of relative upper lid ptosis, resection of vascularized area.
at least 3–4 mm of orbicularis is required. ■ Ensure that there is complete hemostasis by use of a fine

■ No attempt is made to close orbicularis muscle in this forceps cautery, lifting all lid tissues away from the
resection, which could increase the risk of cornea and globe before cauterizing.
lagophthalmos. ■ Anchor the upper third of the tarsus to the remaining

levator with 5–0 silk suture, placed as a horizontal

The key components of formal lid ptosis correction include: mattress.
■ The lid should be flipped to ensure that the suture is not

■ Correct identification of the distal extensions of the exposed posteriorly on the tarsus, which could cause a
aponeurosis and the orbital septal extension. troublesome corneal abrasion.
■ The superior edge of the tarsus is freed from any dermal ■ If performed under sedation or local anesthetic, the level

or tendinous extensions. should be checked by having the patient open the eye.
12 1 Blepharoplasty


Figure 1.19  (A) Preoperative and (B) postoperative photograph depicting predictable results with simple skin excision blepharoplasty.

■ Both sides should be completed before the suture is

permanently tied.

Lower lid blepharoplasty

■ Lower blepharoplasty has evolved substantially.
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.

Transconjunctival blepharoplasty
■ Transconjunctival blepharoplasty is the preferred
procedure for fat reduction in patients without excess
skin and with good canthal position.
■ It is less likely to lead to lower lid malposition than a

transcutaneous 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.
Figure 1.20  Anchor blepharoplasty technique. Attaching the dermis of the ■ Previously suspected septal scarring through
pretarsal skin flap to the superior aspect of the tarsus and to the free edge of the
aponeurosis. (Adapted from Spinelli HM. Atlas of Aesthetic Eyelid and Periocular
transconjunctival fat excision has not been shown to
Surgery. Philadelphia: Saunders; 2004:69.) significantly alter lid posture or tonicity.
■ The lower lid retractors (capsulopalpebral fascia and

inferior tarsal muscle) and overlying conjunctiva lie

■ For cases under general anesthetic, one should attempt directly posterior to the three fat pads of the lower lid.
to create one to two times the amount of lagophthalmos ■ A broad and deep transconjunctival incision severs both

relative to the preoperative ptosis. conjunctiva and retractors but typically should not incise
■ If there is any medial or lateral retraction or ptosis, the the orbital septum, orbicularis, or skin.
central suture should be repositioned medially or ■ The conjunctival incision is made with a monopolar

laterally as many times as needed, with adjustment to a cautery needle tip at least 4 mm below the inferior border
pleasing lid height and contour. of the tarsus – never through the tarsus (Fig. 1.23).
Operative techniques 13

■ Conjunctival closure, when it is elected, is simplified by

Levator aponeurosis a monofilament pull-out suture that enters the eye
Whitnall ligament 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 synovium-appearing
capsule encasing the orbital fat is opened, releasing the fat
to bulge into the operative field (Fig. 1.24).
■ Once fat is removed through a transconjunctival incision,

excess skin can be removed through a subciliary

■ Fat reduction may leave skin excess, leading to

■ 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. 1.25).
■ One should be careful not to incise the orbital septum,

A Medial fat pad removed which leads to increased postoperative retraction.

■ This procedure works particularly well when there is an

Intracuticular running
isolated fat pad, especially medially, accessed through a
Interrupted sutures suture 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.
■ 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.
B Closure ■ The fat can also be retropositioned using

capsulopalpebral fascia placation, or it can be transferred

Figure 1.21  Simple skin excision blepharoplasty. (A) The medial fat pad may into the nasojugular fold.
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. Orbicularis muscle fibers and skin can be excised at closure.
(Adapted from Spinelli HM. Atlas of Aesthetic Eyelid and Periocular Surgery.
Philadelphia: Saunders; 2004:65.) ■ Care must be taken with muscle excision, which can lead
to orbicularis denervation and lid malposition.

Orbital fat transposition

■ A preseptal approach is obtained by entering the
conjunctiva above the level of septal attachment to the ■ An alternative to excising prominent orbital fat is to
capsulopalpebral fascia. redrape the pedicled fat onto the arcus marginalis.
■ A retroseptal approach involves a 1.5- to 2-cm incision ■ Patients with tear trough deformities who have

lower down in the fornix, and is typically used to prominent medial fat pads are excellent candidates.
excise fat. ■ Access to the medial and central fat pads is by the
■ It is preferable to leave the transconjunctival incision subciliary or transconjunctival incision.
open. ■ The minor degree of lateral fat pad prominence is
■ Suturing the wound may trap bacteria or cause corneal generally insufficient to affect any change with
irritation. repositioning.
14 1 Blepharoplasty

Levator plication

Orbital septum
and underlying
(preaponeurotic) fat

Levator aponeurosis


Figure 1.22  (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. (Adapted from Spinelli HM. Atlas of Aesthetic Eyelid and Periocular Surgery. Philadelphia: Saunders;

■ A supraperiosteal or a subperiosteal dissection of Capsulopalpebral fascia plication

8–10 mm caudal to the inferior orbital rim permits
tension-free placement. ■ The capsulopalpebral fascia can be plicated to the
■ The fat can be secured in place with interrupted orbital rim either through a transcutaneous or a
absorbable sutures. transconjunctival approach.
■ Patients must be warned that various degrees of fat loss ■ In the transcutaneous method, dissection is carried out

and hardening are possible. There is also a rare but between the orbicularis and the septum down to the
described possibility of restrictive strabismus related to orbital rim; the capsulopalpebral fascia is then sutured to
aggressive fat mobilization and fixation. the orbital rim.
■ In the transconjunctival method, the capsulopalpebral

Orbital septum plication fascia is divided from the tarsus, and orbital fat is
retroplaced, its position maintained by suturing the
■ In this procedure, the herniated septum is plicated and capsulopalpebral fascia to the periosteum of the orbital
repositioned to its normal anatomic site within the orbit. rim using a continuous running 6–0 nonabsorbable suture.
■ The fat is replaced in the retroseptal position to regain its ■ The conjunctival gap of a few millimeters is allowed to

original anatomic integrity (Fig. 1.26). reepithelialize (Fig. 1.27).

■ Three to four 5–0 polyglycolic acid sutures are placed in ■ One advantage of the transconjunctival approach is the

a vertical fashion from medial to lateral. division of lower eyelid depressors, which helps
■ The protruding fat pads are invaginated, and the maintain the lower eyelid at an elevated level due to the
integrity of the thin, flaccid septum is restored. unopposed action of the pretarsal orbicularis.
■ Additional support may be gained with

septo-orbitoperiostoplasty variation, which plicates the Orbicularis suspension

flaccid septum and secures it to the periosteum of the
inferior orbital rim. ■ Orbicularis repositioning can be used to eliminate
■ Because no disruption of the eyelid anatomy occurs, hypotonic and herniated orbicularis muscle, soften
complications related to lid malposition, such as lid palpebral depressions, and shorten the lower lid to cheek
retraction, scleral show, and ectropion, are reduced. distance.
Operative techniques 15

Retroseptal approach

Pretroseptal (suborbicularis) approach

Nonconductive retractor

Conjunctiva is tented and secured with a stay suture

Orbital septum

Conjunctiva is divided longitudinally

just below the tarsal plate Inferior tarsal plate

Figure 1.23  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. (A) 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. (B) 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. (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. (Adapted from Spinelli HM. Atlas of Aesthetic Eyelid and Periocular Surgery. Philadelphia: Saunders; 2004:86.)

■ The main steps include: • Additional medial dissection is performed to release

• Elevation of a skin muscle flap. the levator labii when a tear trough deformity is
• Release of the orbicularis retaining ligament and present.
resuspension of the orbicularis – frequently after • The skin muscle flap is draped in a superior lateral
lateral canthopexy. vector rather than a pure vertical vector.
• Along the entire infraorbital rim, the orbicularis • Excision of skin and muscle are performed by
retaining ligament is divided. removing a triangle of tissue lateral to the canthus,
16 1 Blepharoplasty

Inferior oblique muscle

Conjunctiva retracted superiorly

Orbital septum opened

Lateral, central, and medial fat pads (left to right)

Remove fat pads if they bulge

Reposition fat pads transconjunctivally

Figure 1.24  (A) The orbital septum may then be punctured and the inferior oblique muscle identified and preserved. (B) The fat pad may be addressed individually in
keeping with preoperative plans with either resection, repositioning, conservation, or any combination of these techniques. (Adapted from Spinelli HM. Atlas of Aesthetic
Eyelid and Periocular Surgery. Philadelphia: Saunders; 2004:87.)

thereby minimizing the amount of tissue removed ■ This technique is best suited for patients with scleral
along the actual lid margin. show, lid laxity, and a negative vector, which put them at
• The lateral suspension of the orbicularis is to the risk for lid malposition in the postoperative period.
orbital periosteum. ■ Disadvantages are it inherently disrupts the orbicularis,

• Lower lid support is gained by resuspension of the which may lead to denervation, and mobilization of the
anterior (skin and muscle) and posterior lamellae levator labii muscles may put the buccal branch of the
(tarsus by canthopexy). facial nerve at risk.
Operative techniques 17


Figure 1.25  (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.

Capsulopalpebral fascia Capsulopalpebral fascia

Protruding inferior orbital fat Inferior orbital septum
Inferior orbital septum

Inferior orbital rim Inferior orbital rim


Figure 1.26  (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. (Adapted from Sensöz O, Unlu RE, Percin A, et al. Septoorbitoperiostoplasty for the treatment of palpebral bags: a 10-year experience. Plast Reconstr Surg. 1998;

Canthopexy ■ A double-armed 4–0 Prolene or Mersilene is used to

suture the tarsal plate and lateral retinaculum to the
■ A lateral canthopexy can establish an aesthetically inner aspect of the lateral orbital rim periosteum above
and functionally youthful eyelid and reduce the the Whitnall tubercle.
incidence of lower lid malposition and scleral show ■ Periosteum is thickest at the superior and lateral orbital

(Fig. 1.28). rim, making it a secure suture site.

■ It has become an integral part of a lower lid ■ The mattress suture is placed through the periosteum

blepharoplasty and midface lifting. within the lateral orbital rim to maintain the posterior
■ A lateral canthopexy is recommended for moderate lid position of the lid margin against the globe.
laxity, which is considered <6 mm of lid distraction away ■ Bone canthopexy is technically possible through

from the globe. upper and lower lid incisions but is technically
■ This technique takes advantage of a bluntly dissected demanding.
tunnel extending from the lateral upper lid ■ Wide exposure through a coronal brow lift provides the

blepharoplasty incision into the lateral aspect of a lower ideal environment and access.
lid incision. ■ Bone fixation gives a profoundly longer-lasting result

■ Next, the lateral retinaculum and tarsal strap are bluntly than does periosteal fixation.
dissected off the periosteum 5 mm in both directions ■ Drill holes (1.5 mm drill bit) are placed 2–3 mm posterior

(Figs. 1.4, 1.29). to the lateral orbital rim.

18 1 Blepharoplasty

Upper (ciliary) flap

Inferior orbital septum

Lower (ocular) flap made up
Fascioseptal triangular space of conjunctiva inferior tarsal
muscle capsulopalpebral fascia


Figure 1.27  (A,B) Suturing the lower capsulopalpebral flap to the arcus marginalis to reduce and contain the herniated fat. (Adapted 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(3):1535–1538.)

■ The inferior and superior holes are separated by Midface lifting

5–10 mm to allow suture separation and ligation
(Fig. 1.30). ■ The middle third of the face, or midface, lies between
■ The vertical position of the lateral canthal suture is the lateral canthal angle and the top of the nasolabial
dependent on eye prominence and pre-existing canthal fold. It includes the lateral canthal tendon; the medial
tilt. Patients with prominent eyes and negative vector canthal tendon; the skin, fat, and orbicularis oculi muscle
morphology are at higher risk for lid malposition and of the lower eyelids; the suborbicularis oculi fat pad;
require additional vertical support of the lateral canthus. the malar fat pad; the orbitomalar ligament (orbicularis
■ While the standard position of the lateral canthopexy ligament); the orbital septum; and origins of the
suture is most commonly at the lower level of the zygomaticus major and minor muscles and levator labii
pupil, patients with prominent eyes or negative superioris.
vectors require additional vertical positioning of the ■ When evaluating the midface for aesthetic surgery, all

lateral canthal support suture at the superior aspect the structures listed above must be considered.
of the pupil. ■ The author’s preferred technique includes
■ Lateral canthoplasty, which includes surgical division of approaching the midface through a transconjunctival
the lateral canthus, is recommended for more significant incision.
lower lid laxity, defined by lid distraction >6 mm away ■ After repositioning or resection of orbital fat, the midface

from the globe. is elevated in a supraperiosteal plane.

■ Lateral canthotomy, cantholysis of the inferior limb of ■ The attachment of the orbicularis oculi muscle to the

the lateral canthal tendon, and release of the tarsal strap orbital septum is preserved.
are performed. ■ Adequate release of the remaining, lax orbitomalar
■ This dissection is followed by a 2- to 3-mm full-thickness ligament then permits malar fat pad suspension in a
lid margin resection, depending on the degree of superolateral vector to the lateral orbital rim and
tarsoligamentous laxity. temporoparietal fascia (Fig. 1.31).
■ The lateral commissure is carefully reconstructed by ■ Canthopexy is then performed to redrape lower eyelid

aligning the anatomical gray line with 6–0 plain gut. skin and recreate a youthful intercanthal angle. Finally, a
■ Final fixation to the lateral orbital periosteum can be as skin-only resection of the lower lid may be necessary to
described above. address any redundancy.
Postoperative considerations 19


Figure 1.28  (A) Preoperative and (B) 5-year postoperative photograph of a
patient with a lower lid blepharoplasty and canthopexy.

Postoperative considerations
■ 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. If one chooses not to

use gently compressive bandages, postoperative edema
can be reduced with cool compresses for up to 20 min
intermittently during the initial 36 h postoperatively.
■ Patients are advised against using frozen compresses

directly over their face in the setting of previous

anesthetic use and pain medication.
■ Additional recommendations include having the patient Figure 1.29  (A–C) Periosteal canthopexy. The inferior ramus of the lateral canthal
lie in a semi-recumbent position while resting and to tendon is secured and elevated to a raised position inside the orbital rim. Tension-
avoid bedrest. free suspension occurs with release of the tarsal strap and lateral orbital thickening.
■ 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.
20 1 Blepharoplasty

in the lower lid margin and fixed to the brow suspends

the lid during early healing.

Complications and outcomes

■ 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

A 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%.
■ Retrobulbar hemorrhage is the most feared complication

of eyelid surgery. Any complaint of severe orbital pain

needs to be examined immediately, especially that of
B 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.

C ■ 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
D ophthalmologist.
■ The most common complication after blepharoplasty is

E chemosis. Disruption of ocular and eyelid lymphatic

drainage leads to development of milky, conjunctival,
and corneal edema.
Figure 1.30  The canthopexy suture series for a two-layered canthopexy. (A) The ■ Chemosis can be limited by atraumatic dissection, cold
canthopexy suture fixating the tarsal tail into the drilled hole. (B) The second-layer
compresses, elevation, and massage.
orbicularis suture. (C) Lateral sutures fix the lateral orbicularis to the deep temporal
■ It is usually self-limited and resolves spontaneously,
fascia. (D) If a midface lift is elected, an inferior drill hole can be made to fixate
the midface tissues. (E) Bury the knot into the drill hole. though prolonged chemosis can be treated with topical
■ Dry eye symptoms are also frequently cited in the

postoperative phase. Patients may complain of foreign

body sensation, burning, secretions, and frequent
■ Patients are permitted to shower the next day and use blinking.
antibiotic ointments as needed for routine incisional care. ■ Ocular protection can be achieved medically with liberal

■ It is also suggested that patients refrain from using use of corneal lubricants.
contacts and to minimize the use of prescription ■ Additional complications such as lower lid malposition,

eyeglasses. lagophthalmos, undercorrection, asymmetry, and

■ When no canthopexy is performed, half-inch Steri-Strips, iatrogenic ptosis all require careful observation and
retracted superiorly, are applied as a “cast” (with photographic documentation.
benzoin or Mastisol for security). This treatment tends to ■ Reoperation should be performed no earlier than 3

reduce lid retraction. Alternatively, a Frost suture placed months later.

Further reading 21

Access via upper or lower blepharoplasty incision

Orbital fat
Orbital septum
Orbicularis oculi

Malar bag

Orbitomalar ligament
Malar fat pad


SMAS Extent of sub-orbicularis muscle/

malar fat pad/SMAS undermining
Buccal fat pad B

Single mattress suture repair

C Cheek flap is elevated and

sutured to deep temporal fascia or
periosteum of lateral orbital rim

Figure 1.31  Midface lift. (A) The arrow in red 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. (Adapted from Spinelli HM. Atlas of Aesthetic Eyelid and Periocular Surgery. Philadelphia: Saunders; 2004:129.)

Few JW. Rejuvenation of the African American periorbital area:

F U RT H E R R E A D I N G dynamic considerations. Semin Plast Surg. 2009;23(1):198–206.
Few’s survey-based study shows that one must prioritize a patient’s ethnic
Codner MA, Wolfi J, Anzarut A. Primary transcutaneous lower identity and heritage when approaching the periorbital area in African
blepharoplasty with routine lateral canthal support: a Americans.
comprehensive 10-year review. Plast Reconstr Surg. Flowers RS. Canthopexy as a routine blepharoplasty component. Clin
2008;121(1):241–250. Plast Surg. 1993;20(2):351–365.
22 1 Blepharoplasty

Flowers RS, Nassif JM, Rubin PA, et al. A key to canthopexy: the tarsal Reid RR, Said HK, Yu M, et al. Revisiting upper eyelid anatomy:
strap. A fresh cadaveric study. Plast Reconstr Surg. 2005;116(6): introduction of the septal extension. Plast Reconstr Surg. 2006;
1752–1758. 117(1):65–70.
Flowers and colleagues detail the anatomy of the lateral orbital This cadaveric and histologic study identifies an extension of the orbital
retinaculum and highlight the importance of full dissection to achieve a septum that must be identified and spared when performing a levator
tension-free canthopexy. advancement for blepharoptosis.
Hirmand H. Anatomy and nonsurgical correction of tear trough Rohrich RJ, Coberly DM, Fagien S, et al. Current concepts in aesthetic
deformity. Plast Reconstr Surg. 2010;125(2):699–708. upper blepharoplasty. Plast Reconstr Surg. 2004;3:32e–42e.
Mendelson BC. Fat preservation technique of lower-lid blepharoplasty. This continuing medical education article provides a concise description
Aesthet Surg J. 2001;21(5):450–459. of upper eyelid aging and a step-by-step guide to popular rejuvenation
Results shown in Mendelson’s article demonstrate the safe, reproducible techniques.
outcomes of a skin-only blepharoplasty, and help swing the pendulum Spinelli HM. Atlas of Aesthetic Eyelid and Periocular Surgery.
away from aggressive fat-excisional techniques. Philadelphia: Saunders; 2004.
Muzaffar AR, Mendelson BC, Adams WP Jr. Surgical anatomy of the Zide BM. Surgical Anatomy Around the Orbit: The System of Zones.
ligamentous attachments of the lower lid and lateral canthus. Plast 2nd ed. Philadelphia: Lippincott, Williams & Wilkins; 2006.
Reconstr Surg. 2002;110(3):873–884.
This chapter was created using content from Neligan & Rubin, Plastic Surgery
4th edition, Volume 2, Aesthetic, Chapter 6.2, Facelift: Principles of and Surgical
Approaches to Facelift, Richard J. Warren, Chapter 6.3, Facelift: Platysma-SMAS
plication, Miles G. Berry, James D. Frame, and Dai M. Davies, Chapter 6.4, Facelift:
Facial rejuvenation with loop sutures – the MACS lift and its derivatives, Mark
Laurence Jewell, Chapter 6.5, Facelift: Lateral SMASectomy facelift, Daniel C. Baker
and Steven M. Levine, Chapter 6.7, Facelift: SMAS with skin attached – the “high
SMAS” technique, Fritz E. Barton Jr., Chapter 6.8, Facelift: Subperiosteal midface lift,
Alan Yan and Michael J. Yaremchuk

■ Facial aging is usually a panfacial phenomenon. Therefore, in order to

SYNOPSIS obtain a harmonious result, patients will often benefit from surgery to
other components of their face.
■ Age-related changes occur in all layers of the face, including skin, ■ The most common complication of facelift surgery is hematoma. This
superficial fat, SMAS, deep fat, and bone. problem should be dealt with promptly.
■ Patients presenting for facial rejuvenation surgery are usually

middle-aged or older, thus increasing the chance of co-morbidities.

Risk factors such as hypertension and smoking should be dealt with
prior to facelift surgery. Brief introduction
■ Careful preoperative assessment will provide the surgeon with

an aesthetic diagnosis regarding the underlying facial shape, the ■ The classic stigmata of the aging face include:
age-related issues that predominate, and the appropriate surgical • Visible changes in skin, including folds, wrinkles,
procedures for every individual patient. dyschromias, dryness, and thinning.
■ Almost all facelift techniques begin with a subcutaneous facelift flap. • Folds in the skin and subcutaneous tissue created by
Careful incision placement, tissue handling, and flap repositioning are chronic muscle contraction: glabellar frown lines,
important in order to avoid the obvious stigmata of facelift surgery. transverse forehead lines, and crow’s feet over the
■ In its pure form, the subcutaneous, skin-only facelift has a limited effect lateral orbital rim.
on the position of heavier deep tissue. • Deepening folds between adjoining anatomic
■ In SMAS plication, a skin flap is created with suture manipulation of the
units: the nasojugular fold (tear trough),
superficial fat and the underlying SMAS/platysma. nasolabial folds, marionette lines, and submental
■ In loop suture techniques (MACS-lift), a skin flap is created with long
suture loops taking multiple bites of superficial fat and platysma – fixed • Ptosis of soft tissue, particularly in the lower cheek,
to a single point on the deep temporal fascia. jowls, and neck.
■ The supraplatysma plane creates a single flap of skin and superficial fat
• Loss of volume in the upper two-thirds of the face,
mobilized and advanced along the same vector.
■ SMASectomy involves a skin flap plus excision of superficial fat and
which creates hollowing of the temple, the lateral
cheek, and the central cheek.
SMAS from the angle of the mandible to the malar prominence, with
• Expansion of volume in the neck and lateral jaw line,
direct suture closure of the resulting defect.
■ A SMAS flap raised with skin attached (deep plane) creates a flap of
which leads to the formation of jowls and fullness of
SMAS/platysma, superficial fat, and skin, all mobilized and advanced the neck (Fig. 2.1).
■ Aging of the face occurs in all its layers, from skin down
along the same vector.
■ A separate SMAS flap (dual plane) creates two flaps, the skin flap and to bone; no tissue is spared. The surgical significance of
the superficial fat/SMAS/platysma, which are advanced along two this concentric layer arrangement is:
different vectors. • Dissection can be done in the planes between the
■ The subperiosteal lift involves dissection against bone, with layers.
mobilization and advancement of all soft tissue elements. • Anatomical changes in each of the layers can be
■ Additional volume augmentation and, in some locations, volume addressed independently, as required to treat the
reduction, should be considered in all cases of facelift surgery. presenting problem.

24 2 Facelift

Transverse forehead creases Frontalis contraction

Temporal wasting
Temporal fat pad atrophy

Upper lid sulcus hollowing Lateral brow ptosis

Crow’s feet Orbicularis contracture
Lower lid laxity
Orbicularis oculi laxity
Tear trough Loss of midface fat
Midface flattening
Cheek descent Malar fat descent
Nasolabial folds Elongating upper lip
Thinning lips Peri oral wrinkles
Marionette lines Buccal fat pad ptosis
Expansion and ptosis of jowl fat

Excess preplatysmal and

subplatysmal fat
Transverse neck folds
Platysma bands Platysma muscle laxity
Vertical neck pleats

Figure 2.1  The aging face exhibits changes in the skin, superficial wrinkles, deeper folds, soft tissue ptosis, loss of volume in the upper third and middle third, and
increased volume in the lower third.

■ Skin aging over time is both intrinsic and extrinsic. ■ Smokers have been shown to exhibit delayed wound
The net result is that facial skin loses its ability to recoil, healing due to microvasoconstriction and abnormal cell
a condition called elastosis. function.
■ Intrinsic aging is the result of genetically determined ■ Nevertheless, there are significant short-term effects,

apoptosis. The skin becomes thinner; there is a decrease which can be reversed by abstaining from tobacco use
in melanocytes, a reduced number of fibroblasts, and a for 2–3 weeks prior to surgery.
loss of skin appendages. In the dermal matrix, there is ■ Prior to surgery, the entire face should be properly

fragmentation of the dermal collagen and impairment of assessed.

fibroblast function. ■ The face should be assessed as a whole – looking for the

■ Extrinsic forces include sun exposure, cigarette smoke, equality of facial thirds, the degree of symmetry, and the
extreme temperatures, and weight fluctuations. overall shape (round, thin, wide).
■ Important anatomic figures have been included ■ Surgeons should develop an organized way to examine

(Figs. 2.2–2.8). all the zones of the face: forehead, eyelids, cheeks, the
perioral area, and the neck.
■ With the diversity of surgical techniques available, a

Preoperative considerations surgeon should think like a sculptor – considering the

face in three dimensions with a view to adding tissue in
■ The quality of surgical result will be affected by many some areas, removing tissue in other areas, and
patient-related factors, including the facial skeleton, the repositioning tissue where indicated.
weight of facial soft tissue, the depth and location of ■ The ear should be examined with a thought to the

folds, and the quality of the skin. potential placement of incisions.

■ Some issues can be reversed, others attenuated, and ■ Important factors: the size and orientation of the earlobe,

some may not be correctable at all. the angle of attachment of the tragus, the difference in
■ Incipient hypertension is common in the general character of the cheek skin and tragal skin, the size of
population and can promote postoperative hematomas if the tragus, the density of the hair surrounding the ear,
it is not identified prior to surgery. and the location of the hairline in the temple, the
■ Uncontrolled hypertension is a contraindication for sideburn, and posterior to the ear.
surgery, while controlled hypertension is not a ■ A careful assessment of the overlying skin is also

contraindication. important to determine if anything of a non-surgical

Operative techniques 25

■ Disadvantage: skin placed under tension to support

heavy underlying soft tissue will stretch, leading to a
loss of surgical effect.
■ Attempts to overcome this problem with excess skin

tension may lead to distortion of facial shape, abnormal

reorientation of wrinkles, and local problems at the
incision line, including stretched scars and distorted

Facelift incisions (Video 2.1; Video 2.2)

■ 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 (Figs. 2.9A–B).
■ The advantage of the incision in the hair is that it is

hidden, but when the flap is drawn up, the anterior

hairline and sideburn will shift; the degree of this
depends on skin laxity.
■ If the incision is placed at the anterior hairline, the scar
Orbicularis oculi
is potentially more visible, but there will be no shift of
the hairline.
Zygomaticus major ■ A transverse incision at the base of the sideburn is a

compromise solution, which ameliorates much of the

hairline shift while preserving a largely hidden scar.
■ Several factors should be assessed before committing to
Malar fat pad
an incision within the temple hair.
■ A preoperative estimate of skin redundancy will give

the surgeon some sense of how far the skin flap

will move.
■ The distance between the lateral orbital rim and the

temporal hairline should be assessed.

■ In youth, this distance is generally <4–5 cm, while in

older patients, the distance increases.

■ 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
Figure 2.2  The malar fat pad is a triangular area of thickened superficial fat (Fig. 2.9C).
with its base along the nasolabial fold and its apex over the superolateral malar ■ Anterior to the ear, the incision can be pretragal or along
the tragal edge (Fig. 2.9D,E).
■ The advantage of the tragal edge incision is that it is

hidden, but care must be taken to thin the flap covering

nature is indicated before, during, or after facelift the tragus in order to simulate a normal tragal
surgery. appearance.
■ Excellent photographic documentation of the ■ Before committing to a tragal edge incision, the quality

preoperative face is very important and should include of tragal skin and that of facial skin must be compared;
frontal, oblique, and profile views. Other optional views if the difference between the tragal skin and facial
include the smile and close-up views of the neck in skin is too great, a tragal edge incision should be
repose and with platysma contracture. avoided.
■ A pretragal incision is preferred in men, as the

hair-bearing portion of the cheek skin will not be drawn

Operative techniques up onto the tragus.
■ Around the earlobe, the incision can be placed either in

Subcutaneous facelift the cleft of earlobe attachment or 1–2 mm distal to the

cleft, leaving a cuff of skin along the earlobe. This cuff
■ Classic procedure that tightens excess skin and relies will ease the process of insetting the earlobe on skin
completely on skin tension to shift underlying facial soft closure.
tissue against the force of gravity. ■ In the retroauricular sulcus, the incision can be placed

■ Advantages: relatively safe, relatively easy to do, and directly in the conchal groove as it courses superiorly.
patient recovery is rapid. ■ The incision is often carried as high as the level of the

■ Effective for the thin patient with excess skin and external auditory canal, or slightly higher, at the level of
minimal ptosis of deep soft tissue. the antihelix.






Nasolabial Medial Middle Lateral

Figure 2.3  (A) 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. (B) The deep facial fat is also compartmentalized
by septae. The deep medial fat pad (here stained blue) is bounded above by the orbicularis retaining ligament, medially by the pyriform aperture, and laterally by the
zygomaticus major (ZM) muscle and the buccal (labeled B) fat pad. (C) Over the body of the zygoma, the suborbicularis oculi fat (SOOF) is deep fat. It is seen here with
a medial portion (yellow) and a lateral portion (stained blue). It is bounded medially by deep medial fat pad (stained red). (A: Courtesy of Rohrich RJ, Pessa JE. The fat
compartments of the face: anatomy and clinical implications for cosmetic surgery. Plast Reconstr Surg. 2007;119:2219–2227; B,C: Courtesy of Rohrich RJ, Pessa JE,
Ristow B. The youthful cheek and the deep medial fat compartment. Plast Reconstr Surg. 2008;121(6):2107–2112).
Operative techniques 27

Galea aponeurotica

Corrugator supercilii

Orbicularis oculi, orbital portion

Orbicularis oculi, preseptal portion
Orbicularis oculi, pretarsal portion
Levator labii superioris alaeque nasi
Levator labii superioris
Auricularis anterior
Zygomaticus minor
Zygomaticus major
Levator anguli oris
Depressor septi nasi
Orbicularis oris
Depressor anguli oris
Depressor labii inferioris

Figure 2.4  Muscles of facial expression. The solid lines demonstrate overlying skin creases caused by repeated contraction of the underlying muscles.

Superficial layer of deep
temporal fascia Temporal crest

Upper edge of temporal fat Temporalis

Orbital ligament
Orbicularis oculi
Occipitalis Temporal fat pad

Zygomatic ligaments
Tympanoparotid Zygomaticus major
(Lore’s) fascia Zygomaticus minor
Masseteric ligaments
Platysma auricular fascia Buccinator
Orbicularis oris
Sternocleidomastoid Depressor anguli oris


Mandibular ligament

Figure 2.5  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.
6.5 cm

Figure 2.6  Mendelson’s interpretation of soft tissue attachments. The fixed McKinney’s point
posterior soft tissue is held in place by the platysma auricular fascia (large red
Great auricular nerve
area). The anterior face is fixed by a vertical column of attachments: orbital
ligament, lateral orbital thickening (superficial canthal tendon), zygomatic External jugular vein
ligaments, masseteric ligaments, and mandibular ligament. 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.”

Figure 2.7  The great auricular nerve crosses the midportion of the
sternocleidomastoid 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 (SMAS), but at the posterior border of the sternocleidomastoid, the nerve is
subcutaneous. The most common point of injury is at the posterior border of the
sternocleidomastoid muscle.

Supratrochlear nerve
Ophthalmic nerve V1 Supraorbital nerve

Lacrimal nerve
Zygomaticotemporal nerve
Infratrochlear nerve
Maxillary nerve V2 External nasal nerve
Zygomaticofacial nerve
Auriculotemporal nerve
Infraorbital nerve

Buccal nerve
Mandibular nerve V3

Mental nerve

Figure 2.8  Major sensory nerves of the face.

Operative techniques 29



Figure 2.9  (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.

■ An extension of the retroauricular sulcus incision toward ■ The principle objectives for the occipital incision are to
the occipital hair-bearing region should be made when gain access to the neck in order to take up redundant
there is a need to remove excess redundant neck skin. neck skin while making the incision as invisible as
■ A “short scar” facelift is one that avoids the occipital possible with little or no distortion of the occipital
incision, and will suffice for many patients. hairline (Figs. 2.10 and 2.11).
30 2 Facelift


Figure 2.10  (A) When there is minimal to moderate skin shift expected, an
appropriate incision will curve from the retroauricular incision directly into the
occipital hair. (B) When a greater amount of skin is to be excised, a “Lazy S”
incision, which partly follows the occipital hairline, is an appropriate choice.

Figure 2.11  The traditional incision for a facelift flap curves vertically or slightly
anteriorly in the temple, follows the contours of the ear, both anteriorly and
posteriorly, and then angles into the posterior scalp.
■ Either the temple dissection or the postauricular
dissection can be done first, depending on surgeon
preference. ■ This change of plane results in a narrow ribbon of
■ In the postauricular area, the flap is firmly attached to superficial temporal fascia, which will contain the
the deep cervical fascia of the sternocleidomastoid and superficial temporal artery and vein and branches
the mastoid. of the auriculotemporal nerve, which must be divided
■ This is the most common location to see skin flap (Fig. 2.12A).
necrosis, so the flap should be raised sharply under ■ The superficial plane preserves the superficial temporal

direct vision, keeping the dissection against the fascia and vessels, but can injure the hair follicles during
underlying deep fascia in order to maintain flap the dissection unless care is taken (Fig. 2.12B).
thickness. ■ Anterior to the anterior hairline, the subcutaneous plane

■ As the dissection continues inferior to the earlobe level, is then developed.

the surgeon must be cognizant of the great auricular • The level of dissection normally leaves 1–2 mm of fat
nerve, where it is most at risk over the posterior border on the dermis.
of the sternocleidomastoid. • This results in a large random-pattern skin flap, the
■ By keeping the dissection in the subcutaneous plane, survival of which will entirely depend on the
the great auricular nerve will be protected. subdermal plexus.
■ In the temple, if the incision has been made along the ■ In the upper face, this dissection continues anteriorly

anterior hairline, dissection is begun directly in the until the orbicularis oculi is encountered, where it
subcutaneous plane. If the incision has been made in encircles the lateral orbital rim. Depending on the type
the hair-bearing scalp of the temple, dissection can be of deep plane surgery planned, the midcheek dissection
carried out in one of two planes: superficial to the may stop short of the malar fat pad or, alternatively,
superficial temporal (temporoparietal fascia), which will carry on over the fat pad, freeing it from the overlying
continue directly into the subcutaneous facelift plane, or skin in the temple and cheek.
between the superficial temporal fascia and the deep ■ Lower in the cheek, immediately anterior to the ear and

temporal fascia. the earlobe, the skin is tethered to underlying structures

■ If the deeper approach is used, the dissection proceeds by secure fascial attachments, but beyond this area, the
quickly against deep fascia, but at the anterior hairline, subcutaneous dissection proceeds relatively easily.
the dissection plane must transition into the ■ Once the skin flaps anterior and posterior to the ear have

subcutaneous facelift plane. been raised, the two dissections are joined.
Operative techniques 31

Figure 2.13  Subcutaneous facelift flap has been raised.

■ The dissection can then be extended into the neck as far

as the technique requires (Figs. 2.13, 2.14). (Video 2.3)
■ After elevation of the subcutaneous tissues, management

of the deep tissues can proceed if needed.

■ Once the deep tissues have been managed, skin flap

mobilization and closure is performed:

• Most techniques advance the skin flap along an
oblique vector, which is slightly more posterior than
the vector for repositioning deep tissues.
• In certain techniques, surgeons employ a nearly
vertical vector to the skin flap.
• One concept is to place the skin flap “where it lies,”
B using the vector that facial skin naturally assumes
when the patient is lying in the supine position.
Figure 2.12  (A) Facelift flap has been raised in two different planes, initially • Another guide is to advance the skin flap toward the
deep to the superficial temporal fascia, against the deep temporal fascia (seen as
temple along a vector that is perpendicular to the
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 nasolabial fold.
■ The anterior anchor point is immediately adjacent to the
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 helix of the ear at the junction of the hair-bearing scalp.
single subcutaneous plane, with dissection directly on the superficial temporal ■ This will be the first of two anchor points; it can be
fascia and deep to the hair follicles of the scalp. The purple line outlines the held in place with a half-buried mattress suture in
course of the anterior branch of the superficial temporal artery. order to minimize the chance of a visible suture mark
(Fig. 2.15).
■ 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

32 2 Facelift

Figure 2.14  (A) Traditional subcutaneous flap dissection with no submental incision. (B) Traditional subcutaneous flap dissection with submental incision.

incision starts to transition posteriorly. Once again, a ■ Earlobe inset is done last and is designed to angle 15°
half-buried mattress suture can be used. posterior to the long access of the ear (Fig. 2.16).
■ At this point, trimming of the overlapping flap and ■ Skin trimming around the earlobe should be

suturing can be done in the temple and in the occipital conservative.

region. ■ Tension on the earlobe can lead to distortions such as the

■ The facelift flap is redraped in the desired direction with pixy ear deformity and the malpositioned earlobe.
gentle tension.
■ Attention is then turned to trimming excess skin around Midfacelift (blepharoplasty approach)
the ear, with absolutely no tension on the closure.
■ If a tragal edge incision is used, the tragal flap is ■ In an attempt to lift the tissue immediately inferior to the
thinned, and hair follicles are removed. infraorbital rim (the midface), an approach through the
■ In the retroauricular sulcus, there is normally little or no lower lid was developed that involves a subciliary or a
skin to be trimmed if the posterior flap has been transconjunctival blepharoplasty–type incision followed
correctly positioned. by a dissection down over the face of the maxilla.
Operative techniques 33

Figure 2.15  Diagram shows typical skin flap redraping along an oblique direction, Figure 2.17  Incision and area of subcutaneous dissection employed with the
which is slightly less vertical than the vector along which deep tissues are moved. platysma SMAS plication (PSP)-lift. Note that the posterior extension is not always
There is considerable variation in this; however, some techniques involve a more required but is useful where excess skin remains in the neck after SMAS plication.
horizontal vector, while other techniques utilize a nearly vertical vector.

■ Performed in either the subperiosteal plane, which

requires an inferior periosteal release, or in a
supraperiosteal plane.
■ After mobilization of the cheek mass, the soft tissue is

Proper insetting of the earlobe fixated superiorly, either laterally along the lateral orbital
rim or more vertically with anchoring to the bone of the
infraorbital rim.
■ Disadvantages of the midfacelift: steep learning curve

and high incidence of revisions.

SMAS plication (Video 2.4)

■ Patients are prepared as for a standard facelift with
tumescent infiltration (20 mL 0.5% bupivacaine and 1 mL
1 : 1000 adrenaline in 200 mL normal saline) into the
subcutaneous plane.
■ The incision extends vertically in the temporal scalp,

along the anterior helical sulcus, then passes post-tragal,

and, on occasion, into the postauricular sulcus (Fig. 2.17).
■ 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
Figure 2.16  The earlobe should be inset with the long axis of the earlobe (dotted (Fig. 2.18).
■ The key suture, using 2-0 PDS (Johnson & Johnson
line) about 15° posterior to the long axis of the ear itself. If the earlobe is pulled
forward, an unnatural appearance results. Medical Ltd), is then inserted to attach this SMAS to the
34 2 Facelift

Figure 2.18  Placement of the first and key suture, which takes a generous bite Figure 2.19  Tying the key suture produces a “dog-ear” of SMAS that produces a
of anterior SMAS and tractions it posterosuperiorly onto the parotideomasseteric convenient malar autoaugmentation. A second suture passes between the posterior
fascia. It can be trialed and its effect easily measured externally by observing platysma and the mastoid fascia to complete the effect on the jowl and commence
reduction of the jowl and effacement of the nasolabial fold as the SMAS is the necklift.
tractioned and the suture tied.

relatively immobile preauricular parotid-masseteric ■ The degree of skin flap undermining typically extends
fascia. inferiorly just past the mandibular angle and anteriorly
■ Further sutures complete plication of the cervical 5–6 cm in front of the ear.
platysma, below the mandibular angle, to the mastoid ■ If an extended MACS-lift is planned, undermining is

fascia (Fig. 2.19), and any surface irregularities are marked over the malar prominence.
addressed by suture imbrication with 3-0 Vicryl (Johnson ■ If autologous fat grafting is considered, the fat is

& Johnson). harvested, processed, and injected at the beginning, prior

■ Excess SMAS in the infra-lobular region is excised, to the incisions for the MACS-lift.
following hydrodissection, and closed with 3-0 Vicryl. ■ Local anesthetic containing epinephrine is injected along

■ Following meticulous hemostasis, excess skin, with the incision line.

low-tension traction only, is trimmed and the wound ■ The short scar incision extends from the earlobe below to

closed over a small suction drain with 4-0 and 6-0 the anterior hairline above.
nylon. ■ It follows the attachment of the earlobe from the

■ A light, compressive facelift dressing remains overnight retroauricular crease, around to the anterior attachment
and is removed with the drain the following morning. of the earlobe, following the tragal edge, the anterior
These can be similarly removed immediately prior to helical attachment to the root of the helix, then across the
discharge in day-case patients. lower portion of the sideburn and up the anterior
■ Sutures are removed at 4–6 days. hairline.
■ Anteriorly, the incision is made in a zigzag pattern

MACS-lift (Chapter 6.4) (Video 2.5) 1–2 mm within the hairline.

■ In the standard MACS-lift, the incision is carried up to

■ The patient is marked before the start of the procedure; the level of the lateral canthus, while in the extended
key points are the planned incision, the degree of MACS-lift, the incision extends up to a point opposite
undermining, and the location of suture loops. the tail of the eyebrow.
Operative techniques 35

Figure 2.20  The short scar incision has been made and the skin flap raised.
The zygomatic arch is marked in purple. Note the marks on the skin designating
the location of the suture loops. The scissors are dissecting a window down to the
deep temporal fascia, which will be used as the anchor point for the vertical and
cheek suture loops.

■ The deep temporal fascia anchor point is chosen to avoid

the superficial temporal vessels and the temporal branch
of the facial nerve.
■ Small scissors are used to create a window in the
subcutaneous tissue approximately 1 cm above the
zygomatic arch and 1 cm in front of the helical rim in
Figure 2.21  (A, B) Cadaveric example demonstrating placement and the effect of
order to expose the deep temporal fascia (Fig. 2.20). the vertical neck suture. The orientation is vertical, and neck traction depends on
■ When placing the suture into the temporalis fascia, the
achieving excellent suture purchase of the platysma muscle below the angle of the
author sews away from the temporal vessel location. mandible.
■ A single anchor point is used for both the neck loop

and the cheek loop in order to diminish the amount of

suture used and the palpability of knots. Absorbable
monofilament sutures such as 0-polydioxanone are
preferred over non-absorbable polypropylene or braided to the first loop and then curves more anteriorly, creating
polyester suture. a wider loop above the jowl, extending anteriorly as far
■ The suture loop for the neck is placed first. Going as the skin flap has been raised.
inferiorly in the natural sulcus that is anterior to the ■ The overall angle of the cheek loop is approximately 30°
tragus, firm bites between 1 cm and 1.5 cm long are across the cheek as compared to the vertical neck loop.
taken into the SMAS. ■ The suture is then tied under tension.
■ Progressing inferiorly past the angle of the mandible, ■ Once the cheek loop is tied, it is possible to add a third
two or three suture bites are taken into the platysma loop for elevation of the malar fat; this constitutes the
before the suturing is directed upward and back to the “extended MACS-lift” variant.
anchor point. ■ A different anchor point is used anterior to the temporal
■ A U-shaped loop about 1 cm wide is created, and the branch of the facial nerve.
knot is then tied at the anchor point under tension. ■ This point can either be the deep temporal fascia just
■ Should additional reinforcement of the neck be desired, lateral to the lateral orbital rim or the periosteum of the
2-0 polydioxanone (PDS) sutures can be placed from the zygoma, approximately 1.5 cm lateral to the lateral
platysma into the fascial zone of adherence just below canthal area.
the tragus (Lore’s fascia) or from the platysma to the ■ Access to either of these anchor points requires a small
mastoid fascia. window in the orbicularis muscle where the fibers run
■ Suture knots in this area should be inverted to avoid vertically.
knot palpability through the skin (Fig. 2.21). ■ This pursestring suture travels obliquely toward the
■ The cheek loop is placed next. It originates at the same malar fat pad where, at a point 2 cm below the lateral
anchor point from the deep temporal fascia. Taking bites canthus, the direction is reversed, creating a narrow
of the SMAS, suturing progresses inferiorly just anterior U-shaped loop that is tight under tension.
36 2 Facelift

■ Tissue bunching is an integral problem with the MACS propofol sedation. Patients are given oral clonidine,
suture loops. It is resolved with imbrications with 4-0 0.1–0.2 mg, 30 min before surgery to control their blood
polyglactin braided suture. pressure.
■ Before leaving the deep tissue, it is necessary to place the
■ The face and neck are infiltrated with local anesthesia,
skin flap over the tissue and observe for unresolved 0.5% lidocaine with 1 : 200,000 epinephrine.
bunching and tissue tethering at the margins of the
■ Incisions are made in similar fashion as described above
undermined area. in the “Subcutaneous facelift” section.
■ Scissor removal of protruding fat may be needed in
■ When the temporal hairline shift is assessed as minimal,
order to produce a smooth tissue surface inside the the preferred incision is well within the temporal hair.
■ When a larger skin shift is anticipated or the distance
■ Imbrication of tissue in the region just anterior to the between the lateral canthus and temporal hairline is
tragus is important in order to preserve this normal >5 cm, an incision a few millimeters within the temporal
sulcus. hairline is preferred.
■ The skin flap is then redraped along a vertical axis, and
■ In short scar facelifting, efforts are made to end the
the excess skin is resected. incision at the base of the earlobe, but sometimes a short
■ The author’s personal technique uses approximately 1 cc retroauricular incision is often necessary to correct a dog
of fibrin glue (5 units/mL dilution) that is sprayed on ear after the facial flap rotation (Fig. 2.22).
the flaps and held for 3 min. This diminishes ecchymosis
■ Subcutaneous dissection is performed as outlined above.
formation and eliminates the requirement for drains.
■ Dissection extends across the zygoma to release the
Care must be given to not apply excessive fibrin glue, as zygomatic ligaments but stops several centimeters short
it can interfere with revascularization of the flaps. of the nasolabial fold.
■ Wound closure is performed with absorbable 5-0
■ In the cheek, dissection releases the masseteric-cutaneous
monofilament in the deeper layers and 5-0 and 6-0 ligaments and, if necessary, the mandibular ligaments.
polypropylene skin sutures placed as interrupted and
■ Subcutaneous dissection continues over the angle of the
continuous (horizontal mattress). mandible and sternocleidomastoid for 5–6 cm into the
neck, which exposes the posterior half of the platysma
Lateral SMASectomy (Chapter 6.5) muscle.

■ If a submental incision has been made, the facial and
■ Virtually all of the author’s procedural facelifts are lateral neck dissection is connected through to the
performed with the patient under monitored intravenous submental dissection.

Preferred incision Optional temporal

incision for
recessed hairlines

Usual extent of
Optional preauricular subcutaneous
or intratragal incision undermining to
lateral canthus
and release of
malar ligaments
Subcutaneous undermining
into neck allows for
exposure of platysma
and skin redraping
Submental incision
Usual lower border of
in normal skin crease.
connects laterally

Figure 2.22  Incisions and extent of skin undermining.

Operative techniques 37

■ Some surgeons may employ closed suction–assisted ■ After SMAS resection, interrupted 3-0 PDS buried
lipoplasty in the neck and jowls. sutures are used to close the SMASectomy, fixed lateral
■ The outline of SMASectomy is marked on a tangent from SMAS being evenly sutured to more mobile anterior
the lateral malar eminence to the angle of the mandible, superficial fascia.
essentially in the region along the anterior edge of the ■ Vectors are usually perpendicular to the nasolabial fold.

parotid gland. ■ The last suture lifts the malar fat pad, securing it to the

■ In most patients, this involves a line of resection malar fascia.

extending from the lateral aspect of the malar eminence ■ If firm monofilament sutures are used, such as PDA or

toward the tail of the parotid gland. Maxon, the sutures should be buried and sharp ends on
■ Usually, a 2- to 4-cm segment of superficial fascia is the knot trimmed.
excised, depending on the degree of SMAS-platysma ■ Final contouring of any SMAS or fat irregularities along

laxity (Fig. 2.23). the suture line is completed with scissors.

■ In SMAS resection, the author likes to pick up the ■ Skin redraping and closure completes the procedure

superficial fascia region of the tail of the parotid, (Fig. 2.24).

extending the resection from inferior to superior in a
controlled fashion. Extended SMAS technique (Chapter 6.6)
■ When SMAS resection is being performed, it is important

to keep the dissection superficial to the deep fascia and (Figs. 2.25–2.28)
avoid dissection into the parotid parenchyma.
■ The various vectors accomplish corrections of the

anterior neck, the cervicomental angle, the jowls, and the SMAS with skin attached – the “high SMAS
nasolabial fold. technique” (Chapter 6.7) (Video 2.6)
■ The first key suture grasps the platysma at the angle of

the mandible and advances it in a posterosuperior ■ The initial incision location in the temporal area depends
direction; it is secured with 2-0 Maxon (United States upon what is to be done with the forehead.
Surgical Corp., Norwalk, CT) to the fixed lateral SMAS ■ If a bicoronal or hairline incision is to be utilized for the

overlying the parotid. forehead, then that extension is used for the cheek
■ This action lifts the cervical platysma and cervical skin. dissection.
■ If only an endoscopic approach or no forehead surgery is

planned, then only a horizontal sideburn incision is done.

■ A post-tragal auricular incision is used routinely in both

males and females, except in dark-skinned males with

very dark, heavy beards.
■ The cheek dissection is begun by elevating the skin in

the preauricular area sharply.

■ Above the level of the tragus, a subcutaneous tunnel is

formed to the lateral border of the orbicularis oculi

■ This tunnel will facilitate later horizontal division of the

upper SMAS.
■ From the tragus down, the skin flap is thinly dissected

only to the extent of estimated skin excision (Fig. 2.29).

■ Care is taken not to overly separate the skin from the

SMAS, especially at the upper corner where the previous

tunnel was made.
Lateral SMASectomy ■ The lower extent of the subcutaneous cheek dissection
extends from tail of
parotid to lateral extends below the mandibular border.
canthus ■ If no previous neck skin dissection has been done, the

submandibular skin dissection is carried approximately

Resection is at interface of
fixed and mobile SMAS halfway down the neck and halfway to the midline.
■ With the skin dissection complete, attention is turned to
Width of resection
determined by SMAS laxity the SMAS. The safest place to penetrate the SMAS is
and desired debulking between the top of the tragus and the bottom of the ear
Undermining posterior border lobule where the SMAS is thickest.
of platysma for advancement ■ The proper dissection plane leaves a thin, translucent,
to mastoid fibrous layer over the visible parotid acini.
■ As this dissection plane is extended anteriorly and

inferiorly, an areolar plane on the underside of

identifiable platysma fibers can be visualized.
■ Once in this areolar plane, dissection is carried to the

anterior border of the parotid gland and down the

Figure 2.23  Lateral SMASectomy. anterior border of the sternocleidomastoid muscle.
38 2 Facelift

Temporalis fascia Last suture lifts

malar fat pad
Zygomatic arch

Plication of
mobile to fixed SMAS

Figure 2.24  Optional plication of SMAS for thin faces when debulking is not indicated.

■ At the anterior border of the parotid gland, the ■ With the inferior-lateral border of the orbicularis oculi
dissection method changes from sharp to blunt muscle as a depth gauge, the dissection is carried over
spreading in the anterior areolar plane. the lateral border of the zygomaticus major muscle into
■ Over the parotid gland, the SMAS is fixed to the gland the subcutaneous plane.
capsule – the so-called “fixed SMAS.” ■ Dissection is then carried down the lateral border of the
■ Anterior to the parotid gland, in the buccal area, there zygomaticus major muscle to the level of the modiolus
is an areolar gliding plane, which can be separated (Fig. 2.30).
bluntly to avoid any risk to the underlying facial nerve ■ In patients with minimal nasolabial fold depth,

branches. dissection stops short of the fold to preserve attachment

■ It is imperative to maintain the filmy, near-transparent of the fat to the cheek flap (Fig. 2.31).
deep fascia over the masseter muscle, since the facial ■ In patients with deep nasolabial folds, usually associated

nerve branches lie just beneath. with a thin face, complete dissection across the
■ Inferiorly, the dissection continues down the fascial nasolabial fold into the lip is done (Fig. 2.32).
fusion plane at the anterior border of the ■ With completion of this release, the entire subcutaneous

sternocleidomastoid muscle. cheek mass, from mandible to orbit, will freely move
■ Here, a short 2- to 3-cm “back cut” in the investing fascia superiorly.
and platysma is made about 4 cm below the mandibular • It is paramount to mobilize the cheek in a pure vertical
border. – not horizontal or oblique – direction. The primary
■ The “back cut” is made at this level to avoid any vector is vertical along the lateral orbital rim (Fig. 2.33).
aberrant branches of the marginal mandibular facial ■ Key sutures are placed in the deep temporal fascia and

nerve. in the mastoid fascia.

■ The SMAS is divided horizontally above the zygomatic ■ The periauricular SMAS is then completely closed with a

arch over to the lateral orbicularis. continuous suture to disperse the tension from the key
■ Using the visible edge of the orbicularis as a depth sutures.
marker, the dissection is carried over the malar area to ■ Redundant skin is trimmed in place and closed in

release the zygomatic-retaining ligaments. similar fashion as described above.

Operative techniques 39


Figure 2.25  (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.

■ In the open approach, the incision is either a coronal

Subperiosteal midfacelift (Chapter 6.8) incision if the forehead lift is also done concomitantly or
(Video 2.7; Video 2.8) a limited temporal-frontal incision.
■ Dissection in the temporal area separates the superficial

■ In this author’s particular technique, the subperiosteal temporal fascia from the temporal fascia proper in the upper
midfacelift is often combined with a functional lower temporal area and the superficial temporal fascia from the
blepharoplasty in an effort to rejuvenate the lower eyelid intermediate temporal fascia in the lower temporal area.
while preserving its function. ■ In the endoscopic technique, dissection continues in this

■ The midfacelift begins with xylocaine 0.5% mixed with plane until the superior border of the zygomaticus arch
epinephrine at 1 : 200,000 dilution, which is infiltrated in is reached.
the temporal and midface areas. ■ With upward traction of the temporal flap, the

■ The midface is approached from above through a periosteum of the zygomaticus arch is elevated with a
temporal incision and from below through an intraoral sharp periosteum elevator.
buccal mucosal incision. ■ In the open approach, the intermediate temporal fascia

■ The length of the incision in the temporal area will with its attached intermediate fat pad is elevated 2–3 cm
depend on the technique used. Some surgeons avoid a above the zygomaticus arch, and the periosteum is
temporal incision altogether and perform the MACS-lift dissected in continuity.
using only the intraoral approach and transconjunctival ■ This fascial flap will be used as an anchor suspension of

lower lid incision. In this case, a small crow’s foot the midface.
incision can be added to gain additional lateral exposure ■ Next, the intraoral buccal incision is made at the level of

and preserve the integrity of the lateral canthus by the first premolar and done either vertically or slightly
avoiding a lateral canthotomy. obliquely.
40 2 Facelift


Figure 2.26  (A) In patients with malar deflation or malar pad descent, an extended SMAS dissection can be performed in which 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.

■ The initial incision is done through the mucosa only; ■ The attachments around the infraorbital nerve are freed
then the buccinator muscle is spread with the periosteal after the fixation points on the midface are applied and
elevator, and a subperiosteal dissection is carried out on just before their fixation in the temporal fascia proper.
the maxilla and malar bones. ■ Subperiosteal dissection of the midface is connected with

■ Medially, this extends to the pyriformis area and laterally the temporal optical cavity over the anterior two-thirds
underneath the fascia of the masseter muscle. of the zygomatic arch (Fig. 2.34).
■ This lateral extension goes about 2.5 cm over the ■ Dissection includes elevation of the soft tissues from the

masseter tendon. external lateral orbital rim.

■ Dissection superiorly is done to separate the orbicularis ■ The sutures applied to the midface have the following

muscle attachments to the inferior orbital rim, thus effects: suspension, volumetric remodeling, and lifting.
releasing the arcus marginalis. ■ The author routinely uses four sutures per side (Fig. 2.35).
Operative techniques 41

Figure 2.28  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 2.27  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 portion of the intraoral incision to the temporal region
surface of the elevators of the upper lip and the overlying subcutaneous fat. Once using a 4-0 PDS suture.
the scissors are inserted in the proper plane, the surgeon bluntly dissects in a ■ The final suture is applied to the Bichat or buccal
series of passes past the nasolabial fold (area marked in green). As long as the fat pad.
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
■ To place the suture, you must first open the
flap mobility. anterior-medial wall of the fat pad, just medial to the
masseter tendon using a blunt and long scissor.
■ Once the blades of the scissors are opened, the fat pad
will extrude from its encased buccal space.
■ The first suture anchors the anterior central SOOF ■ It is then gently pulled with two blunt scissors and
(suborbicularis oculi fat) to the most anterior portion of delivered with external pressure on the cheek.
the temporal fascia proper near the lateral orbital rim ■ Once the fat pad has been delivered, a 4-0 PDS suture
using a 4-0 PDS suture. with an RB1 needle is weaved into the fat pad, utilizing
■ Prior to passing to the temporal area, it can be anchored two or three passes.
to the immediately superior arcus marginalis, which will ■ This suture is then anchored to the loop of the SOOF
act as a pulley to direct the anterior SOOF towards the suture applied beforehand, using a “piggy backing”
orbital rim area, helping to efface the tear trough area. technique.
■ The second suture anchors the lateral SOOF to the ■ This limits the upward mobilization of the buccal fat pad
compound periosteum/SOOF tissue 3 cm inferior and and its potential avulsion.
vertical to the lateral canthal tendon insertion using a 3-0 ■ All the sutures anchored to the temporal area are done
PDS suture. using the endoscopic sliding Peruvian fisherman’s knot.
■ The third suture, the modiolus suspension, anchors the ■ A 2-mm “butterfly” drain is introduced via a mini stab
fibro-adipose tissue just inferior to the most anterior incision.
42 2 Facelift

Subcutaneous tunnel
superior to arch
dissection 4cm
Only skin expected
to be removed is undermined

Subcutaneous dissection of neck from

mastoid to midline superficial to platysma

Figure 2.29  In the high SMAS technique, the skin flap is thinly dissected only to the extent of estimated skin excision.

Temporal branch,
facial nerve
Upper lateral corner of SMAS
remains attached to skin
SMAS incision

Dissection from beneath SMAS

over zygomaticus major thus
releasing restraint of investing fascia

Marginal mandibular
branch of facial nerve

Figure 2.30  Complete release of the SMAS.

Operative techniques 43

Stops before anterior

facial vascular and
lymphatic territory

Figure 2.31  In patients with minimal nasolabial fold depth, dissection stops short
of the fold to preserve attachment of the fat to the cheek flap.

Figure 2.33  The cheek mass is suspended vertically (shown with key sutures),
and the entire SMAS flap is closed with a continuous suture to disperse the tension
from the key sutures. An orbicularis flap is then done to suspend the orbicularis.

■ The last suspension suture is applied to the superficial

temporal fascia at the inferior lip of the temporal
entrance port and anchored to the temporal fascia proper
above and anterior to it.
■ The scalp is closed with staples.

■ The midface cavity is irrigated with antibiotic solution,

and closure of the intraoral incision is done with

interrupted 4-0 chromic catgut sutures.
■ Once the midface lift is completed, the lower

blepharoplasty can be performed.

■ For the lower blepharoplasty in this instance, this

author makes a skin incision 2 mm below the ciliary

border, which is extended directly into the crow’s
foot area.
■ The full-thickness lower eyelid skin is “peeled” off the

orbicularis muscle layer for an average of 1.5–2 cm

inferiorly, creating a pure skin flap.
Dissection across
■ The exposed lateral extension of the preseptal portion is
nasolabial fold onto lip
anchored to the most anterior portion of the temporal
fascia proper with a 5-0 or 6-0 Prolene suture.
■ For this maneuver, a window in the lateral orbital

portion of the orbicularis muscle is created with a blunt

■ The lower eyelid incision can be closed as described in
Figure 2.32  Cheek dissection across the nasolabial fold into the lip in patients
with deep nasolabial folds. the blepharoplasty chapter.
44 2 Facelift

SOOF with
MS with

BF with
suspension suture

Figure 2.35  An endoscopic browlift is shown in conjunction with an endoscopic

midfacelift. For the midfacelift, four sutures are used to obtain the maximal
remodeling and beneficial effect of the subperiosteal dissection. The anterior SOOF
(suborbicularis oculi fat) effaces the infraorbital V deformity. The lateral SOOF lifts
the midface. The MS (modiolus suspension) lifts the corner of the mouth. These
Figure 2.34  The “endo-midface” is approached by a single temporal and an three sutures also produce imbrication, thus increasing the anterior projection of
intraoral incision. For this reason, it is better called an endotemporo-midface the cheek. The last suture suspension is the buccal (Bichat) fat pad (BF). This is
procedure. The midface and temporal cavities are connected across the zygomatic the structure that helps more than any other to create the ogee line of the midface.
arch. The subperiosteal dissection here is critical to avoid injuring the frontal
branch of the facial nerve. The midface dissection extends under the masseteric
fascia for 2–3 cm.
■ 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.
■ Photographic documentation of the surgical result

Postoperative considerations should be deferred for at least 6 months to allow for all
postoperative swelling to settle completely.
■ Most surgeons use light dressings to protect the incisions
and to act as an absorbent for wound drainage.
■ Dressings should not be tight or constrictive, but rather Complications and outcomes
soft and comfortable and are typically removed on the
first postoperative day. Hematoma
■ In the initial postoperative period, the patient is kept

still, and blood pressure is monitored closely. ■ Postoperative hematoma is the most common facelift
■ If an increase in blood pressure is endogenous, it should complication.
be treated pharmacologically. ■ Incidence in women has been reported at 2–3%.

■ The patient should keep the head of the bed elevated but ■ Incidence in men has been reported between 4 and 8%.

avoid flexion of the neck. ■ Hematomas typically develop in the first 12 h after

■ Avoiding the use of a pillow for 10–14 days will help surgery.
keep the patient’s head in a neutral, non-flexed position. ■ If an expanding hematoma is identified, it should be

■ Cool packs to the face will increase comfort and help promptly drained.
decrease swelling. ■ If skin flap compromise is suspected and there is a delay

■ Analgesics and antinauseants are used as necessary. in returning to the operation, a temporary solution can
Further reading 45

be the removal of sutures in order to relieve pressure Infection

(Fig. 2.33).
■ Infection is reported to be rare in facelift surgery, with
Sensory nerve injury various series indicating an incidence of less than 1%.

■ A self-limiting paresthesia, which usually recovers

completely in 6–12 months, can occur after facelift F U RT H E R R E A D I N G
■ The great auricular nerve is the major sensory nerve at Coleman SR. Facial recontouring with lipostructure. Clin Plast Surg.
greatest risk of damage during facelift surgery.
A pioneer of facial fat grafting presents early experiences with
■ If knowingly transected during facelift surgery, either
lipoinjection of the face.
partial or complete, it should be repaired Coleman SR. Structural Fat Grafting. St Louis: Quality Medical; 2004.
intraoperatively. This text is a comprehensive review of the history, basic science, and
technical details of fat harvest and fat injection.
Gosain AK, Amarante MTJ, Hyde JS, et al. A dynamic analysis of
Motor nerve injury changes in the nasolabial fold using magnetic resonance imaging:
implications for facial rejuvenation and facial animation surgery.
■ Damage to a facial nerve branch can easily go unnoticed Plast Reconstr Surg. 1996;98:622.
by the surgeon until muscle paralysis is identified A comparative MRI study demonstrates the changes in subcutaneous
fat that develop with age. The authors conclude that superficial fat in
postoperatively. However, permanent paralysis is a rare
the cheek becomes ptotic, while the underlying elevators of the lip do not
event and has been reported to occur in less than 1% elongate with age.
of cases. Jones BM, Grover R. Avoiding hematoma in cervicofacial rhytidectomy:
■ Persistent dysfunction may be due to surgical traction or a personal 8-year quest. Reviewing 910 patients. Plast Reconstr Surg.
the effect of cautery near a nerve branch; these issues can 2004;113:381.
The authors review a large facelift series where the most common
be expected to resolve spontaneously over days or weeks. complication of facelift surgery, hematoma, is addressed. Variables thought
■ If a facial nerve branch has been transected or wrapped
to influence the formation of hematoma were reviewed, including the use
in a suture, complete functional recovery may still be of dressings, drains, soft tissue adhesives, and epinephrine.
possible if the target muscle receives collateral Marten TJ. Facelift planning and technique. Clin Plast Surg.
This review article covers the planning, surgical marking, and technical
■ The most commonly injured branches are thought to be
details of two-layer facelift surgery. Details regarding the skin incisions
the buccal branches, although long-term sequelae are rare are emphasized.
due to multiple interconnections between nerve branches. Mitz V, Peyronie M. The superficial musculoaponeurotic system
■ Damaged temporal or marginal mandibular branches are (SMAS) in the parotid and cheek area. Plast Reconstr Surg.
less likely to recover because they are terminal branches This paper is the first description of the superficial musculoaponeurotic
with less collateral support. system.
Rohrich RJ, Pessa JE. The fat compartments of the face: anatomy and
Unsatisfactory scars clinical implications for cosmetic surgery. Plast Reconstr Surg.
Anatomic dissections are presented that demonstrate how the
■ Improper placement of incisions can lead to distortion of subcutaneous fat of the face is partitioned into multiple, independent
the ear and unnatural shifting of the hairline. anatomical compartments. In some locations, the septae dividing the fat
■ Excessive tension can lead to loss of hair, depigmentation compartments are aligned with retaining ligaments.
and widened scars, and/or hypertrophic scars. Rohrich RJ, Pessa JE, Ristow B. The youthful cheek and the deep
medial fat compartment. Plast Reconstr Surg. 2008;121(6):2107–2112.
Anatomic dissections of deep facial fat are presented (fat which is deep
Alopecia to the muscles of facial expression). The deep fat is compartmentalized
by septae, creating the deep medial fat pad and the suborbicularis
■ Loss of hair can occur along the incision line or within oculi fat.
Stuzin J. Restoring facial shape in facelifting: the role of skeletal
the hair-bearing scalp, which has been raised as a flap.
support in facial analysis and midface soft-tissue repositioning
■ Permanent hair loss can be treated in some cases by
(Baker Gordon Symposium Cosmetic Series). Plast Reconstr Surg.
mobilization of an adjacent flap of hair-bearing scalp. 2007;119:362.
■ For significant alopecia, achieving adequate coverage This review discusses the changes in facial shape that occur with aging,
with hair growth in the proper direction is best achieved the surgical means we have to correct these changes, and alterations that
should be made with different degrees of underlying skeletal support.
with micro-hair grafting. Stuzin JM. Discussion: essays on the facial nerve: part I. Microanatomy.
Plast Reconstr Surg. 2010;125(3):890–892.
Skin loss 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.
■ Factors that can contribute to the avascular loss of skin
Anatomic dissections confirm the presence of retaining ligaments
include excessive tension, an overly thin flap, hematoma, previously described by other authors as well as newly described
constrictive dressings, and perhaps the most damaging masseteric ligaments. The authors discuss the support these structures
of all – smoking. supply between fixed bone and deep fascia and the superficial fascia.
■ Established skin necrosis should be dealt with Tzafetta K, Terzis J. Essays on the facial nerve: part I. Microanatomy.
Plast Reconstr Surg. 2010;125(3):879–889.
conservatively; the majority of such cases will eventually The authors review facial nerve anatomy and present anatomic findings,
heal spontaneously. Scar revision can be done at a which confirm extensive arborization between facial nerve branches. The
later date. discussion by Stuzin highlights clinically important issues.
Forehead rejuvenation
This chapter was created using content from Neligan & Rubin, Plastic Surgery
4th edition, Volume 2, Aesthetic, Chapter 7, Forehead Rejuvenation, Richard J.
Warren, and Chapter 8, Endoscopic Brow Lifting, Renato Saltz and Alyssa Lolofie.

■ Alteration in components of the orbital frame and/or the
eyelids will affect facial appearance.
■ In the younger patient, rejuvenation of the forehead is
■ Detailed knowledge of forehead anatomy is the basis for rejuvenation
strategies of the forehead region. generally limited to non-surgical alleviation of glabellar
■ Eyebrow position is the net result of forces that depress the brow, frown lines and lateral orbital wrinkles.
■ In older patients, the forehead typically becomes
forces that raise the brow, and the structures that tether the eyebrow in
place. ptotic laterally, while in the orbit, there is a relative
■ Brow depression is caused by glabellar frown muscles, the orbicularis, loss of orbital fat with an accumulation of loose
and gravity. Frontalis is the only effective brow elevator. eyelid skin.
■ Attractiveness of the periorbital region is intimately related to eyebrow ■ Understanding the interplay between these anatomical

shape and eyebrow position as it relates to the upper eyelid and the changes is critical in choosing the appropriate surgical
upper lid sulcus. strategy to rejuvenate the upper third of the face.
■ 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.
■ Key elements of forehead rejuvenation are the attenuation of frown
Anatomical pearls
muscle action and the repositioning of ptotic eyebrow elements. ■ The temporal bone is crossed laterally by a curved ridge,
The lateral eyebrow is often the only portion requiring elevation. called the temporal ridge or temporal crest, and is the
■ Forehead rejuvenation can be accomplished using a combination of
palpable landmark that separates the forehead from the
surgical and non-surgical techniques.
■ If surgical elevation of the brow complex fails early, it is usually due to
temporal fossa (Fig. 3.1).
lack of soft tissue release. If it fails late, it is usually due to failure of
• The significance of this landmark is that all fascial
fixation. layers of the forehead are tethered to bone along a
■ Many methods of soft tissue fixation and bony fixation have been 5-mm-wide band immediately medial to the palpebral
proven effective in maintaining the position of the surgically elevated ridge, called the zone of fixation.
brow. • The inferior zone of fixation as it approaches the
■ Brow aesthetics and surgical options for brow lift and forehead orbital rim is called the orbital ligament.
rejuvenation. • All fascial attachments in this region must be released
■ Forehead and periocular anatomy. from bone when a full-thickness forehead flap is being
■ Ideal candidates for the endoscopic brow lift technique. repositioned.
■ Surgical techniques and key steps for endoscopic brow rejuvenation. ■ The inferior temporal septum is the crisscrossing white
■ Long-term results and complications. fibers that loosely attach the superficial to the deep
temporal fascia (Fig. 3.2).
• It is a useful landmark during endoscopic dissection
Brief introduction from above because it separates the safe upper zone
containing no vital structures from the lower zone
■ The periorbital region is the most expressive part of the where facial nerve branches travel in the cavity’s roof.
human face: the eyes are central, framed above by the • The medial zygomatic temporal vein (sentinel vein) is
eyebrow and below by the cheek. also present in this lower zone, adjacent to the lateral

Anatomical pearls 47

Superior temporal
fusion line

Zone of fixation
(zone of adhesion)

Temporal ridge
(temporal crest)

Figure 3.3  Endoscopic view of the medial zygomaticotemporal vein (sentinel

vein), right side.
Figure 3.1  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
• When the eyebrow is raised by contraction, the soft
along the temporal ridge where all layers are bound down to the periosteum.
tissue is allowed to slide because of the glide plane
space, which is defined by the two deepest layers of
the galea between the galeal fat pad and the skull.
■ Eyebrow level is the result of a balance between the
muscular forces that elevate the brow, the muscular
forces that depress the brow, and gravity.
■ Brow depressors (Fig. 3.5):
• Procerus: located in the glabella, runs vertically,
originates from bone, and inserts into soft tissue.
• Depressor supercilii: in glabella, runs obliquely,
originates from bone, and inserts into soft tissue.
• Transverse corrugator supercilii: largest and most
powerful depressor, runs transversely, originates from
orbital rim at superomedial corner before passing
through galeal fat and interdigitating with orbicularis
and frontalis to insert into skin.
• Orbicularis: encircles the orbit acting like a sphincter;
medial and lateral fibers run vertically and act to
depress the brow, only muscle that depresses brow
position laterally (Fig. 3.6).
■ Frontalis muscle:
• The only elevator of the brow (Fig. 3.7).
• Originates from the galea aponeurotica superiorly
Figure 3.2  Endoscopic view of the inferior temporal septum, right side. and interdigitates inferiorly with the orbicularis.
Contraction raises the orbicularis muscle mass and
thereby lifts the overlying skin, including the
orbital rim. The temporal branches pass immediately eyebrow.
superior to this vein (Fig. 3.3). • Primary effect is on medial and central eyebrow, as
■ In the forehead, the galea aponeurotica splits into a the frontalis is deficient laterally.
superficial and deep layer encompassing the frontalis ■ Sensory nerves (Fig. 3.8):
muscle (Fig. 3.4). • The infratrochlear nerve: exits the orbit medially,
• Inferiorly, the deep galea layer separates further into sensory to the nasal dorsum and medial orbital rim.
three separate layers: one layer immediately deep to • The zygomaticotemporal nerve: exits posterior to the
the frontalis forming the roof of the galeal fat pad, a lateral orbital rim, piercing the deep temporal fascia
second layer forming the floor of the galeal fat pad just inferior to the sentinel vein, often avulsed with
but not adherent to bone, and a third layer adherent complete release of the lateral orbital rim during brow
to periosteum. lifting.
48 3 Forehead rejuvenation

Galeal aponeurosis

Subgaleal space

Superficial galea
Frontalis muscle

Deep galea

Figure 3.6  Lateral orbicularis acts like a sphincter, depressing the lateral brow.
Galeal fat pad

Glide plane space

Corrugator supercilii muscle

Frontalis muscle

Orbital rim Temporal crest line

Orbicularis oculi

Preseptal fat (ROOF)

Suborbital fascia
Orbicularis oculi muscle
Orbital septum

Figure 3.4  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. Figure 3.7  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.
Depressor supercilii Corrugator supercilii

• The supratrochlear nerve: exits the orbit

superomedially, immediately divides into 4–6
branches, which can pass superficial to, or directly
through, the corrugator; sensory to the central
• The supraorbital nerve: exits the superior orbit either
through a notch in the rim (located, on average,
25 mm from midline), or through a foramen superior
to the rim (can be as high as 19 mm above the rim);
after exit, it immediately divides into superficial and
deep segments. The superficial branch pierces the
orbicularis and frontalis and travels superficially to
supply sensation to the central forehead. The deep
branch travels laterally within the periosteum before
Orbicularis oculi Procerus
piercing the frontalis to innervate the rest of the scalp
Figure 3.5  Glabellar frown muscles. (Fig. 3.9).
Anatomical pearls 49

Supratrochlear nerve ■ The temporal branch of the facial nerve is the only
Infratrochlear nerve
motor nerve of concern in forehead rejuvenation
(Fig. 3.10).
• Temporal nerve injury results in brow ptosis and
Superficial branch of
supraorbital nerve asymmetry due to impaired frontalis function.
• 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
Deep branch of
supraorbital nerve branches become more superficial, entering the
superficial temporal fascia (temporoparietal fascia)
and then traveling on to innervate the frontalis,
superior orbicularis, and glabellar muscles.
■ Critical landmarks to predict the location of the temporal

temporal nerve
• The middle third of the palpable zygomatic arch.
• 1.5 cm lateral to the tail of the eyebrow.
• Parallel and adjacent to the inferior temporal
• Immediately superior to the sentinel vein (medial
zygomaticotemporal vein).
Zygomatico- ■ In forehead lift procedures, dissection planes are
facial nerve designed to protect the temporal branches by staying
deep to these areas:
• In the temple – dissection should be directly on the
deep temporal fascia.
• Over the frontal bone – dissection should either be in
Infraorbital nerve
the subgaleal or subperiosteal plane, or superficial to
the frontalis, orbicularis, and the superficial temporal
Figure 3.8  Sensory nerves. fascia.

deep branch

Figure 3.9  The deep branch of the supraorbital nerve travels in a 1-cm-wide band between 5 and 15 mm medial to the temporal ridge.
50 3 Forehead rejuvenation

■ Although the “ideal eyebrow” can vary according to

Preoperative considerations gender, ethnicity, and age, there are certain themes that
define the ideal aesthetic today (Figs. 3.12 and 3.13):
■ Forehead aging is characterized by vertical and • The medial eyebrow level should lie over the medial
transverse frown lines (from repetitive action of the orbital rim.
underlying musculature), crow’s feet, furrowing, and • The medial border of the eyebrow should be vertically
brow ptosis (Fig. 3.11). in line with the medial canthus.
• As the brow complex becomes more ptotic, • The eyebrow should rise gently, peaking slightly at
particularly laterally, it can also cause pseudo-excess least two-thirds of the way to its lateral end; typically
of upper eyelid skin. this peak lies vertically above the lateral limbus.
• Performing blepharoplasty alone in this circumstance, • The lateral tail of the brow should be higher than the
without addressing the brow issues, will result in medial end.
unmasking of the compensated brow ptosis, causing • The male brow should be lower and less peaked.
the medial and central brow to fall and worsening ■ Proper patient selection is critical to obtaining optimal

ptosis. results.
■ Assessment should be done with the patient’s head in

the vertical position.

■ The following issues should be evaluated and noted:

• Visual acuity.
Facial nerve, temporal branch • Eyebrow and orbital symmetry.
• Position of anterior hairline and thickness of
scalp hair.
• Presence and severity of 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.
• Presence of old scars or tattoos.
• Upper eyelid assessment (soft tissue redundancy,
hollowness, ptosis, lid retraction, levator function).
• 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 without frontalis
■ A patient may be a candidate to have their entire brow

complex lifted or, more commonly, to have only part of

Facial nerve, zygomatic branch the eyebrow raised, thus improving eyebrow shape.
■ Weakening or eliminating the glabellar frown muscles is
Figure 3.10  Facial nerve branches in the periorbital region. Note the corrugator
has dual innervation from the temporal branch and the zygomatic branch. The a useful parallel objective, and there are numerous
temporal branch crosses the middle third of the zygomatic arch as 2–4 branches. methods available to accomplish this task.

Vertical frown lines:

Corrugator Oblique frown lines:
Corrugator oblique
Brow ptosis head (variable)
Depressor supercilii
Orbicularis oculi
Crow’s feet:
Orbicularis oculi
Transverse frown lines:

Figure 3.11  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.)
Operative techniques 51



Figure 3.12  The modern ideal brow/upper eyelid complex.

Figure 3.14  Coronal and anterior hairline approaches.


Figure 3.13  Brow aesthetics. (A) The ideal brow position for females lies
above the supraorbital rim with its highest peak vertically in line with the lateral
corneoscleral 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, PA: Saunders Elsevier; 2009.)

Operative techniques
Figure 3.15  Open coronal flap dissection shown in the subgaleal plane.
Open coronal approach (Figs. 3.14–3.16)
■ Long considered the “gold standard” against which
other techniques must be measured with surgical results
that are stable and relatively long lasting.
■ Advantages: unparalleled surgical exposure, which

facilitates release and mobilization of brow soft tissues,

as well as the modification of glabellar muscles under
direct vision.
■ Disadvantages: scalp numbness, which may be

permanent; a long scar; disruption of hair follicles; and

scalp dysesthesia. Also, the anterior hairline will be
raised, and some hair-bearing scalp will be sacrificed
– thus, this technique should be used cautiously or not at
all in patients with a high anterior hairline, with thin
hair, or in patients who may eventually lose their hair.
■ The technique involves an incision over the top of the

head that is made full thickness down to periosteum. Figure 3.16  Coronal approach showing corrugator muscles.
52 3 Forehead rejuvenation

• The classic incision is made about 6–8 cm behind the Fibers of frontalis muscle
anterior hairline (Fig. 3.14).
• An anterior hairline incision involves less scalp
dissection, better visibility, and a closer point of
traction on the eyebrows and should be used in
patients with a high anterior hairline, thin hair,
or in patients who may eventually lose their hair
(Figs. 3.14–3.16).
■ After incision, 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. 3.15).
• The frown muscles, corrugator, depressor supercilii,
and procerus can be removed or weakened as Figure 3.17  Limited hairline subcutaneous approach.
necessary (see Fig. 3.16).
• 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.
■ 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
■ To reposition the brows, the flap is drawn
superolaterally, and a full-thickness strip of scalp is
■ 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 Figure 3.18  Anterior hairline incision to lower the anterior hairline.
open coronal lift relies on scalp excision alone to
maintain brow position.
origin, and risk for skin compromise with a
Anterior hairline approach subcutaneous dissection.
■ This approach can also be used to lower an excessively

■ Similar to the coronal approach above, but using an high anterior hairline or to lower overly high eyebrows.
incision that is placed along the anterior hairline, until it • Hairline lowering involves a posterior dissection past
reaches the hairline laterally, where it transitions into the the vertex of the skull in order to extensively mobilize
hair-bearing temporal scalp (Fig. 3.14). the scalp. Releasing incisions are made in the galea,
• Alternatively, the incision can follow the hairline over and the scalp is advanced, utilizing bony fixation
its entire extent. to maintain the new hairline position (Figs. 3.18
• Another popular modification of this method is a and 3.19).
short incision in the widow’s peak, which is used to
target only the lateral brow (Fig. 3.17). Endoscopic approach
■ Dissection of the forehead flap from the anterior hairline

incision can be elevated in three different planes: ■ Involves the same amount of dissection and soft tissue
subperiosteal, subgaleal, and subcutaneous. release as the open coronal approach, but with much
■ Advantages: excellent surgical exposure without smaller access incisions and with visibility provided by
the disadvantage of moving the anterior hairline an endoscope.
posteriorly, the option of subcutaneous dissection ■ Basic anatomic principles are integral to the theory of

plane because there is no undermining of hair endoscopic brow lifting:

follicles. • Laterally, brow lifting is accomplished by releasing
■ Disadvantages: presence of a permanent scar along the all periorbital galeal attachments and relying on
anterior hairline, potential for worse scalp denervation mechanical fixation, not scalp excision, to maintain
because sensory nerves are transected closer to their the scalp in a higher position.
Operative techniques 53

Figure 3.19  Hairline lowering.

Temporal pocket – against deep temporal fascia

Frontal pocket – subperiosteal

Figure 3.21  Preoperative markings. The course of the sensory and motor nerves
to the brow are marked. In addition, the desired vector of brow elevation is also
mapped. The paramedian incisions should be in line with the desired pull of the
lateral brow peak. (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.)

• Paramedian incisions are marked as 1-cm vertical

lines posterior to the hairline along a vector from the
mid-pupil superiorly.
• The zone of fixation should be identified and marked.
• The location of the supratrochlear and supraorbital
nerves are identified and marked, as is the location of
Figure 3.20  Five-port endoscopic approach.
the deep branch of the supraorbital nerve (~1 cm
medial to the zone of fixation) to avoid injury.
• Medially, brow lifting happens passively by removing ■ Medial to the zone of fixation: dissection plane can be
muscular depressors and allowing the frontalis to lift subgaleal or the more popular subperiosteal approach.
unopposed. • Flap dissection can be done blindly at first but is
■ Advantages: very good surgical exposure, magnification completed under endoscopic control when
of the surgeon’s view, less risk of scalp denervation approaching the orbital rim in order to avoid
compared to open coronal approach, and short, damaging the supraorbital nerve.
undetectable incisions (Fig. 3.20). ■ Lateral to the zone of fixation: dissection plane is on top
■ Disadvantages: technical demands of using endoscopic of the deep temporal fascia, with the inferior temporal
equipment, the potential of overly elevating or septum and the sentinel vein used as landmarks for
separating the medial eyebrows, and some uncertainty the position of the overlying temporal nerve order to
about maintaining adequate fixation. avoid injury.
■ Preoperative markings and access incisions: three to five ■ The medial and lateral dissection pockets are then joined
small (1–2 cm) incisions are placed within the by dividing the soft tissue over the temporal crest from
hair-bearing scalp (Fig. 3.21). lateral to medial (Fig. 3.22).
• A 2-cm curved incision is marked 2 cm behind the ■ At this point, a 4-mL 30° scope is introduced to continue
temporal hairline and centered over superolateral the dissection.
vector lines from the nasal ala crossing the lateral • The sentinel veins are identified and preserved
canthus. (Fig. 3.23).
54 3 Forehead rejuvenation

Zone of fixation

Supraorbital nerve


Inferior temporal

Sentinel vein

Figure 3.22  Release of the temporal zone of fixation. Periosteal dissectors are used 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. (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.)

• The “fusion ligament” is identified and divided using

endoscopic scissors.
• Soft tissue attachments along the lateral orbital
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
the lateral canthus in order to allow lateral brow
• The dissection continues medially, where the
supraorbital nerve is identified and preserved.
• The corrugator muscles are identified and completely
excised, or avulsed with biting forceps. Care should
be made to visualize and protect the supratrochlear
nerves as they pass through the substance of the
muscle. Also, the periosteal attachments between the
corrugator muscles should be left intact, as this will
Figure 3.23  Sentinel vein. The sentinel vein is encountered during endoscopic minimize over-elevation of the medial brow and a
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. “surprised look” (Fig. 3.24). Likewise, this will
(Reproduced from Saltz R, Codner M. Endoscopic brow lift. In: Nahai FR, Nahai F, prevent separation of the eyebrows.
Codner M (eds). Techniques in Aesthetic Plastic Surgery: Minimally Invasive Facial ■ Manual palpation and gentle pressure over the skin

Rejuvenation. Philadelphia, PA: Saunders Elsevier; 2009.) avoids trauma to the dermis and possible indentations
during endoscopic corrugator resection.
• In case of very thin skin and possible indentation,
immediate placement of fat grafts with suture fixation
Operative techniques 55

Depressor Corrugator Corrugator

Procerus supercilii muscle, muscle,
muscle muscle oblique head transverse head

Orbital rim Trochlear nerve branch

Figure 3.24  Endoscopic view of corrugator. The corrugators may be resected

endoscopically with grasping forceps, taking care not to injure the supraorbital or A
supratrochlear nerves. (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.)

will reduce the risk for postoperative contour

■ Once dissected, the forehead flap is drawn superiorly

and somewhat laterally. Specific vectors have been

described in this regard, but the surgeon can make an
artistic decision during preoperative planning, with B
appropriate vectors customized for each individual
patient. Figure 3.25  Endotine fixation. (A) The Endotine divot hole is drilled through
• Three methods of fixation have been described: no the first layer of calvarial bone and situated at the caudal extent of the incision.
fixation, suture fixation in the lateral dissection pocket The Endotine is snapped into place. (B) The scalp can then be repositioned
from the superficial to the deep temporal fascia, and/ vertically and held in place by fixation tines. (Reproduced from Saltz R, Codner
or bony fixation in the paramedian dissection via M. Endoscopic brow lift. In: Nahai FR, Nahai F, Codner M (eds). Techniques in
cortical tunnels, cortical screws, or the Endotine Aesthetic Plastic Surgery: Minimally Invasive Facial. Philadelphia, PA: Saunders
Elsevier; 2009.)
■ After fixation and intraoperative confirmation of brow

symmetry, the skin is closed.

• The central portion of the inferior scalp flap may be
excised in triangular wedges in order to prevent
redundancy at the lateral brow (Fig. 3.25).

Temple approach
■ Involves a full-thickness scalp incision in the temple,
lateral to the temporal crest line.
• Knize improved and popularized this approach with
dissection on the deep temporal fascia, releasing of
the lateral orbital rim, the supraorbital rim, and the
zone of fixation with using an endoscope (Fig. 3.26).
■ Advantages: limited skin incisions, less risk for scalp

denervation that open coronal approach.

■ Disadvantages: limited visibility of the central and

medial supraorbital rim, an oblique vector applied to the

lateral brow.
■ After flap mobilization, fixation is done with sutures

between the superficial and deep temporal fascia.

■ If surgical modification of glabellar frown muscle

modification is desired, a transpalpebral approach can

be used. Figure 3.26  Temple approach.
56 3 Forehead rejuvenation

Transpalpebral approach – muscle ■ The above procedure can be combined with a

modification transpalpebral browpexy using the same blepharoplasty
incision to address the ptotic lateral brow.
■ Using the upper lid blepharoplasty approach, the • The lateral portion of the superior orbital rim is easily
glabellar frown muscles can be approached directly. exposed, and dissection proceeds superiorly over the
■ Advantages: hidden incision that can be used for two frontal bone, superficial to the periosteum.
purposes: blepharoplasty and frown muscle ablation, • Dissection should continue for 2–4 cm above the
excellent method to attenuate glabellar frown lines in orbital rim, or at least 1 cm above the level of planned
patients who do not require a forehead lift; can also be fixation.
used as an adjunct to the patient undergoing an isolated • Several sutures are then used to tether the mobilized
elevation of the lateral third of the brow (temple lift). brow in a more superior position, fixating the
■ Disadvantages: potential damage to sensory nerves underside of the orbicularis to the periosteum.
(supraorbital and supratrochlear) and increased bruising • Overly tight sutures must be avoided because of
and edema compared to an isolated upper lid suture dimpling in the eyebrow.
blepharoplasty (Fig. 3.27). • A more modest pexy is achieved if the cut edge of
■ After access through an upper blepharoplasty incision, orbicularis oculi is simply sutured to the orbital rim,
dissection proceeds superiorly deep to the orbicularis with no superior dissection at all.
oculi, but superficial to the orbital septum. • Advantages of transpalpebral browpexy: ease of the
■ Over the supraorbital rim, the transverse running fibers procedure and a hidden scar.
of the corrugator supercilii will be found. • Disadvantage: limited effect achieved and
• The muscle becomes more superficial as it courses questionable longevity.
laterally through the galeal fat pad, eventually
combining with the orbicularis oculi and the lower Lateral brow approach
■ Once visualized, the muscle can be removed, although ■ Similar to temple approach, but utilizes a more medial
care must be taken to protect supratrochlear nerve incision.
branches, which travel through the substance of the • The incision location is based on the observation that
muscle or around its inferior border. the most effective vector for elevating the lateral half
■ Medially in the wound, portions of the depressor of the eyebrow is directly along the temporal crest
supercilii (seen coursing almost vertically) and line (Fig. 3.28).
orbicularis oculi (seen coursing obliquely) can be ■ Advantages: limited incisions, more direct approach to

removed. the most ptotic portion of the aging brow or congenitally

■ The procerus can be transected by dissecting across the downturned brow, an endoscope can be utilized, and
root of the nose. similar strength of fixation provided by a coronal lift.




Supratrochlear Figure 3.28  Preoperative marking for modified lateral brow lift. The planned
nerve branches 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.
nerve branches
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,
Figure 3.27  Transpalpebral exposure of the frown musculature. depressor supercilii, and procerus are marked in black.
Operative techniques 57

Figure 3.29  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.

■ Disadvantages: longer incision compared with the pure Figure 3.30  A 74-year-old man shown (A) before and (B) 8 months following
endoscopic approach. a direct brow lift with excision of full-thickness skin in a transverse brow crease.
■ Access is through a 5- to 6-cm incision in the scalp, In addition, the upper orbicularis had been sutured onto the frontalis muscle in a
approximately 1 cm behind the hairline. more superior position.
• 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.
• A full-thickness excision of scalp is done (like an open
coronal lift), but nerve branches are preserved as a ■ Good candidates: older men with deep forehead creases
neurovascular bundle. or thick eyebrows, patients with facial palsy and
■ Orbital rim release can be done with or without an significant brow (Fig. 3.30).
■ Fixation is accomplished with deep temporal sutures and
Suture suspension brow pexy
by direct galeal closure; bony fixation can also be added
(Fig. 3.29). ■ A number of methods have been developed to elevate
the brow only using sutures, with no dissection at all,
Direct suprabrow approach including barbed sutures, or suture loops, that are placed
blindly through subcutaneous tunnels.
■ Direct brow excision is a simple technique that was ■ Advantages: extreme simplicity, relative safety, limited

described almost a century ago. scarring.

■ Advantages: easy, well tolerated by the patient, no scalp ■ Disadvantages: limited effect achieved, limited longevity

denervation, no risk to motor nerves, relatively of results.

predictable results.
■ Disadvantages: potentially visible scar along the brow,
Postoperative considerations
potential for early relapse (up to 50%) in the first few
months following the procedure, eventual recurrence of ■ Postoperative care for minor brow procedures is limited
brow ptosis as the brow depressing forces will stretch to head elevation, cold packs, ointment application, and
out the skin again. analgesics.
• In cases of recurrent brow ptosis, the procedure can ■ More extensive procedures (e.g., open coronal lift,

easily be repeated again if necessary. endoscopic lift) will require dressings and the possibility
■ An excision of full-thickness skin is done along the of drains for 24 h.
upper margin of the eyebrow or, alternatively, within a ■ Supraorbital and supratrochlear nerve blocks with

deep forehead crease. bupivacaine are helpful in decreasing the incidence of

• On closure, there is initially a 1:1 relationship postoperative headache.
between the amount of skin removed and brow ■ Patients can shower after 48 h.

elevation. ■ Scalp sutures are usually removed in 7–10 days.

• The closer the incision is to the eyebrow, the less will ■ After initial healing, the following measures may help

be the relapse. prevent relapse of lateral brow ptosis: use of botulinum

58 3 Forehead rejuvenation

toxin in the lateral orbicularis, and use of sunglasses ■ Localized alopecia: result of hair follicle damage by
and sun avoidance to prevent squinting in the first incisions, electrocautery, or tension.
postoperative month. • Hair loss may be temporary, but if permanent, can be
treated with scar excision or hair grafting.
Complications and outcomes ■ Hematoma: uncommon and will usually resolve if they

are small; however, a significant hematoma should be

■ The surgical result of forehead rejuvenation depends on treated with surgical drainage.
the type of deformity, the procedure done, and the ■ Infection: rare (reportedly < 1%), treated with wound

quality of its execution, with lesser procedures generally care and appropriate antibiotics.
producing lesser results. ■ Contour deformities: can occur in areas of muscle

■ More involved procedures afford the opportunity for excision.

greater anatomic intervention, more dramatic results, • If identified early/intraoperatively, they can be
and potentially greater longevity. prevented by the intraoperative use of filling material
■ As our understanding of the aging brow has progressed, such as fat or temporal fascia.
it is clear that brow shape is aesthetically more • If identified late, similar tissue can be added at a
important than the actual height of the eyebrow. separate procedure.
Therefore, the aesthetic outcome of surgery will ■ Sensory nerve damage: common, especially with longer

depend on what portion of the brow is being raised incisions, e.g., coronal approach.
(Fig. 3.31). • Initially, the resulting scalp denervation can be
• Unfortunately, an overly elevated medial brow will profound and extend to the vertex, but will gradually
create a chronically surprised look, while an overly recover, often continuing to improve over many years.
elevated lateral brow will create an angry look – both • With limited incisions, such as endoscopic ports or
of which are difficult situations to correct. lateral brow lifts, sensory change is less of an issue,
■ The patient who is a candidate for brow lift surgery may but sensory nerves may still be traumatized due to
also benefit from simultaneous procedures such as traction, cautery, or instrumentation.
blepharoplasty, periorbital fat grafting, or eyelid ptosis • The expectation is that normal sensation will likely
repair (Fig. 3.32). return over time.
• The key step in determining the correct combination • With frown muscle ablation, temporary neurapraxia is
of surgical procedures is to make the correct aesthetic normal, with sensory return typically appearing by
diagnosis at the outset. 2–3 weeks.
■ Surgical complications following brow lift can include

aesthetic concerns, scar alopecia, hematoma, infection,

contour abnormalities, and nerve damage.

B Figure 3.32  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
Figure 3.31  Young woman with congenitally downturned lateral eyebrows. She is (B) 12 months after a right-sided endoscopic brow lift, bilateral upper sulcus fat
shown (A) before and (B) 6 months after a modified lateral brow lift. grafting, and excisional upper eyelid blepharoplasty.
Operative techniques 59

Figure 3.34  Over-elevated medial brow after endoscopic brow lift.

Figure 3.33  Temporary neurapraxia of left temporal branch after coronal brow lift.

■ When overly aggressive brow lift surgery has been done,

■ Temporal nerve damage: the most worrisome local the most frequent result is over-elevation of the medial
complication in brow lift surgery. brow (Fig. 3.34).
• Temporary neurapraxias are relatively common, while • If it is minimal, botulinum toxin injection in the
permanent damage is rare. central frontalis will help attenuate the problem.
• Should a neurapraxia develop, watchful waiting is a • If pronounced, the medial brow can be surgically
must (Fig. 3.33). lowered, which requires a full release of the scalp’s
• If the palsy does not improve with time, treatment attachment to the underlying skull, lowering of
options include use of botulinum toxin to the frontalis the medial brow, and bone anchoring to the
on the NORMAL side, or alternatively, repeat brow orbital rim.
lift on the affected side. • Successful reversal of an overdone brow lift is
typically more difficult to achieve than the original
Secondary procedures brow lift itself.
■ Another common variation of unfavorable brow shape

■ The most common reason for revision surgery after brow occurs when the medial brow has been appropriately
surgery is to correct aesthetic deformities. elevated, but the lateral brow remains unelevated,
• Recurrent ptosis, if significant, can often be treated causing a laterally downturned appearance.
with repeat brow lift, preferably using a different • This abnormality can be treated with an isolated
dissection plane and method of fixation. lateral brow lift.
This chapter was created using content from Neligan & Rubin, Plastic Surgery 4th
edition, Volume 2, Aesthetic, Chapter 16, Open technique rhinoplasty, Rod J. Rohrich
and Jamil Ahmad/Chapter 17, Closed technique rhinoplasty, Mark B. Constantian.

airflow and physiology are the foundations for

SYNOPSIS successful aesthetic and functional rhinoplasty.

■ Proponents of open rhinoplasty argue that closed rhinoplasty
Open rhino is difficult because the surgeon does not have good binocular
■ Accurate preoperative analysis and clinical diagnosis set the foundation
vision through small incisions, the dissection is blind, the
for successful primary open rhinoplasty. anatomy is complex, and the operation is technically difficult.
■ Open rhinoplasty allows anatomic exposure, identification, and

■ Proponents of endonasal or closed rhinoplasty
correction of nasal deformities. techniques point to two common considerations:
■ Component dorsal hump reduction allows accurate and incremental
• First, by separating columellar skin from the medial
reduction of the nasal dorsum while preventing problems with internal
crura, the surgeon loses an important component of
valve collapse or dorsal irregularities.
■ Nasal tip suturing techniques allow control of definition without
tip stability and projection, which therefore requires
some method (suture fixation or columellar strut) to
damaging the osseocartilaginous framework and compromising
support. support the medial crura so that a new nasal tip can
■ Knowledge of the normal course of recovery and potential be made. The strut can impart rigidity to the
complications is key to managing patient expectations in the columella and increases graft requirements.
postoperative period. • In primary patients, this consideration may be
unimportant, but in secondary patients whose donor
Closed rhino
sites are already depleted, every bit of graft material
■ Nature is predictable – therefore, nasal phenomenology can be
■ Rhinoplasty has consistent “behavioral” rules, like all surgery –
• Though incisions are limited, endonasal rhinoplasty is
not a blind operation. Most procedures are performed
therefore, the surgeon can control the result.
■ Nasal deformities are not limitless or lawless but follow patterns –
under direct vision with greater access than
therefore, their solutions follow patterns. endoscopic surgery permits.
■ Sequential intraoperative photography teaches nasal behavior and • The operative strategy, making skeletal changes
structural interactions. through limited incisions and judging progress by
■ Follow the technical rules that apply to all other surgery: limit feeling the surface, is precisely the same discipline
dissection, morbidity, and tension on closure. required by suction-assisted lipectomy.
■ Reconstruct anatomically. • Limited pocket dissection minimizes the need for
■ Never forget function. graft fixation and simplifies some procedures.
■ Never forget the patient’s own aesthetic. • Solid or crushed grafts can be used in ways that
■ Remember that most problems are under the surgeon’s control. would be tedious or impossible by the open approach,
■ Always follow your patients closely. although some solutions have been described.

■ In rhinoplasty, there are four common anatomic variants
that predispose to unfavorable results:
Brief introduction
■ Low radix or low dorsum:
• Low radix or low dorsum begins caudal to the level
■ Regardless of your preferred technique, a thorough of the upper lash margin with the patient’s eyes in
knowledge of nasal anatomy and understanding of nasal primary gaze.

Preoperative considerations 61

• The low radix is one of several primary causes of ■ For many years, the following concepts provided the
nasal imbalance: an upper nose that seems too small basis for analysis of the obstructed nose:
for its lower nasal component. • The bony and cartilaginous septal partition, deformed
• When the radix begins lower than the upper lash by congenital or traumatic causes, may obstruct the
margin, dorsal length is therefore shorter, and so nasal nasal airway.
base size appears larger. • Compensatory hypertrophy of the contralateral
• If the surgeon reduces the nasal dorsum, the patient’s inferior turbinate frequently occurs so that both
preoperative skeletal and skin sleeve maldistribution airways eventually become obstructed.
will worsen, and the lower nose will appear even ■ These concepts are more understandable if the reader

larger. considers airway size to be the product of at least four

• The surgeon should instead either limit tip reduction factors: (1) mucosal sensitivity to the environment or
or raise the dorsum segmentally or entirely to balance hereditary factors, (2) inferior turbinate hypertrophy
the nasal base. from many causes, (3) septal deviation, and (4) position
■ A narrow middle vault: and stability of the lateral nasal wall during the dynamic
• Arbitrarily defined as any upper cartilaginous vault process of ventilation.
that is at least 25% narrower than the upper or lower
nasal third. This variant is a trait that places the
patient at special risk for internal valvular obstruction, Preoperative considerations
which can exist preoperatively or may be produced
by dorsal resection. ■ Obtain information on the patient’s medical and
• Inadequate tip projection is defined as any tip that emotional suitability to undergo rhinoplasty.
does not project to the level of the anterior septal ■ Feelings of inadequacy, immaturity, family conflicts,

angle. divorce, and other major life changes may be unhealthy

• Alar cartilages sufficiently strong to support the motivating factors behind the patient seeking aesthetic
tip to the level of the septal angle are “adequately surgery.
projecting”; alar cartilages too weak to do so are ■ Poor postoperative patient satisfaction is often based

“inadequately projecting”. on emotional dissatisfaction as opposed to technical

• The practical value of this definition lies in its ability failure, and this can be avoided by the preoperative
to define treatment: adequately projecting tips do not identification of these unhealthy motivating factors.
need increased support, whereas inadequately ■ Review past medical history and specifically note a

projecting tips do. history of allergic disorders, including hay fever, asthma,
• “Alar cartilage malposition” describes cephalically and other problems, including vasomotor rhinitis and
rotated lateral crura whose long axes run on an sinusitis. These conditions should be controlled prior to
axis toward the medial canthi instead of toward rhinoplasty; however, patients should be informed that
the lateral canthi, the position of orthotopic lateral they may be exacerbated in the postoperative period and
crura. can persist for weeks to months.
• This anatomic variation was first recognized by Sheen ■ Nasal obstruction is usually found in patients with a

as an aesthetic deformity that produced a round or long history of allergic rhinitis secondary to inferior
boxy tip lobule with characteristic “parentheses” on turbinate hypertrophy. Engorgement of the inferior
frontal view. turbinates causes these symptoms to be worse at night.
• Malposition also has two additional ramifications that Patients may also complain of headache because of the
are not aesthetic: inadequacy of the inferior turbinate to warm inspired air.
• First, the abnormal cephalic position of the lateral ■ Prior nasal trauma and surgeries, including rhinoplasty,

crura places them at special risk if an septal reconstruction/septoplasty, and sinus surgery,
intercartilaginous incision is made at its normal should be noted.
intranasal location. ■ Smoking, alcohol consumption, and use of illicit drugs,

• Second, most malpositioned lateral crura do not in particular cocaine, can compromise outcomes.
provide adequate external valvular support, and so Medications including acetylsalicylic acid, nonsteroidal
malposition is not only associated with boxy or ball anti-inflammatory drugs, fish oil, and certain herbal
tips but also the leading cause of external valvular supplements may cause increased risk of bleeding and
incompetence. postoperative ecchymosis.
• None of these four anatomical variants (low radix ■ Anatomic examination includes both external nasal

or low dorsum, narrow middle vault, inadequate analysis (Table 4.1) and internal nasal examination
tip projection, and alar cartilage malposition) (Table 4.2). In addition, facial analysis plays a key role in
always require treatment, but they do supply achieving facial harmony after rhinoplasty.
cautionary notes. ■ Standardized photography is obtained for every patient

• The most common grouping in both primary presenting for rhinoplasty and includes frontal, lateral,
and secondary patients was the triad of low oblique, and basal views of the patient.
radix, narrow middle vault, and inadequate tip ■ It is useful to review photographs with the patient to

projection. identify areas of concern that can be addressed with

• The second most common grouping was the surgery and deformities that may persist after surgery,
association of all four anatomic traits. including notches, grooves, and irregularities. Facial
62 4 Rhinoplasty

Table 4.1  External nasal analysis disproportions and asymmetries should be pointed out
to the patient as these may require orthognathic surgery
Frontal view to address.
Facial proportions
■ Identifying the patient’s expectations preoperatively is a
Skin type/quality Fitzpatrick type, thin or thick, sebaceous
key component to postoperative patient satisfaction and
successful rhinoplasty.
Symmetry and nasal Midline, C-, reverse C-, S- or S-shaped
■ Common concerns include asymmetry, tip deformities,
deviation deviation dorsum irregularities, and nasal airway obstruction.
Bony vault Narrow or wide, asymmetrical, short or
■ The patient should attempt to rank these concerns in
long nasal bones order of importance.
Midvault Narrow or wide, collapse, inverted-V
■ A patient who focuses on minor or uncorrectable
deformity problems or who has unrealistic expectations despite
extensive discussion will likely be disappointed
Dorsal aesthetic lines Straight, symmetrical or asymmetrical,
following surgery regardless of the aesthetic
well- or ill-defined, narrow or wide
improvement; it is better to avoid operating on these
Nasal tip Ideal/bulbous/boxy/pinched, supratip, patients.
tip-defining points, infratip lobule
■ In general, the ideal candidate for surgery has legitimate
Alar rims Gull-shaped, facets, notching, retraction concerns and realistic expectations and is secure and
well-informed and understands the limitations of
Alar base Width
Upper lip Long or short, dynamic depressor septi
■ The acronym SYLVIA has been used to describe the ideal
muscles, upper lip crease patient: secure, young, listens, verbal, intelligent, and
Lateral view attractive.

■ The poor candidate for surgery has excessive concerns
Nasofrontal angle Acute or obtuse, high or low radix
about minimal deformities and unrealistic expectations,
Nasal length Long or short and is insecure, poorly informed, and fails to recognize
Dorsum Smooth, hump, scooped out the limitations of surgery. These patients are likely
to be unsatisfied following surgery regardless of the
Supratip Break, fullness, poly beak
aesthetic improvement. They should be approached
Tip projection Over- or underprojected with caution and, in most cases, should not be
Tip rotation Over- or underrotated operated on.

■ The acronym SIMON has been used to describe this
Alar–columellar Hanging or retracted alae, hanging or patient: single, immature, male, overly expectant, and
relationship retracted columella
has narcissistic traits.
Periapical hypoplasia Maxillary or soft tissue deficiency
■ Proper identification of causative factors of nasal airway
Lip–chin relationship Normal, deficient obstruction is key to successful treatment. Nasal airway
obstruction can have both medically and surgically
Basal view correctable causes.
Nasal projection Over- or underprojected, columellar–
■ Common surgically correctable causes include nasoseptal
lobular ratio deviation, internal or external valve dysfunction, and
Nostril Symmetrical or asymmetrical, long or inferior turbinate hypertrophy.
■ Primary and secondary rhinoplasty patients differ in
three characteristic ways.
Columella Septal tilt, flaring of medial crura
• First, the secondary patient’s scarred, contracted soft
Alar base Width tissues will not tolerate aggressive dissection, multiple
Alar flaring incisions, or tight dressings.
• Second, graft donor sites may have already been
harvested, necessitating the use of more difficult
(distorted septum or concha), painful (costal), or
frightening (calvarial) donor sources.
• Third, the secondary rhinoplasty patient’s morale is
often more fragile. Having already invested money,
Table 4.2  Internal nasal exam time, discomfort, and emotion in one or more
unsuccessful procedures, what secondary rhinoplasty
External valve Collapse patients fear most and need least are additional
Internal valve Narrowing, collapse disappointments.

■ For secondary rhinoplasty patients, the surgeon
Mucosa Edema, irritation
should be careful to construct a plan that is based
Inferior turbinates Hypertrophy on a clear understanding of what is possible and
Septum Deviation, tilt, spurs, perforation, cartilage founded on sound surgical and biologic principles
that maximize the airway and respect the patient’s
Masses Polyps, tumors
aesthetic goals.
Anatomical pearls 63

■ Before agreeing to operate on a patient, the surgeon ■ The inner layer contains everything else (the bony and
must be able to answer each of the following questions upper cartilaginous vaults, the nasal septum, and their
affirmatively: associated linings).
• Can I see the deformity? This question eliminates ■ This two-layer concept associates those structures that

delusional patients or those with minimal defects that behave together anatomically and functionally, and
may not be surgically correctable. provides an explanation for the “global” manifestations
• Can I personally fix it? This criterion will vary from of some surgical changes (e.g., the effect of dorsal
surgeon to surgeon and must be based on operative reduction or augmentation on nasal length).
experience and ease in correcting specific problems. ■ The internal nasal valve is formed by the articulation of

• Can I manage the patient? A patient who is the caudal and anterior (or dorsal) edges of the upper
unacceptably nervous, impossible to examine, or lateral cartilages with the anterior septal edge (Fig. 4.2).
unwilling to comply with preoperative and
postoperative instructions is a poor candidate, even if
all other conditions are met.
• If there is a complication, will the patient remain controlled
and cooperate with treatment? No patient enjoys a
complication, but there are those who, although
disappointed, quietly understand and will await the
proper time for revision. There are others who become
hysterical, angry, disruptive, or accusatory and want
an immediate correction.
• Does the patient accept the margin of error inherent in
surgery? This is the most important criterion. The
patient’s willingness to accept the imperfection that is
inherent in surgery is a willingness to accept the
imperfection that is inherent in being human.

Anatomical pearls
■ It is helpful to conceptualize the nose as a system of two
interrelated layers (Fig. 4.1). $ %
■ The outer layer, like a soft, elastic sleeve, slides over the
Figure 4.1  The structural layers of the nose, which separate those anatomical
inner semirigid layer and contains the entire investing units that move together. The investing soft tissues and alar cartilages (A) glide
nasal soft tissues plus the alar cartilages and their over the inner, fixed, semirigid layer, which contains the bony vault, the upper
associated lining. cartilaginous vault, and the nasal septum (B).

Internal valve

External valve

Figure 4.2  The nasal valves. The internal valves are formed by the articulation of the upper lateral cartilages with the anterior (dorsal) septal edge; the external valves are
formed by the alar cartilage lateral crura and their associated investing soft tissue cover.
64 4 Rhinoplasty

■ The external nasal valve is composed of the cutaneous Table 4.3  Classification of nasal deviations
and skeletal support of the mobile alar wall (the alar
cartilage lateral crura with their associated external and I. Caudal septal deviation
a. Straight septal tilt
vestibular skin coverings).
b. Concave deformity (C-shaped)
c. S-shaped deformity
Upper cartilaginous vaults II. Concave dorsal deformity
a. C-shaped dorsal deformity
■ The width and stability of the upper cartilaginous vault b. Reverse C-shaped dorsal deformity
(formed by the upper lateral cartilages and the anterior III. Concave/convex dorsal deformity (S-shaped)
septal edge), the critical area of the internal nasal valves,
depend not only on the width of the bony vault but also
on the height and width of the middle vault roof. ■ Septal tilt is the most common type where the
■ Resection of the middle vault roof during hump quadrangular cartilage and perpendicular plate of the
reduction removes this most critical anterior stabilizing ethmoid are straight, but the quadrangular cartilage is
force on the upper lateral cartilages, which will fall tilted to one side internally and to the opposite side
medially and produce a characteristic “inverted-V” externally. Hypertrophy of the inferior turbinate
deformity and consequent narrowing at the internal contralateral to the side of internal deviation is usually
valves. present.
■ Middle vault collapse virtually always occurs when the ■ The turbinates exist as three or four bilateral extensions

cartilaginous roof has been resected, whether or not from the lateral nasal cavity.
osteotomy has been performed, but may not be visible if ■ The inferior turbinate consists of highly vascular

the overlying soft tissues are sufficiently thick. mucoperiosteum covering a thin semicircular conchal
■ To avoid middle vault collapse and internal valvular bone and is involved in regulation of filtration and
incompetence, the surgeon should plan to reconstruct the humidification of inspired air.
normal distracting forces by a substantial dorsal graft or ■ In combination with the internal nasal valve, the anterior

by spreader grafts, which provide the same degree of extent of the inferior turbinate can be responsible for up
functional mean nasal airflow improvement (see below). to two-thirds of the upper-airway resistance.
■ Inferior turbinoplasty is performed in patients with nasal

Middle and lower cartilaginous vaults airway obstruction secondary to inferior turbinate
hypertrophy refractory to medical management.
■ The upper lateral cartilages are supported caudally by ■ Overly aggressive surgical management may be

their relationship to the cephalic margins of the lateral complicated by bleeding, mucosal crusting and
crura in the region of the so-called “scroll”. desiccation, ciliary dysfunction, chronic infection,
■ Radical alar cartilage resection can compromise middle malodorous nasal drainage, or atrophic rhinitis.
vault support and may leave an external deformity ■ In most cases, inferior turbinoplasty with outfracture of

typified by deepening and lengthening of the alar the inferior turbinate or submucous resection is adequate
creases. to achieve significant improvement (Fig. 4.3).
■ Resect the upper lateral cartilages submucosally only ■ In cases of severe inferior turbinate hypertrophy,

when failure to do so would allow them to prolapse into submucous resection of the inferior turbinate is
the airway or when necessary to shorten the nose. indicated.
■ The point of intersection of the upper and lower lateral ■ Autologous grafts are preferential to homografts

cartilages creates the “watershed” area between the and alloplastic implants because of their high
internal and external nasal valves, and aggressive biocompatibility and low risk of infection and extrusion.
surgery in this area also affects external valvular ■ Disadvantages include donor site morbidity, graft

competence, particularly in patients whose alar cartilage resorption, and unavailability of sufficient quantities of
lateral crura are cephalically rotated. graft material.
■ Grafts are most commonly obtained from septal, ear, and

Dorsum and tip costal cartilage. Other sites include calvarial, nasal bone,
and the olecranon process of the ulna.
■ Tip projection, that is, the intrinsic ability of the alar ■ Concerns regarding donor site morbidity, graft

cartilages to support the tip lobule independent of dorsal availability, and graft resorption will necessitate the use
height, depends on alar cartilage middle crural size, of homologous or alloplastic implants.
shape, and substance. ■ Septal cartilage is the primary choice for autogenous

■ Septal deviation can involve deviation of the septal grafts in rhinoplasty. It can be used in all areas including
cartilage, perpendicular plate of the ethmoid bone, or tip grafts, dorsal onlay grafts, columellar strut grafts, and
vomer away from the midline and can cause obstruction nasal spreader grafts. It is easily harvested, leaves
of one or both of the nasal airways, along with external minimal donor site morbidity, and is available in the
deviation of the nose. operative field.
■ Nasal deviations can generally be classified into three ■ The ear can provide a significant amount of cartilage

basic types: (1) caudal septal deviations, (2) concave for rhinoplasty when septal cartilage has been depleted.
dorsal deformities, and (3) concave/convex dorsal It can be used for tip grafts, dorsal onlay grafts, alar
deformities (Table 4.3). contour grafts, and reconstruction of the lower lateral
Anatomical pearls 65

Table 4.4  Tip-suturing techniques

Medial crural suture
Interdomal suture
Transdomal suture
Joined transdomal suture
Intercrural septal suture
Lateral crural mattress suture

■ The straightest, smoothest cartilage graft is used for the

nasal dorsum to reconstruct this dominant area covered
by thin soft tissues.
■ If septum is available, it is used. Failing that, use rib

cartilage for the dorsum.

■ Bone that may be unsuitable elsewhere can be used

instead for spreader grafts, lateral wall grafts, or alar

wall grafts. And primarily in closed techniques, solid or
lightly crushed cartilage scraps can fill regional
■ The key principle in all augmentation is to match the

graft material to the patient’s soft tissue characteristics

and to his or her aesthetic goals.
■ Unmodified rib cartilage is stiff, ear cartilage is rubbery,

and septal cartilage is the most “plastic”.

■ Thicker skin needs more augmentation to provide a

Resected lateral given result but will hide more underlying flaws.
mucosa and ■ Thinner skin requires softer, well-contoured grafts that
lamina propria will not show excessively.
■ A graduated approach to nasal tip surgery requires a

combination of techniques including the cephalic trim,

the use of a columellar strut graft, nasal tip suturing, and
nasal tip grafting.
■ Compared with the closed approach, the open approach

may cause mild loss of tip projection due to disruption

of ligamentous support and increased skin undermining.
As such, columellar strut graft and nasal tip suturing
techniques are often employed to maintain nasal tip
support during open rhinoplasty.
■ Nasal tip grafts are used in primary rhinoplasty only if

adequate tip projection, definition, or symmetry cannot

be obtained by the use of the previously discussed
techniques. Visible nasal tip grafts are used infrequently
in primary rhinoplasty because of the potential for
long-term resorption leading to asymmetries or sharp
angulations requiring revision.
Figure 4.3  Inferior turbinate outfracture and submucous resection. ■ Tip suturing techniques (Table 4.4) are used to refine the

tip by controlling the subtle contours of the lower lateral

■ When nasal tip grafts are used, it is important that they

cartilages. However, its flaccidity does not allow it to be have smooth, tapered edges. Nasal tip grafts of all
used where structural support is necessary. Donor site shapes and sizes have been described (Fig. 4.4).
morbidity and scarring are minimal. ■ The presence of deformities of the alar rims such as alar

■ Costal cartilage provides abundant autogenous graft notching or retraction, facets of the soft tissue triangles,
material. It can be used for tip grafts, columellar strut malposition of the lateral crura, or functional problems
grafts, nasal spreader grafts, alar cartilage grafts, and including external valve collapse may require the use of
dorsal onlay grafts. Given the size, amount, and intrinsic lateral crural horizontal mattress sutures, lower lateral
qualities, costal cartilage lends itself well to use as a crural turnover flaps, or alar contour or lateral crural
dorsal onlay graft and where structural support is strut grafts to correct.
required. ■ Nasal osteotomies are a key component to shape the

■ It can be carved into any shape. However, allowing at bony vault in rhinoplasty. They are used to narrow a
least 30 min to pass prior to carving allows initial wide bony vault, close an open-roof deformity, or
warping to occur, minimizing late deformity. straighten deviated nasal bones.
66 4 Rhinoplasty


Figure 4.4  Nasal tip cartilage grafts. (A) Supratip; (B) infratip; (C) anatomic.

A Low-to-high B Low-to-low C Double-level

Figure 4.5  Percutaneous discontinuous lateral nasal osteotomies. (A) Low to high; (B) low to low; (C) double level (right).

■ The goals of nasal osteotomies are maintenance or those with relatively thick nasal skin, and some
creation of smooth dorsal aesthetic lines and obtaining a non-Caucasian patients with extremely low and
desirable width of the bony vault. broad noses.
■ Osteotomies can be classified by approach (external or

internal), type (lateral, medial, transverse, or a

combination), and level (low to high, low to low, or Operative techniques
double level) (Fig. 4.5).
■ A transition zone of decreased bony thickness exists
Open rhinoplasty (Video 4.1)
along the frontal processes of the maxilla near its
junction with the nasal bone, from the pyriform aperture ■ It is our preference to perform primary open rhinoplasty
to the radix. under general endotracheal anesthesia.
■ This area of relatively thin bone allows for consistent ■ Prior to sterile prep, the nose and septum are infiltrated

osteotomies and predictable fracture patterns. with a total of 10 mL 1% lidocaine with 1 : 100,000
■ Relative contraindications to the use of osteotomies epinephrine.
during rhinoplasty include patients with short nasal ■ Oxymetazoline-soaked cottonoid pledgets are inserted

bones, elderly patients with excessively thin nasal bones, into the nasal cavities. One drop of methylene blue is
Operative techniques 67

Figure 4.6  Transcolumellar stair-step incision.

instilled in the oxymetazoline to differentiate this from

the local anesthesia and prevent inadvertent injection.
■ Comparable hemostasis can be obtained using lidocaine Infracartilaginous
with oxymetazoline while avoiding the use of a
controlled substance with potential cardiac effects, as
seen with cocaine.
■ Adequate exposure during primary open rhinoplasty is
best obtained using a transcolumellar incision with
infracartilaginous extensions.
■ Several transcolumellar incisions are commonly used,
including stair step, inverted-V, and transverse.
■ Blood supply to the nasal tip is preserved with the
transcolumellar incision provided that extensive
defatting of the nasal tip or extensive alar base resections
above the alar grooves are not performed.
■ We prefer to use a stair-step incision made at the
narrowest part of the columella (usually its midportion,
Fig. 4.6), which camouflages the scar, provides Transcolumellar
landmarks for accurate closure, and prevents linear scar
contracture. Figure 4.7  Transcolumellar stair-step incision with infracartilaginous extensions.
■ The incision is carried into the nasal vestibule and then
continued along the caudal border of the medial crus
towards the middle crus of the lower lateral cartilage.
■ After everting the ala using external digital pressure ■ A Joseph elevator is then used to elevate nasal skin in a
against a double hook placed within the alar rim, a subperiosteal plane off nasal bones to radix.
separate incision is started at the caudal border of the ■ This dissection over the nasal bones is only performed

lateral crura and connected with the medial incision, in the central area to allow for bony dorsal hump
caudal to the middle crus (Fig. 4.7). reduction, while the lateral periosteal attachments of the
■ Fine dissecting scissors are used to elevate the nasal bony side wall should not be disrupted, as they provide
skin in a supraperichondrial plane starting from the necessary stability to the bony vault after percutaneous
columellar incision in a superior direction to the nasal tip. osteotomies have been performed.
■ Next, dissection is started over the lateral crus and
continued in a medial direction, connecting the
supraperichondrial dissection planes over the Component dorsal hump reduction
middle crus. ■ Dorsal hump reduction without careful attention to the
■ Dissection to elevate the nasal skin in the anatomic and physiologic functions of the nasal dorsum
supraperichondrial plane is carried superiorly to 2 mm and internal nasal valve can lead to irregularities of the
above the keystone area. nasal dorsum, excessive narrowing of the midvault, the
68 4 Rhinoplasty

Keystone area

Figure 4.8  Nasal dorsum.

Table 4.5  Component dorsal hump reduction

■ Only in limited circumstances is reduction of the upper
lateral cartilages indicated. Overresection must be
Separation of the upper lateral cartilage from the septum avoided to prevent internal valve collapse or long-term
Incremental reduction of the septum proper
dorsal irregularities. Patients with short nasal bones and
Incremental dorsal bony reduction (using a rasp)
Verification by palpation
high and narrow osseocartilaginous framework are at
Final modifications, if indicated (spreader grafts, suturing higher risk for these problems.
■ Spreader grafts may be added and are indicated in
techniques, osteotomies)
primary rhinoplasty to recreate the dorsal aesthetic
lines, widen the midvault, or correct the deviated nose
(Fig. 4.9).
inverted-V deformity, and underresection or ■ They may be fashioned from harvested septal cartilage

overresection of the osseocartilaginous hump. and are typically 5–6 mm in height and 30–32 mm in
■ We prefer a graduated approach using component dorsal length and can be placed either unilaterally or bilaterally.
hump reduction (Table 4.5) over earlier techniques of ■ If indicated for improvement of the dorsal aesthetic lines,

composite dorsal hump reduction (Fig. 4.8). they can be visible, placed above the plane of the dorsal
■ Preservation of the upper lateral cartilages during dorsal septum, and if indicated to improve function of the
reduction of the cartilaginous septum is important in internal nasal valve, they can be invisible, placed below
achieving smooth dorsal aesthetic lines. the plane of the dorsal septum.
■ Equal resection of the septum and upper lateral ■ Spreader grafts are secured to the septum using 5–0 PDS

cartilages results in rounding of the dorsum, and horizontal mattress sutures.

excessive resection of the upper lateral cartilages results ■ Following re-establishment of the cartilaginous midvault,

in the inverted-V deformity. percutaneous osteotomies are performed to correct

■ For dorsal reduction of the bony hump less than 3 mm, a widened or asymmetrical nasal bones, or close the
down-biting diamond rasp is used to reduce the bony open-roof deformity if present after dorsal reduction.
dorsum incrementally.
■ Rasping should proceed along left and right dorsal
aesthetic lines and then centrally, employing short Septal reconstruction
excursions of the rasp for maximal control. ■ Exposure of all deviated structures through the open
■ Care is taken to avoid avulsing the attachments of the approach.
upper lateral cartilages from the undersurface of the ■ Release of all mucoperichondrial attachments to the

nasal bones. septum, especially the deviated part.

■ If a larger reduction of the bony dorsum is required, a ■ Straightening of the septum and, if necessary, septal

guarded 8-mm osteotome can be used. reconstruction while maintaining an 8–10 mm caudal
■ The osteotomy should start at the caudal aspect of the and dorsal L-strut.
nasal bones and is directed toward the radix. A rasp is ■ Restoration of long-term support with buttressing caudal

used for final adjustments. septal batten or dorsal nasal spreader grafts.
Operative techniques 69

Spreader grafts

Figure 4.9  Dorsal spreader grafts.

Figure 4.10  Submucoperichondrial dissection.

■ If necessary, submucous resection of hypertrophied ■ Dissection should be continued to the maxillary crest
inferior turbinates. and posteriorly to the vomer (Fig. 4.11).
■ Precisely planned and executed external percutaneous ■ The contralateral mucoperichondrium may be left

osteotomies. attached to the septum, and only the portion of the

septal cartilage to be harvested is released. This method
leaves contralateral mucoperichondrium attached to the
Septal graft harvest L-strut for more support and decreases the amount of
■ A 15-blade scalpel is used to score the dissection and dead space with the potential for
mucoperichondrium of the septal angle. hematoma formation.
■ A Cottle elevator is used to develop the ■ Alternatively, development of these

submucoperichondrial pocket on one side of the septum submucoperichondrial pockets can be performed
(Fig. 4.10). bilaterally, allowing for improved visualization.
70 4 Rhinoplasty


Figure 4.11  Submucoperichondrial flaps.

■ Care is taken to avoid perforations of the mucosa.

Anterior perforations should be repaired with 5–0
chromic gut sutures, while posterior perforations can be
left, as they allow for drainage of any blood.
■ An 8- to 10-mm-wide dorsal and caudal L-strut is

created using a 15-blade scalpel to incise the septal

cartilage parallel to the dorsal edge of the septum from
the perpendicular plate of the ethmoid to a point
8–10 mm from the caudal edge of the septum (Fig. 4.12).
This incision is then continued posteriorly and parallel to
the caudal edge of the septum until the crest of the
■ During septal cartilage harvest, pressure on the

L-strut must be avoided to prevent its fracture. If

this occurs, it should be repaired to restore nasal
■ After cartilage grafts have been fashioned, any excess

material should be replaced between the

mucoperichondrial flaps in case it is required in
subsequent procedures.
■ The mucoperichondrial flaps can be sutured together

using a 5–0 chromic gut quilting suture and are

bolstered by placement of Doyle splints to support
the mucoperichondrial flaps and minimize dead

Ear cartilage
■ An anterior approach is used if autogenous graft
material is required for tip grafts or lower lateral
cartilage reconstruction (Fig. 4.13).
■ A posterior approach is used if a longer, more malleable
Figure 4.12  Septal L-strut.
piece of cartilage is required.
■ Hemostasis is obtained, and the incision is closed with a

5–0 plain gut running suture. Costal cartilage

■ A tie-over Xeroform-cotton bolster held in place with a ■ Various authors have described harvesting costal
3–0 nylon suture through the anterior and posterior cartilage from different ribs, but it is the author’s
auricular skin is used to obliterate dead space and preference to harvest the ninth rib because it is straight
prevent hematoma formation. medially and provides 4–5 cm of autogenous graft
■ This is removed on postoperative day 3. material (Fig. 4.14).
Operative techniques 71

Figure 4.13  Harvesting ear cartilage.

Figure 4.14  Harvesting costal cartilage.

72 4 Rhinoplasty


Figure 4.15  Cephalic trim. (A) Lateral and middle crura; (B) lateral crus (right).

■ If there is concern about pneumothorax during costal

cartilage harvest, the wound is filled with saline, and
positive-pressure ventilation can be performed by the
anesthesia provider to ensure that there are no gas
bubbles escaping from the chest cavity.
■ If the parietal pleura has been violated, the tip of a red

rubber catheter is inserted into the defect, and a 3–0 Vicryl

pursestring suture is performed around the catheter.
The anesthesia provider performs a Valsalva maneuver
while suction is applied to the red rubber catheter. As the
catheter is withdrawn, the pursestring suture is tied to seal
the parietal pleural defect followed by wound closure.
■ An upright chest X-ray should be performed postoperatively

to confirm resolution of the pneumothorax.

The nasal tip

■ Cephalic trim should be performed with the bulbous or
boxy tip (Fig. 4.15).
■ Paradomal fullness is secondary to prominence of the

cephalic border of the middle and lateral crura of the

lower lateral cartilages.
■ Cephalic trim of this area reduces paradomal fullness

and helps to define the tip and narrow the distance

between the tip defining points.
■ A rim strip of at least 5 mm is preserved for adequate

support of the external valve. B

■ Calipers should be used to measure the rim strip accurately.

Figure 4.16  (A) Floating and (B) fixed columellar strut grafts.
Columellar strut graft
■ An intercrural columellar strut graft is used to maintain medial crura and rests in the soft tissues 2–3 mm
or increase nasal tip projection, and aids in unifying the anterior to the nasal spine.
nasal tip. It can be either floating or fixed (Fig. 4.16). ■ A fixed columellar strut graft is used to increase tip

■ A floating columellar strut graft is used more commonly projection and is positioned between the medial crura
to maintain tip projection and is positioned between the and rests on the nasal spine.
Operative techniques 73

■ The columellar strut graft is typically fashioned from overall width of the columella, and to stabilize a
septal cartilage to measure 3 × 2 mm. columellar strut.
■ The columellar strut graft is placed in a pre-dissected ■ Interdomal sutures: used to increase infratip columellar
pocket and with the tip defining points held at the same projection and definition, further increase tip projection,
level; a 25 G needle is placed through the medial crura or narrow the interdomal distance.
and columellar strut graft to stabilize the complex for ■ Transdomal sutures: used to control dome asymmetry
suturing. (Fig. 4.18).
■ A 5–0 PDS suture is used to stabilize the medial crura to ■ Intercrural septal sutures: used to alter tip rotation (Fig.
the columellar strut graft, followed by two additional 4.19) (usually a 5–0 clear nylon is used for permanency).
5–0 PDS sutures to unify the nasal tip complex. ■ Lateral crural mattress sutures: used to reduce the
■ The columellar strut graft is then trimmed to alter or convexity and straighten the lateral crus (Fig. 4.20).
refine the infratip lobule.
Nasal tip grafting techniques
Nasal tip suturing techniques (Fig. 4.17) ■ A shield graft: used to increase tip projection and
■ Medial crural sutures: used to correct medial crural improve definition of the tip and the infratip lobule.
asymmetries, to reduce flaring, to control the ■ Placed adjacent to the caudal edges of the anterior

middle crura and extends into the tip. It is placed so that

it extends 2–3 mm past the tip defining points and
should be sutured with at least two 5–0 PDS sutures to
the caudal margins of the dome and medial crura.
■ Approximately 8 mm wide and 10–12 mm long. The

width of the base of the graft is the same as the distance

between the caudal margins of the medial crura.
■ An onlay graft: placed horizontally over the alar domes

and is used to camouflage tip irregularities and can

provide increased tip projection.
■ Cartilage removed from the lower lateral cartilages after

cephalic trim is usually sufficient for use as an onlay



Figure 4.17  Nasal tip suturing techniques. (A) Medial crural; (B) transdomal;
(C) interdomal. Figure 4.18  (A,B) Joined transdomal sutures.
74 4 Rhinoplasty

■ An anatomic tip graft: in primary rhinoplasty, the

anatomic tip graft is reserved for the patient with
inadequate tip projection or thick skin.
■ A combination of the shield and onlay grafts and reflects

the surface anatomy of the ideal tip.

Alar contour grafts

■ Used as a simple and effective method to correct and
prevent alar notching or retraction, and facets of the
soft tissue triangles after correcting the tip deformity
(Fig. 4.21).

Lateral crural strut grafts

■ Used to support weak lateral crura, prevent collapse of
the external nasal valve, address malposition of the
lateral crura, or increase tip projection (Fig. 4.22).
■ A 4 × 25 mm lateral crural strut graft rests on the

pyriform aperture posteriorly. The anterior aspect

of the graft is placed deep to the lateral crus and
secured with two or three 5–0 PDS simple interrupted

The alar–columellar relationship

■ The alar–columellar relationship demonstrated on the
lateral view is dictated by the relative positions of the
Figure 4.19  Intercrural septal suture. alar rim and the columella to a line drawn through
the long axis of the nostril (Fig. 4.23). The ideal distance
from the long axis to both the alar rim superiorly and
the columella inferiorly is 1–2 mm.
■ Six classes of alar–columellar relationship have been

■ Class I (Hanging columella): the distance from the

long axis to the columella is greater than 2 mm, while

the distance from the long axis to the alar rim is
1–2 mm.
• Correction involves resection and reapproximation of
the membranous septum to reposition the columella
superiorly. It may also be necessary to resect part of
the caudal septum or medial crura if they contribute
to the hanging columella.
■ Class II (secondary to alar retraction): the distance from

the long axis to the columella is 1–2 mm, while the

distance from the long axis to the alar rim is greater
than 2 mm.
• Correction may involve caudal repositioning of the
lateral crus, the use of alar contour or lateral crural
strut grafts, or composite grafts from the septum or
■ Class III: a combination of both classes I and II and

requires the use of techniques described for both

■ Class IV (hanging ala): the distance from the long axis to

the columella is 1–2 mm, while the distance from the

long axis to the alar rim is less than 1 mm.
• Correction involves resection of a horizontal ellipse of
vestibular skin no more than 3 mm in width to raise
the hanging ala.
■ Class V (secondary to columellar retraction): the distance

Figure 4.20  Lateral crural mattress suture. from the long axis to the columella is less than 1 mm,
Operative techniques 75

Figure 4.21  Alar contour grafts.

Figure 4.22  Lateral crural strut grafts.

76 4 Rhinoplasty







Figure 4.23  Alar–columellar relationships. (A) Class I; (B) class II; (C) class III; (D) class IV; (E) class V; (F) class VI.

while the distance from the long axis to the alar rim parallel to the surface of the maxilla, down through the
is 1–2 mm. periosteum.
• Correction involves placing a contoured columellar ■ A lateral subperiosteal sweep to the bony nasofacial
strut graft between the medial crura to push the groove is performed to displace the angular artery
columellar skin inferiorly. laterally and prevent its injury.
■ Class VI: a combination of both classes IV and V and ■ The discontinuous osteotomy is performed from
requires the use of techniques described for both classes. inferiorly, preserving the caudal aspect of the frontal
process of the maxilla at the pyriform aperture to
prevent collapse of the internal nasal valve, to the level
Percutaneous lateral nasal osteotomies of the medial canthus superiorly, and then continued
■ Various authors have described their experience using into a superior oblique osteotomy medially.
different approaches, including intranasal, intraoral, and ■ The osteotomy should not be continued superior to
percutaneous techniques. We prefer percutaneous lateral the medial canthus to avoid injury to the lacrimal
discontinuous osteotomies because this technique results system.
in a more controlled fracture with less intranasal trauma ■ After the osteotomies have been completed, the thumb
while minimizing morbidity, including bleeding, and index finger are used to exert gentle pressure to
ecchymosis, and edema (Fig. 4.24). perform a greenstick fracture of the nasal bones to
■ A 2-mm incision is made in the nasofacial groove at the reposition them in the desired location. If more than
level of the inferior orbital rim, and a sharp 2-mm gentle pressure is required, the osteotome should be
straight osteotome is inserted through the incision and reinserted to ensure that there are no significant areas of
Operative techniques 77

nonosteotomized bone between the discontinuous

perforations. Alar base surgery
■ Alar base surgery is indicated for abnormalities
including alar flaring, nostril asymmetry, excessively
Closure large nostrils, elongated alar side walls, widened alar
■ Closure of the incisions is begun by lining up the base, large alae, and alar asymmetry (Fig. 4.25).
transcolumellar stair-step incision in the midline and at ■ Alar flaring is the most common problem requiring

the junction of the columellar skin and nasal vestibule modification of the alar base. The relationship between
bilaterally. the alar and basal planes, alar base width, and the nostril
■ This closure must be meticulously performed to prevent shape and size should be taken into consideration when
notching leading to a noticeable columellar scar. choosing the appropriate surgical technique.
■ The bilateral infracartilaginous incisions are closed next ■ Alar flaring in the presence of normal nostril shape and

with simple interrupted sutures using 5–0 chromic gut. symmetry is corrected by limiting excision to the alar
■ The mucosa should be exactly reapproximated, lobule; the incision is not continued into the vestibule.
particularly around the middle crura, to prevent The incision is not made directly in the alar–cheek
distortion of the soft triangle or webbing at the nasal groove but within 1 mm of the groove, allowing for an
vestibule. everted closure with improved scarring. In addition,
1–2 mm of the alar base is preserved, preventing alar
base notching.
■ Alar flaring with nostril asymmetry or excessively large

nostrils requires a wedge excision of the alar lobule and

vestibule. The alar lobule incision is continued into the
vestibule 2 mm above the alar groove. The medial
incision is made using an 11-blade scalpel angled 30°
laterally, resulting in a small medially based flap.
Straight-line closure is avoided to prevent distortion of
the nostril or notching of the nostril sill.

Closed rhinoplasty
■ The operation is routinely performed under general
■ The patient is placed supine with the arms and legs

padded and the knees slightly flexed; the operating table

is in 10–15° reverse Trendelenburg position to minimize
■ After induction of general anesthesia, the nose is blocked

with a freshly prepared solution of 1% carbocaine with

epinephrine 1 : 100,000 (20 mL of 1% carbocaine plus
0.2 mL of epinephrine 1 : 1000).
■ Infiltration begins at the nasal root, along each lateral

Figure 4.24  Percutaneous discontinuous lateral nasal osteotomies. nasal wall, into the columella, across the maxillary arch,


Figure 4.25  Alar base surgery. (A) Alar flaring; (B) alar flaring with modification of nostril shape.
78 4 Rhinoplasty

and into the alar lobules to vasoconstrict the branches of ■ It is important for the surgeon to obtain smooth
the primary supplying vessels (angular, anterior elevation of all soft tissues to ensure good cover and
ethmoidal, superior labial) and the relevant nerves avoid dermal injury.
(anterior ethmoidal, infraorbital, infratrochlear). ■ If no transfixing incision is necessary, the

■ This infiltration usually consumes about 7 mL of the intercartilaginous incision stops at the junction of the
anesthetic solution, the rest of which is saved for the anterior and middle thirds of the membranous septum.
septal surgery. ■ If the caudal septum requires shortening, the incision can

■ Nasal vibrissae are shaved with a No. 15 blade, and the be carried toward the anterior nasal spine.
nose is thoroughly cleansed internally with a povidone–
iodine solution.
■ Internal preparation of the nose should be even more Dorsal resection
fastidious than skin preparation, not the reverse, ■ Producing a straight dorsum from a convex one is not a
remembering that the nasal lining is the real operative simple matter.
surface. ■ The surgical plan must consider: (1) radix position, (2)

■ For hemostasis and anesthesia of the nasopalatine nerve, dorsal height, and (3) the adequacy of tip support.
the internal nasal and posterior nasal branches of the ■ The author performs the dorsal resection under direct

anterior ethmoidal nerve, the internal nasal branch of the vision using a sharp Fomon rasp.
nasociliary nerve, and the nasal branch of the anterior ■ Resection of the dorsal border of the septum is

superior alveolar nerve, two cotton packs soaked in 4% accomplished with a No. 11 blade from which the tip
cocaine solution and squeezed dry with sterile gauze are has been broken to avoid lacerating the contralateral
placed in each airway. Only 4 mL of 4% tinted cocaine dorsal skin.
solution is made available for each patient (160 mg), ■ The dorsum should feel and appear perfectly smooth

safely below the maximum allowable dosage (200 mg). through the skin surface after dorsal resection.
■ The patient’s face is prepared and draped.
■ The author ordinarily skeletonizes the nose through
unilateral or bilateral intracartilaginous incisions (Fig. Nasal spine–caudal septum
4.26), depending on whether alar cartilage modification ■ Caudal septal resection may change the relationship of
will be necessary. the columella to nostril rim, nasal length, subnasale
■ The incision runs from the lateral end of the caudal contour, and upper lip carriage.
reflection of the upper lateral cartilage around the septal ■ If the nasolabial angle and upper lip relationships are

angle. satisfactory, no transfixing incision and no caudal septal

■ With Joseph scissors (Fig. 4.27) and then a broad Cottle or nasal spine modifications are necessary.
periosteal elevator, the soft tissues are elevated over the ■ If columellar position is satisfactory but the subnasale is

bony and upper cartilaginous vaults only as necessary full, a short incision can be made in the posterior
for access. membranous septum and septal floor, the nasal spine
exposed and resected with a small rongeur.
■ If the columella is low but the nasolabial angle is

satisfactory, the caudal or membranous septum is

resected, paralleling the nostril rims and without
shortening the nose. Finally, if the columella is low or the

Figure 4.26  The intercartilaginous incision, which can be lengthened into a Figure 4.27  The intercartilaginous skeletonizing incision begins at the apex and
transfixing incision if necessary, gives access to the dorsum, upper and lower proceeds laterally only as far as necessary. Dorsal access and visualization are
lateral cartilages, and the septal angle. Dorsal modification; upper and lower lateral easiest for a right-handed surgeon through a left-sided incision, and vice versa. If
cartilage resection; spreader, radix, dorsal, and lateral wall grafts can all be the surgeon does not need to shorten the upper or lower lateral cartilages, only a
performed through this excellent access point under direct vision. single intercartilaginous incision is needed.
Operative techniques 79

nasolabial angle is acute, more caudal septum and ■ Spreader graft tunnels are facilitated by prior infiltration
membranous septum is resected anteriorly than beneath the mucoperichondrium with local anesthetic.
posteriorly. ■ By identifying the septal angle, the surgeon can incise to

■ Be cautious about over-resection; 1 or 2 mm makes the cartilage beneath each mucoperichondrial flap and
difference between normal columellar position and develop the tunnels themselves with the sharp end of a
retraction. Cottle perichondrial elevator.
■ Each tunnel must follow the dorsal septal edge and

should extend beneath the caudal edge of the bony arch

Alar cartilage resection on each side, leaving a narrow mucoperichondrial
■ In the majority of primary rhinoplasties in which only attachment along the top edge.
conservative reductions of the cephalic lateral crura ■ For septoplasty access, the initial mucoperichondrial

edges are necessary, the cartilages are modified incision is made 15 mm above (cephalad to) the caudal
retrograde through the intercartilaginous incisions. septal edge.
■ If the cartilages are distorted, they can be delivered ■ Using first the sharp and later the blunt end of a Freer

as bipedicle flaps by intercartilaginous and elevator in one hand and a Frazier suction in the other,
infracartilaginous incisions. dissection proceeds under the mucoperichondrial flap
■ If only the arch needs interruption (e.g., to narrow the onto the perpendicular plate of the ethmoid and over
tip or to resect a “knuckle” at the lateral genu), only that any posterior bony obstructions.
portion of the alar cartilage should be exposed. ■ Once the first flap has been developed, the sharp end of

■ If the lateral crus or dome areas are so distorted that a the elevator can cut the septal cartilage at the site of the
simple reduction or tip grafting will not provide the opening incision, and dissection then proceeds on the
intended result, the distorting structures can be dissected second side.
free from the vestibular and overlying skin and (1) ■ Elevation of the perichondrium at the junction of

resected and replaced after modification, (2) resected and septal cartilage and vomer is particularly difficult
replaced by septal cartilage grafts, or (3) delivered as a because the periosteal and perichondrial fibers are
medially based flap and replaced along the alar rims. interlaced.
■ Radical freeing of the lateral crura, dome resection, or ■ Because the periosteal fibers are stronger, the mucosal

division of the alar cartilage arch reduces tip projection, flaps are less likely to tear if the surgeon begins
and so, tip grafts are necessary to reconstruct the lobule. dissection beneath the maxillary and vomerine
Lining should never be resected to avoid vestibular mucoperiosteum and works cephalad.
stenoses and iatrogenic airway obstruction. ■ The first septal cut is made 15–20 mm below the dorsal

septal edge with angled Knight septal scissors, which cut

through septal cartilage and ethmoid.
Upper lateral cartilages: shortening the nose ■ Make sure that both blades are within the

■ A variety of interventions shorten the nose. In mucoperichondrial flaps before making the cut.
descending order of their effect, they are dorsal resection, ■ A parallel cut is performed 10 mm inferiorly, and using

caudal septal resection, resection of the cephalic edges of Killian septal forceps, the first graft, now free on three
the alar cartilage lateral crura, and resection of the sides, can be twisted so that the ethmoid fractures and is
anterocaudal ends of the upper lateral cartilages. removed in one piece.
■ The posterior edges of the upper lateral cartilages should ■ This maneuver often provides an initial graft of

be left to abut the lateral crura; mucosa should never be 25–30 mm long containing the flattest, thickest, longest
resected. piece of septal cartilage, ideal for a dorsal graft.
■ The caudal edge of the upper lateral cartilage can be ■ Dissection continues posteriorly and caudally with the

drawn downward by a single hook in its lining, sharp end of a Cottle perichondrial elevator.
exposing the caudal edge for submucosal resection with ■ The septal cartilage in the vomerine groove can often be

Joseph scissors. dislodged by a bit of judicious wiggling with a narrow

■ With an osteotome and septal forceps, additional pieces
Septoplasty, spreader graft tunnels of vomer or perpendicular plate of the ethmoid can be
■ Septoplasty is performed to relieve an airway obstruction removed if obstructing or if additional graft material is
from septal deflection and to provide graft material for needed, always working under direct vision.
the reconstruction itself. ■ In areas of severe deflection, tears in the

■ The surgeon should leave 15–20 mm intact, undissected mucoperichondrial flaps may be unavoidable, but the
cartilage along the nasal dorsum and 15 mm caudally in surgeon should nevertheless proceed cautiously and
performing any submucous resection to preserve repair any tears.
stability and to make spreader graft placement simpler. ■ Close the septal pocket with 4–0 chromic mattress

■ Recent trauma (within 3 months) is an indication to sutures.

postpone the rhinoplasty until any fractures have healed
and until postoperative edema allows accurate judgment
of the aesthetic contours. Turbinectomy
■ If they are needed, spreader graft tunnels are performed ■ Partial inferior turbinectomy, defined as a trim of the
before septoplasty. anterior edge sufficient to obtain 3 mm clearance to the
80 4 Rhinoplasty

septum or nasal floor, is valuable adjunctive airway ■ Even with the medial flap, excess resection of even 1 mm
treatment if indicated. can notch the nasal floor.
■ Turbinate crushing and outfracture may suffice in ■ Be conservative.

patients whose turbinates contain significant cystic bone ■ An external incision made slightly outside the alar crease

and in whom adequate airway size can be achieved is preferable in order not to destroy this important
without resection. landmark, a unique structure that simple skin repair
■ When resection is necessary, biopsy forceps allow does not reduplicate.
smaller, more incremental changes than angled scissors. ■ Accurate closure with 6–0 nylon suffices, and this suture

■ The raw surfaces left will contract and epithelize, further should be removed by 5 days; 5–0 plain catgut is used
reducing the size of the remaining turbinate. for the nasal floor.

Graft placement and wound closure Spreader grafts

■ Close some of the wounds with 5–0 plain catgut sutures ■ Although septal cartilage provides the ideal spreader
before placing grafts so that their position will be easier graft, strips of costal or conchal cartilage, ethmoid, or
to maintain. vomer may be used instead (Fig. 4.28).
■ This sequence keeps grafts from slipping out of one ■ After spreader grafts are placed, caudal slippage can be

incision as the surgeon closes another. avoided by a single 4–0 plain catgut transfixing suture
placed at the septal angle.
■ Before performing any osteotomy, the surgeon should be Lateral wall and columellar grafts
sure that one is necessary. ■ Cartilage provides the ideal lateral wall graft, split
■ If the lower nasal third is already appropriately wider tangentially or crushed to fit the defect.
than the bony vault, narrowing the upper nose further ■ Augment the columella through a short lateral incision

may be counterproductive by making the nasal base in the membranous septum, limiting cephalic dissection
appear larger. so that the grafts provide adequate augmentation but do
■ If there is a high septal deviation, bilateral osteotomies not disappear between the medial crura.
may create a newly asymmetric nose because one nasal
bone will move medially farther than the other.
■ In the elderly patient (in whom comminution of the Tip grafting
nasal bones may occur), the patient who wears heavy ■ The surgeon who uses tip grafts commonly finds that
eyeglasses, or the patient with nasal bones extending less they not only increase tip projection but also alter tip
than one-third the distance to the septal angle (in whom lobular and nostril contour, increase lobular volume
middle vault width depends partially on bony vault (reducing relative nostril size), impart a different ethnic
width), the surgeon may wish to omit osteotomy. character, and enlarge the nasal base, therefore changing
■ Finally, osteotomy may lengthen a long nose further by the balance between dorsal height and tip projection.
reducing support beneath a large skin sleeve. ■ Tip grafts are placed through an infracartilaginous

■ A single lateral osteotomy that begins intranasally, low at incision on the side from which the surgeon operates.
the pyriform aperture, and ends higher toward the nasal ■ It is important to dissect the recipient pocket adequately

root (at the attachment of the nasal pyramid to the but not so liberally that the grafts cannot create the
maxilla) is effective and seems the most anatomically required support and projection.
correct. ■ Complete access incision closure is mandatory to

■ Gentle digital pressure causes a greenstick fracture at the minimize infection.

remaining cephalic attachment and will reform the bony ■ The grafts should be manipulated as little as possible

pyramid. and rinsed in saline in an antibiotic solution before

■ Use a guarded osteotome facing the button laterally to insertion.
constantly assure correct orientation. ■ The author now places tip grafts in almost every patient,

except for those whose preoperative tip aesthetics are

Alar wedge resection
■ In considering the degree of resection, the surgeon
should assess the proportion of tip lobular size to nostril Postoperative considerations
length, remembering that tip grafting (if part of the
preoperative plan) will increase tip lobular size and may ■ Postoperative care begins preoperatively with a thorough
eliminate the need for nostril reduction. review of the plan of care and expected postoperative
■ Because the alar rim has both external and vestibular recovery.
skin surfaces, the requirements of each must be assessed ■ Steri-Strips are often applied starting at the supratip

and treated individually. break, carefully contouring the soft tissue to the
■ If nostril size is excessive, however, it is important to underlying osseocartilaginous skeleton and then
preserve a medial flap at the sill to lessen the possibility continuing superiorly along the dorsum with Steri-Strips
of alar notching. of progressively shorter length.
Postoperative considerations 81



Figure 4.28  (A) Septal cartilage is not uniform in thickness but broadens along its anterior edge, where it becomes confluent with the upper lateral cartilages and forms
the middle vault roof. (B) Any dorsal resection thicker than 2 mm interrupts this cartilaginous arch and removes the widened septal area, regardless of whether the mucosa
is intact. (C) The surgeon has now created a disequilibrium in which the upper lateral cartilages are no longer held apart by the spreading action of the intact roof. Even if
the internal valves were not incompetent preoperatively, they are now. (D) Spreader grafts recreate the former intact septal width and reconstitute competent internal valves.
Thus spreader grafts are indicated whenever the internal valves are incompetent preoperatively or when the surgeon resects an intact cartilaginous roof, unless the nasal
contour independently suggests a substantial dorsal graft (which duplicates the functional effect of spreader grafts).

■ A Denver dorsal splint (Shippert Medical Technologies, ■ Despite better symmetry, a straighter bridge, or increased
Centennial, CO) is shaped over a cylindrical object with tip contour, many patients are disappointed 1 week after
a diameter similar to the width of the osseous base surgery and need repeated assurance that the nose is still
of the nose. This splint is applied over the superior swollen.
two-thirds of the dorsum, and the edges are compressed ■ Generally, most of the nasal swelling and ecchymosis

medially to support the osteotomized nasal bones. The will resolve within 3–4 weeks of following surgery;
inferior edge of this splint should be superior to the however, soft tissue edema, both external and internal,
supratip area. may take 6–12 months to resolve and external subtle
■ If septal reconstruction and/or inferior turbinoplasty nasal definition and internal nasal airflow will continue
was performed, Doyle septal splints (Micromedics, St to improve over this period.
Paul, MN) are applied to avoid hematoma formation ■ First- or second-generation cephalosporins are generally

deep to the mucoperichondrial flaps, support and used for antibiotic prophylaxis.
stabilize the structures, protect the septal mucosa, and ■ Some surgeons will prescribe a short course of high-dose

prevent synechiae formation between adjacent mucosal corticosteroids, which is started intraoperatively and
surfaces. continued in the early postoperative period to minimize
■ These splints are covered with antistaphylococcal edema and ecchymosis.
antibiotic ointment, inserted into each of the nasal ■ Intraoperatively, 8 mg intravenous dexamethasone can

cavities, and secured using a 3–0 nylon horizontal be given and continued postoperatively in the form of
mattress suture through the membranous septum, oral methylprednisolone (Medrol Dosepak) for 6 days.
loosely tied to prevent ischemia of this delicate Although the efficacy of high-dose corticosteroids
tissue. remains debatable, newer data suggest their utility in
■ Both Denver and Doyle splints are removed, typically on open rhinoplasty.
postoperative day 7, along with any columellar sutures. ■ Postoperative pain and discomfort are highly variable. In

If the patient has undergone extensive septal general, oral narcotic analgesia is used for several days,
reconstruction, the splints are left in place for after which nonsteroidal anti-inflammatory drugs are
approximately 10 days. Alar base sutures are also adequate.
removed on postoperative day 10. ■ During the initial 48 h following rhinoplasty, the patient

■ A nasal drip pad is fashioned using 2 × 2 gauze and held should keep his/her head elevated greater than 30°
in place under the nose with paper tape secured to tape degrees and gently apply cold compresses to help
on the cheeks. decrease postoperative edema and ecchymosis.
82 4 Rhinoplasty

■ Head elevation should be continued until there is Table 4.6  Complications following rhinoplasty
no longer edema in the morning. This is typically
7–10 days. Anosmia
■ The patient should avoid any straining, including
Arteriovenous fistula
Bleeding (ecchymosis, epistaxis, hematoma)
strenuous activity or heavy lifting, for 3 weeks. Trauma Deformities and deviation
and pressure on the nose, including wearing glasses, Epiphora
should be avoided for 6 weeks. Infection (cellulitis, abscess, granulomas, toxic shock syndrome)
■ The following sequence generally occurs in most patients
Intracranial injury
during the first postoperative year: Nasal airway obstruction (external valve collapse, internal valve
• The nose becomes longer and “deskeletonizes” as collapse, septal deviation, synechiae, vestibular stenosis)
upper lip edema abates so that the nasolabial angle Nasal cyst formation
decreases, and the nostrils become less visible. Nasolacrimal apparatus injury
• The nasal base rotates caudally, depending on skin Prolonged edema
elasticity and the degree of skeletal support; the long
Septal perforation
preoperative nose has the greatest tendency to
elongate postoperatively.
• The profile assumes its final postoperative shape
sooner than the frontal view; the nose narrows on
frontal view for at least 12–18 months, particularly in ■ Head elevation greater than 60°, oxymetazoline nasal
the middle third. During this time, the unsupported spray into the affected nostril, and gentle pressure for 15
middle vault narrows and demarcates from the caudal minutes are usually enough to stop any mild epistaxis.
edges of the bony vault. The nasal skin tries to ■ If epistaxis persists, removal of Doyle splints and silver

assume its preoperative shape, a characteristic nitrate cautery, followed by anterior nasal packing, can
that has particular implications for tip grafting: be attempted.
the flatter, more contracted preoperative tip will ■ If bleeding remains refractory, posterior nasal packing

compress tip grafts and alter postoperative contour should be considered, along with hospital admission for
more than the larger tip with a more pliable soft observation.
tissue cover. ■ In less than 1% of patients, major epistaxis occurs and

• Skeletal irregularities or asymmetries may appear should be addressed in the operating room with
(and sometimes disappear). exploration and cauterization. Inferior turbinate resection
• Areas of underlying skeletal change or grafts may is usually the source.
become visible and suggest the need for revision; ■ If all of the above measures fail, consultation for

conversely, early postoperative improvement may angiographic embolization should be obtained.

become obscured by soft tissue contraction and ■ Regardless of the location, all hematomas should be

thickening. drained.
■ Hematomas deep to the skin will cause fibrosis, leading

to scarring and contour deformities affecting the final

Complications and outcomes nasal appearance.
■ Septal hematomas (ecchymotic septal mass that

■ Following rhinoplasty, most patient dissatisfaction is resembles a “blackberry”) can create septal perforations
seen in the lower third of the nose, including the nasal or necrosis of septal cartilage, leading to a saddle-nose
tip, followed by the middle and upper thirds. deformity.
■ Poor results in the lower third typically arise from nasal ■ Hematomas can usually be drained in the office with

tip asymmetries, notching of the alae, and inadequate tip appropriate lighting. Following drainage, the area should
rotation. be packed to prevent recurrence for 24 h and then
■ Common problems in the middle third include supratip reinspected.
fullness or a pinched supratip. ■ Although infections are rare following rhinoplasty,

■ Complaints in the upper third include excessive diligent physical examination to identify early signs of
reduction of the dorsum, asymmetrical or ill-defined infection allows early initiation of treatment to prevent
dorsal aesthetic lines, and other dorsal irregularities. serious complications such as tissue necrosis, toxic shock
■ The reported incidence of significant complications syndrome, and cavernous sinus thrombosis. In the event
following rhinoplasty ranges from 1.7% to 18%. of an infection, internal nasal splints or packing may
■ Common complications following rhinoplasty include need to be removed.
bleeding, infection, prolonged edema, deformities and ■ In cases of severe cellulitis, the patient may need to be

deviation, and nasal airway obstruction (Table 4.6). admitted for intravenous antibiotics. Abscesses are
■ Epistaxis is one of the most common complications usually found at the nasal dorsum, nasal tip, and the
following rhinoplasty. Most patients, particularly those septum. Any abscess identified should be drained and
who have undergone septal or turbinate surgery, have irrigated, and purulent material should be cultured to
moderate bleeding for the first 48–72 h postoperatively, guide antibiotic therapy.
after which drainage subsides. ■ Toxic shock syndrome has been described after

■ A total of 3% of patients, however, classically rebleed rhinoplasty with the use of both nasal packing and
between postoperative days 5 and 10. internal nasal splints.
Further reading 83

■ It is an acute, multisystem disease caused by release of ■ Following rhinoplasty, most patients experience transient
exotoxins from Staphylococcus aureus or Streptococcus nasal airway obstruction secondary to edema. This
pyogenes causing excessive activation of inflammatory typically resolves over 2–3 weeks as edema subsides.
cells and release of inflammatory cytokines, often ■ When nasal airway obstruction persists after 3 weeks,

resulting in tissue damage and organ dysfunction. internal nasal examination using a topical vasoconstrictor
■ Patients can present with fever, a diffuse macular should be performed to identify the cause.
erythroderma rash, desquamation, nausea, vomiting, ■ If it is secondary to edema, nasal decongestants can be

diarrhea, tachycardia, and hypotension. used, but topical vasoconstrictors should not be used for
■ Removal of nasal packing or internal nasal splints, more than 7 days because of rebound congestion
administration of intravenous antibiotics, supportive following cessation of these medications.
care, and intensive care unit monitoring are indicated in ■ If an anatomical cause of obstruction is identified, such

this rare event. as internal nasal valve collapse or synechiae, surgical

■ Soft tissue edema in the early postoperative period is treatment will be required but should be delayed for at
largely prevented by preoperative patient education least 1 year to allow for complete resolution of edema
about postoperative care and recovery, perioperative and maturation of scar tissue.
corticosteroid use, head elevation, taping, and ■ The “post-rhinoplasty red nose” is a cutaneous

application of cold compresses. Most edema will resolve manifestation of postoperative circulatory readjustment
within 4 weeks. and is displayed varyingly in patients; many never
■ Septal perforations occasionally occur after difficult develop this condition, whereas others develop it after
septoplasties but can be minimized by cautious the first rhinoplasty.
dissection over the vomer, by repairing tears in the ■ Most improve spontaneously during the first

mucoperichondrial flaps, and by placing 1-mm silicone postoperative year. When the condition persists, laser
splints on each side of the septal partition before the treatment is simple and effective.
nose is packed. ■ Lacrimal duct injury, cerebrospinal fluid rhinorrhea,

■ Even with these precautions, the occasional septal cavernous sinus thrombosis, meningitis, permanent
perforation may be unavoidable and is usually anosmia, recurrent intradermal cysts, and blindness after
asymptomatic. corticosteroid injection for supratip deformity have been
■ Small perforations may cause a curious whistling. reported but are fortunately uncommon.
■ Larger perforations cause crusting, epistaxis, and rhinitis ■ Although it is difficult to determine an exact revision

as the turbulent airflow spins through the perforated rate following primary open rhinoplasty, a recent survey
mucosa. revealed that 58% of those surveyed cited their revision
■ Temporary rhinitis may occur for several weeks rate less than 5%, while another 33% reported their
postoperatively, particularly when an obstructed airway revision rate between 6% and 10%.
has been improved.
■ Late soft tissue edema persists several months to more
than a year postoperatively and represents scar
remodeling. It can be seen in situations such as
Constantian MB. Rhinoplasty: Craft and Magic. St Louis: Quality
secondary rhinoplasty or patients with thick skin. Medical; 2009.
■ Patients should be reassured that it will resolve on The author’s complete text. Covers nasal phenomenology, so that
its own. preoperative and postoperative deformities can be seen to form patterns;
■ In certain circumstances where excessive scarring therefore, the solutions are not limitless but also form patterns. The
rhinomanometric improvement in airflow is given for each case where the
threatens to cause loss of definition, such as in the information was available, and analysis and exposition of intraoperative
supratip area or radix, corticosteroid injection may be changes are emphasized. Chapters cover not only rhinoplasty analysis
indicated to decrease the production of scar tissue. and technique but anatomic variants, function, right-brain training
■ Triamcinolone acetate 3–5 mg (10 mg/mL) mixed with for rhinoplasty, body dysmorphic disorder, and the author’s own
2% lidocaine in a 1 : 1 ratio is injected into the supratip
Edwards B. A New Drawing on the Right Side of the Brain. New York:
area with a 27 G needle. Penguin Putnam; 1999.
■ Depending on the clinical scenario, injections may be A delightful and instructive adventure into art. Most of us lose the
administered as early as 1 week postoperatively and ability to “see” what is really in front of us as the left brain begins to
repeated at 4- and 8-week intervals. dominate at about age 10, which is why most adults draw at that level
■ Deformities may be identified in the postoperative
of sophistication. Yet plastic surgery, not only rhinoplasty but breast
reduction, TRAM flap shaping, forehead flaps, and many other procedures
period. Mild deformities should be observed. If they benefit from the ability to call upon right-brain skills at will. This book
persist beyond 1 year, surgical treatment is required. teaches how, in an entertaining way.
Significant deformities should be corrected as soon as Fomon S, Gilbert JG, Caron AL, et al. Collapsed ala: pathologic
physiology and management. Arch Otolaryngol. 1950;51:465.
they are identified to avoid patient dissatisfaction.
A classic paper on what we now call external valvular collapse by a
■ Deviations are managed similarly to deformities. Mild
pioneer who intuitively understood what the next generation of surgeons
deviation may be corrected using nasal molding forgot: that each airway has two sides.
techniques. The patient is instructed to apply controlled Ghavami A, Janis JE, Acikel C, et al. Tip shaping in primary
pressure using his/her thumb along the nasal side wall rhinoplasty: an algorithmic approach. Plast Reconstr Surg.
3–4 times per day for 4–6 weeks postoperatively. If the Underprojection and lack of tip definition often coexist. Techniques that
deviation is significant or persistent beyond 1 year, improve both nasal tip refinement and projection are closely interrelated.
surgical treatment is required. The authors present a simplified algorithmic approach to creating
84 4 Rhinoplasty

aesthetic nasal tip shape and projection in primary rhinoplasty to aid the Rohrich RJ, Gunter JP, Deuber MA, et al. The deviated nose:
rhinoplasty surgeon in reducing the inherent unpredictability of combined optimizing results using a simplified classification and algorithmic
techniques and improving long-term aesthetic outcomes. approach. Plast Reconstr Surg. 2002;110:1509–1523.
Gunter JP, Rohrich RJ. Management of the deviated nose: the The deviated nose frequently causes both functional and aesthetic
importance of septal reconstruction. Clin Plast Surg. 1988;15:43–55. problems. The authors present a classification and approach to the
Gunter JP, Landecker A, Cochran CS. Frequently used grafts in deviated nose that relies on accurate preoperative planning and precise
rhinoplasty: nomenclature and analysis. Plast Reconstr Surg. intraoperative execution of corrective measures to return the nasal dorsum
2006;118:14e–29e. to midline, restore dorsal aesthetic lines, and maintain airway patency.
Howard BK, Rohrich RJ. Understanding the nasal airway: principles An operative algorithm is described that emphasizes simplicity and
and practice. Plast Reconstr Surg. 2002;109:1128–1146. reproducibility.
Phillips KA. The Broken Mirror: Understanding and Treating Body Rohrich RJ, Janis JE, Kenkel JM. Male rhinoplasty. Plast Reconstr Surg.
Dysmorphic Disorder. New York: Oxford University Press; 2005. 2003;112:1071–1085.
A text written by a noted authority on body dysmorphic disorder, intended Rohrich RJ, Muzaffar AR. Rhinoplasty in the African-American patient.
for the lay public but so well referenced that it can be an introduction and Plast Reconstr Surg. 2003;111:1322–1339.
reference work for the interested physician as well. Rohrich RJ, Muzaffar AR, Janis JE. Component dorsal hump reduction:
Rohrich RJ, Krueger JK, Adams WP Jr, et al. Achieving consistency in the importance of maintaining dorsal aesthetic lines in rhinoplasty.
the lateral nasal osteotomy during rhinoplasty: an external Plast Reconstr Surg. 2004;114:1298–1308.
perforated technique. Plast Reconstr Surg. 2001;108:2122–2130. Dorsal hump reduction may result in dorsal irregularities caused
The lateral nasal osteotomy is an integral element in rhinoplasty. The by uneven resection, over-resection, or under-resection of the
authors present a reproducible and predictable technique for the lateral osseocartilaginous hump, the inverted-V deformity, excessive narrowing
nasal osteotomy and discuss the role of the external perforated osteotomy of the midvault, and collapse of the internal valve. The authors present a
technique in reproducing consistent results in rhinoplasty with minimal technique for component dorsal hump reduction that allows a graduated
postoperative complications. approach to the correction of the nasal dorsum by emphasizing the
Rohrich RJ, Raniere J Jr, Ha RY. The alar contour graft: correction and integrity of the upper lateral cartilages when performing dorsal reduction.
prevention of alar rim deformities in rhinoplasty. Plast Reconstr Rohrich RJ, Ahmad J. Rhinoplasty. Plast Reconstr Surg.
Surg. 2002;109:2495–2505. 2011;128:49e–73e.
Deformity of the alar rim is a common problem after primary and Sheen JH, Sheen AP. Aesthetic Rhinoplasty. 2nd ed. St Louis: Mosby;
secondary rhinoplasty. It is caused by congenital malposition, hypoplasia, 1987:988–1011.
or surgical weakening of the lateral crura, with the potential for both This two volume text is the second edition of the book that started the
functional and aesthetic consequences. The authors describe the use of the revolution in rhinoplasty of the 1980s and beyond. Our entire rhinoplasty
alar contour graft to provide the foundation for the reestablishment of a lexicon derives from it. Virtually all of the text is still current, and any
normally functioning external nasal valve and an aesthetically pleasing surgeon seriously interested in learning rhinoplasty and its modern roots
alar contour. should own and study a copy.
This chapter was created using content from Neligan & Rubin, Plastic Surgery
4th edition, Volume 2, Aesthetic, Chapter 20, Otoplasty and Ear Reduction,
Charles H. Thorne.

and both parents and grandparents may be involved in
surgical decision making for the patient who cannot yet
■ Analysis. Analyze the problem in thirds. express himself or herself.
■ Endpoint. Know what normal looks like, so you know your surgical
■ The overall size and shape of the ear is evaluated to
endpoint. determine if the ear is prominent with an otherwise
■ Do not be destructive. Do not do anything to the ear that cannot be normal size and configuration, or if there are
reversed. abnormalities in addition to the prominence.
■ Skin is precious but weak. Preserve skin in the sulcus, and do not rely
■ The upper third of the ear is evaluated to determine if
on skin tension to maintain ear position. it is prominent, if the antihelix/superior crus of the
■ Lobule. Consider lobule setback in every case. triangular fossa is well formed, and if the helical rim is
■ Asymmetry. In asymmetric cases, operate on both ears most of well defined.
the time.
■ The middle third of the ear is evaluated to determine if
■ Facelifts are otoplasties. Do not deform the tragus, lobule, or sulcus. the concha is overly deep or protruding.

■ The relationship between the antihelix and the helix
is examined to determine if any underdevelopment
Brief introduction of the antihelix/superior crus in the upper third
extends into the middle third or if it is confined to the
■ “Otoplasty” refers to surgical changes in the shape or upper third.
position of the ear.
■ The lobule is evaluated to determine if it is prominent.
■ The most common indication is the patient with
■ Even if the lobule is not particularly prominent on initial
prominent but normally shaped ears. examination, it may become prominent once the upper
■ The single most important exercise for the surgeon, two-thirds of the ear have been corrected.
before performing any procedure in the otoplasty
■ Asymmetry is noted, mostly because patients and
spectrum, is to have the characteristics of a normal ear families will always comment on it.
firmly in his/her mind. With proper choice of technique,
■ In asymmetric cases, it is usually preferable to operate
the surgeon can usually avoid the uncorrectable on both ears rather than attempt to set back only the
problems of overcorrection and unnatural contours prominent ear to match its less prominent counterpart
(Figs. 5.1 and 5.2). (see Fig. 5.1).
■ It has also never been shown that an otoplasty retards
■ The degree of prominence/deformity and the age at
auricular growth. presentation will determine when a surgical
recommendation is made.

■ For young children with very prominent ears and whose
Preoperative considerations parents desire early correction, otoplasty is recommended
as early as age 4 years.
■ Otoplasty is unique in that it is perhaps the only
■ Four years of age can be viewed as a minimum for most
cosmetic procedure that can be performed in childhood, otoplasty procedures.

86 5 Otoplasty

■ It is common to have patients present at approximately

Triangular fossa Crura of antihelix
18 years of age, when they are legally independent, or
later when they have earned the money for the
■ It is not unusual for adults at almost any age to request
Tubercle correction, either because they have wanted it all their
of helix Crus of helix
lives or because their desire to have other procedures
(e.g., a facelift) has led to the realization that their ears
Scapha Anterior are also prominent.

Tubercle Anatomical/technical pearls
of tragus
■ While the delicate, complex contours of the ear
may be difficult to create de novo (i.e., microtia),
External anatomic considerations are minimal in standard
Antihelix meatus otoplasty.
■ There is abundant blood supply, making almost any
incisure combination of incisions acceptable without the risk of
■ There are no motor nerves in the neighborhood. The

terminal branches of the great auricular nerve will

Posterior sulcus Antitragus Lobe always be injured, but normal sensory function usually
Figure 5.1  Anatomical structures of the ear. The tubercle of the helix is ■ The one anatomic structure that can be compromised in
synonymous with Darwin’s tubercle. (Reprinted with permission from Janis JE, otoplasty is the external auditory canal (conchal setback
Rohrich RJ, Gutowski KA. Otoplasty. Plast Reconstr Surg. 2005;115(4):60e–72e.) narrows the meatus). Otherwise, the anatomic
considerations of otoplasty are those of preservation:
• Preservation of the sulcus.
• Preservation of the natural softness of the auricular
• Preservation of the normal landmarks such as the
posterior wall of the concha (i.e., the middle third of
the antihelix).
■ Otoplasty surgery is all about the endpoint. The right

endpoint can be achieved with a thorough knowledge of

Loss of antihelical fold a normal ear. If the surgeon remembers the following
regarding how the ear should look from various vantage
points, it will aid tremendously in the intraoperative
decision making:
Concho scaphal angle
• From the front, the helical rim should be visible,
greater than 90º poking out from behind the antihelix.
• From the side, the contours of the ear should be
round and soft, never sharp.
Conchal excess • From behind (and this is the most helpful to the
surgeon who is sitting behind the patient
intraoperatively), the contour of the helical rim should
be a straight line, not a “C”, or a “hockey stick”, or
any other shape. If the helical contour is a straight
line, it almost ensures that a harmonious correction
will be achieved.
• Regardless, if the ultimate correction is slightly
Figure 5.2  Main components of the prominent ear. (Reprinted with permission
from Janis JE, Rohrich RJ, Gutowski KA. Otoplasty. Plast Reconstr Surg. under- or slightly overcorrected, a harmonious
2005;115(4):60e–72e.) correction will read as “normal” to the outside
world, and almost all patients will be happy. This is
perhaps the single most important lesson from this
■ When the entire ear requires reconstruction, as in chapter.
microtia, this author prefers to wait until approximately ■ The last judgment is how close to the head the ear

10 years of age. should be placed. The final position of the ear should be
■ In some cases, the parents may want the child to overcorrected minimally to allow for some relapse, but
participate in the decision process, and that will not enough to create an unsatisfactory result if no relapse
necessitate later intervention. should occur.
Operative techniques 87

■ A small crescent of cartilage (≤3 mm at its widest point)

Operative techniques is excised from the posterior wall of the concha at its
junction with the conchal floor.
■ The defect in the concha is closed primarily using
Standard otoplasty for prominent ears numerous 4–0 nylon sutures.
of normal size ■ It is important that the conchal resection be placed

precisely, as lack of attention to the placement of the

■ The incision is made in the retroauricular sulcus. conchal resection is a common cause of complications.
■ In the upper third of the ear, it can be extended up to ■ If the resection is too large or if it is too far up the

the back of the ear to provide adequate exposure to posterior conchal wall, then it will irrevocably deform
place Mustarde sutures between the triangular fossa the antihelix.
and scapha. ■ If the resection is too far anterior in the floor of the

■ No skin is excised, except a small triangle from the concha, it will not decrease the height of the posterior
medial surface of the lobule (not the retrolobular skin), conchal wall, and the closure may be visible.
taking care to preserve enough tissue for a normal ■ A conchal setback suture (Furnas suture) is then placed

earlobe and retrolobular sulcus. between the reduced concha and the mastoid fascia
■ This skin excision on the lobule is frequently necessary using a single 3–0 nylon or 3–0 PDS suture.
for repositioning of the lobule at the end of the ■ This combination of a small conchal resection and a

procedure. small conchal setback avoids the distortion of a large

■ The cartilage is exposed on the posterior (medial) surface conchal resection and the unreliability of a large conchal
of the ear, and soft tissue is excised from deep to the setback.
concha. ■ This author avoids conchal setback alone in all but the

■ In the region of the earlobe, deep dissection is performed mildest cases, as it can narrow the external auditory
under the concha in preparation for lobule repositioning. meatus to the point of significant stenosis (Fig. 5.4).
Branches of the great auricular nerve will be seen and ■ The earlobe is repositioned by closing the triangular

divided. defect on the medial surface of the lobule created by the

■ Mustarde concha–scapha and triangular fossa–scapha skin excision (Fig. 5.5).
sutures are placed using 4–0 clear nylon sutures on an ■ The 5–0 PDS sutures do not just approximate the skin;

FS-2 needle (Fig. 5.3). rather, they approximate the skin AND take a bite of the
■ The number of sutures depends on the how far into the concha deep in the sulcus (similar to Gosain and Recinos).
middle third of the ear the antihelical deficiency extends. ■ Ideally, the endpoint of earlobe repositioning should

■ These sutures are placed in order to create a soft be slight overcorrection because the skin will stretch
curvature to the antihelix, and no attempt is made to over time.
correct the prominence of the ear at this point. ■ The skin is approximated using 5–0 plain gut sutures

■ The Mustarde sutures are not parallel to each other (Figs. 5.6 and 5.7).
but, instead, are arranged like spokes on a wheel,
all pointing toward the top of the tragus (center of Otoplasty for large ears or ears with
the wheel).
■ Care is taken to create a superior crus that curves inadequate helical rim definition
anteriorly such that it terminates almost parallel to the
inferior crus. Incision
■ If the superior crus is created such that it is a direct, ■ An incision is made on the lateral (visible) surface of the
cephalad extension of the antihelix (straight line), the ear, just inside the helical rim (or where the helical rim
result will appear unnatural and amateurish. would be if it is underdeveloped).


Figure 5.3  Technique for the standard otoplasty. The combination of Mustarde sutures, conchal resection/closure, and concha–mastoid sutures is shown. (A) Suture
placement. (B) Suture tightened and ties appropriately. (C) Position of sutures as shown from the surgeon’s vantage point.
88 5 Otoplasty


Figure 5.4  Placement of Furnas concha–mastoid sutures. Note that suture placement too close to the external auditory canal can constrict the canal (far right). (Reprinted
with permission from Janis JE, Rohrich RJ, Gutowski KA. Otoplasty. Plast Reconstr Surg. 2005;115(4):60e–72e.)

■ In addition, an incision in the retroauricular sulcus may

also be required, depending on what additional
maneuvers are required.
■ The lateral incision is extended through the cartilage.

The posterior surface of the cartilage is dissected, just as

if a standard posterior incision had been made.
■ In the case of excessively large ears, the scaphal cartilage

(and perhaps some scaphal skin) are trimmed to the

desired size and shape.
■ Care is taken to excise more cartilage than skin.

■ At this point, the helical rim will be too long for the new

scapha and will require shortening at the end of the

B procedure.
■ Mustarde sutures are placed, if necessary, through this
A anterior access.
■ Conchal resection/setback and earlobe repositioning are

Figure 5.5  Lobule repositioning. The technique for lobule repositioning is performed through a separate incision in the sulcus if
shown. A triangle of skin is excised on the earlobe (A), never compromising the necessary (Fig. 5.8).
appearance of the lobe or the ability for the patient to wear earrings. Sutures are ■ A wedge is then removed from the helical rim so that
placed (B) close to the skin defect while catching a bite of the concha deep in the it will fit the scapha, which is now of lesser
■ The desired resection will leave the helix the correct

length for the new scapha and allow closure without

excess tension.
■ The helix is reapproximated carefully using horizontal

mattress sutures of 5–0 nylon sutures attempting to evert

the skin edges to avoid notching.
■ The lateral incision is closed with a combination of a few

interrupted 5–0 plain sutures and a running 6–0 plain


Otoplasty for constricted ears

■ Constricted ears are tremendously variable, and no
single technique is applicable to all. Tanzer divided
constricted ear deformities into three types: type 1
– involving only the helix, type II – involving the
A B helix and scapha, and type III – extreme cupping of
the ear.
■ The simplest constricted ear deformity is the “lop ear” in
Figure 5.6  Otoplasty. The patient is shown (A) before and (B) after standard
otoplasty. The upper, middle, and lower thirds of the ear have been set back in a which the upper pole of the ear is turned over. There is
harmonious fashion. The contours are soft and natural. always deficiency of tissue in this region.
Operative techniques 89


Figure 5.7  Otoplasty. (A,B) Posterior view before and after otoplasty. The helical rim contour is straight, and the scars are hidden within the sulcus. (C,D) Frontal view
showing harmonious correction and soft natural contours.

■ Other constricted ears may appear prominent because

the helical circumference is inadequate as if the helix has
been tightened excessively like a drawstring, forcing the
ear forward. Thus, the ear cannot lie flat because the
excessively short helical rim draws the auricle into a cup.
■ Any attempt to set back a constricted ear must be

accompanied by elongation of the helix.

■ The most common technique for elongating the helix is by

a variation of the incision described above for large ears.

■ The incision is made inside the helical rim and extended

anteriorly around the crus of the helix into the

preauricular region to the junction of the ear and the
temporal scalp.
■ The crus of the helix is then mobilized, and when

A standard otoplasty maneuvers are performed, the crus of

the helix is recruited into the helical rim.
■ The donor site in the concha is closed primarily as if the

crus of the helix had been taken for a composite graft to

the nose.
■ Any excess or unusable crus of the helix is discarded.

■ In the case of more severely constricted ears (Tanzer type

B III), it is preferable to discard the cartilage and construct
a framework as if the patient had classic microtia.

Otoplasty for cryptotia

■ Cryptotia is the rare condition where the upper portion
of the ear is buried beneath the temporal scalp. The ear
C can often be pulled out of the scalp to examine it.
■ Correction is performed by pulling the ear out of its bed
Figure 5.8  Ear reduction. The technique of ear reduction is shown. (A) The large in the scalp, incising around it in order to release it fully,
ear is examined and reduction is planned. (B) Scaphal cartilage and helical rim and resurfacing the defect behind the upper pole of ear
are excised to the desired size. (C) Helical rim and scaphal defect are closed.
(Redrawn from Argamaso RV. Ear reduction. Plast Reconstr Surg. 1990;85(2):316.) with a skin graft or a local flap.
■ In some cases, the auricular cartilage is normal in

■ In some cases, it is adequate to excise directly the contour and only requires the soft tissue rearrangement
leading edge of the overhanging skin and cartilage to described above for correction.
create a less hooded appearance. ■ In other cases, the cartilage is misshapen, as in a lop ear,

■ In more significant deformities (Tanzer type II), it is and requires cartilage grafting to augment the deficient
necessary to expand the overhanging cartilage with native cartilage framework in addition to the soft tissue
radial cuts and reinforce the area with a conchal graft. considerations.
90 5 Otoplasty

Otoplasty for Stahl’s ears

■ Stahl’s ear is defined by an abnormal crus extending
superolaterally, and the deformity is variable.
■ In the mildest cases, the extra crus is barely noticeable

and can be ignored and the otoplasty performed as if it

were a standard case of prominent ears.
■ More severe deformities include excess scapha in the

region of the abnormal crus and termination of the

abnormal crus in a point (“Mr. Spock” ears).
■ In the most severe cases, there is also complete absence

of the normal superior crus.

■ Correction of the deformity mandates resection of the

abnormal crus.
■ The author makes an incision inside the helical rim as
described above but not through the cartilage.
■ The skin is carefully dissected off the lateral surface of

the cartilage (Fig. 5.9). B

■ The abnormal crus is resected and placed as an onlay

graft to reconstruct the absent superior crus.

■ The cartilaginous defect left by the resected crus is closed

primarily, and the skin is then reapproximated.

Correction of aging, elongated ear lobes

■ A number of techniques have been described, and
the anatomy of the individual patient dictates the
■ The most common procedure in the author’s hands,

however, is amputation of the caudal border of the

lobule with scar placement on the backside of the
earlobe where it is not visible.
■ The ideal contour is drawn on the lobule. The excision is

designed asymmetrically so that the incision is made

caudal to this line on the lateral surface and cephalic to it C
on the medial surface. D
■ This asymmetry leads to greater resection from the

medial side of the earlobe and creates a longer skin flap

on the lateral surface. Figure 5.9  Correction of Stahl’s ear. The lateral skin is reflected, the abnormal
■ The lateral flap is thinned so it is more mobile than its
crus is excised, the cartilage defect is closed primarily, and the cartilage from the
excised crus is used as an onlay graft to recreate the normal superior crus. (A) The
medial counterpart. skin incision is shown inside the helical rim. (B) The abnormal crus is excised.
■ The combination of the asymmetric design, the thinner
(C) The cartilage defect is reapproximated, and the excised cartilage is placed
lateral flap, and the fact that the ends of the defect are as an onlay graft to reconstruct the superior crus. (D) The final result. (Redrawn
not located precisely on the margin of the lobule but from Kaplan HM, Hudson DA. A novel surgical method of repair for Stahl’s ear;
rather slightly medial to it result in the ultimate scar a case report and review of current treatment modalities. Plast Reconstr Surg.
being hidden on the medial surface of the lobule. 1999;103:566–569.)
Numerous sutures, meticulous tapering, and some
patience are required for the best outcome. ■ The medial and lateral skin is closed with nylon sutures,
and no deep, absorbable sutures are used.
Correction of earring-related complications ■ Avoiding absorbable sutures in the subcutaneous tissue

of the lobe seems to minimize the inflammation and

■ While a number of procedures have been described for shorten the recovery and the waiting period before
correction of elongated piercings, the author has found re-piercing.
that simple excision and closure is most effective. ■ The earlobes can be re-pierced in 6 weeks, depending on

■ This technique applies to both elongated earring holes how stiff and fibrotic they are after the repair.
and those that have torn completely through the lobule
■ In the case of a complete traumatic cleft lobule, a Correction of facelift deformities
Z-plasty can be added in an effort to avoid a notch. around the ear
■ In reality, an everted closure using horizontal mattress

sutures seems to yield equivalent results at the lobule ■ Facelift deformities of the ear are frequently
margin. unfixable, leading to lesson number 1 in facelifting:
Further reading 91

AVOID THEM. Problems fall into the following ■ The nocturnal headband is continued for 4–6 weeks,
categories: although most patients confess to discarding it much
• Deformities of the lobule (pixie ear): the result of sooner than that. Remember, the headband should only
excessive anterior and inferior traction on the lobule be tight enough so that it does not fall off.
due to inexpert trimming of the facelift flap. Such
deformities are completely avoidable but difficult to
correct. Complications and outcomes
• The facial skin should be trimmed so that the ear can
barely be pulled out from under it. ■ Most patients who undergo otoplasty are satisfied with
• Deformities of the tragus: consist of either anterior the results, making the procedure gratifying for the
traction on the tragus, amputation of some of the surgeon as well.
tragal cartilage, or excess facial skin at the bottom of ■ Suture complications are relatively common:

the tragus that serves as an across-the-room surgical • The nylon Mustarde sutures may eventually protrude
signature. through the posterior skin. This may occur within the
• There is little that can be done for the first two first few weeks or not for years.
conditions, since too much tissue has been • In some cases, the sutures are associated with
removed. inflammation or a granuloma.
• A lack of definition of the caudal tragus can be • Suture removal immediately cures any apparent
corrected by removing a triangle of skin from the infection and does not seem to lead to recurrence of
caudal aspect of the tragus to recreate the natural, the prominent ear.
right-angle contour. ■ The second most common complication is

• Deformities of the retroauricular sulcus: placing undercorrection or recurrence:

facelift incisions high up on the back of the ear • While this is not ideal, it is far better, in this author’s
repeatedly may result in thinning of the skin and a opinion, than overcorrection or distortion.
pulled-back appearance. ■ Infection and hematoma may also occur.

• Once the deformity is created, there is no solution ■ Unfortunately, patients requesting secondary procedures

except release of the ear and placement of a are not uncommon. The most common complaints of
full-thickness skin graft. these patients are:
• Unsightly scarring: can frequently be improved by ■ Overcorrection. This can usually be improved by

excision and additional facelifting maneuvers as long removing sutures, undermining skin, and occasionally
as no tension is placed on the closure. placing a skin graft.
• The facelift flap should be redraped and trimmed so ■ Visible cartilage irregularities or unnatural contours.

the edges are touching. While a few sutures are Firmin has the best and most impressive series of
placed, no sutures should really be necessary in the patients in this category in whom she has removed the
preauricular region or the postauricular sulcus. damaged cartilage and placed expertly carved pieces of
• Hypertrophic scars are more problematic. Therefore, rib cartilage.
revision of scars should be approached with ■ Unpleasing shape of the ear (e.g., telephone ear,

trepidation. protruding lobules).

• Kenalog injection is helpful and eliminates the need ■ Unpleasing shapes of the ear, such as telephone ear

for revision in many cases. (where the middle third of the ear is overcorrected
• If recurrent hypertrophic scars or real keloids develop, relative to the upper and lower poles), can usually be
the author recommends scar revision with improved significantly simply by restoring the natural
postoperative radiation beginning immediately on the contour harmony.
day of the scar revision. ■ Undercorrection, usually of the upper pole of the ear.

Often easily corrected by revision otoplasty.

Postoperative considerations F U RT H E R R E A D I N G
■ A piece of Xeroform and a soft, bulky dressing are
placed on the skin. The purpose of the dressing is to Argamaso RV. Ear reduction with or without setback otoplasty. Plast
Reconstr Surg. 1989;83(6):967–975.
protect the repair, keep the skin of the ear moist, and Converse JM, Wood-Smith D. Technical details in the surgical
absorb drainage. correction of the lop ear deformity. Plast Reconstr Surg. 1963;31:
■ No attempt is made to put pressure on the ear, and often 118–128.
a doughnut of gauze is placed around each ear Firmin F. Ear reconstruction in cases of typical microtia. Personal
experience based on 352 microtic ear corrections. Scand J Plast
specifically to avoid pressure.
Reconstr Surg Hand Surg. 1998;32(1):35–47.
■ The dressing is left in place 3–5 days depending on
Furnas DW. Correction of prominent ears by concha mastoid sutures.
when the most convenient day for an office visit occurs. Plast Reconstr Surg. 1968;42:189–193.
■ The patient or family is instructed to wear a loose Gosain AK, Recinos RF. A novel approach to correction of the
headband at night only. The goal is to have no pressure prominent lobule during otoplasty. Plast Reconstr Surg.
on the ear during the day and only enough at night to Kajikawa A, Ueda K, Asai E, et al. A new surgical correction of
prevent inadvertent pulling forward of the repaired cryptotia: a new flap design and switched double banner flap. Plast
auricle. Reconstr Surg. 2009;123(3):897–901.
92 5 Otoplasty

Kaplan HM, Hudson DA. A novel surgical method of repair for Stahl’s Stenstroem SJ. A “natural” technique for correction of congenitally
ear: a case report and review of current treatment modalities. Plast prominent ears. Plast Reconstr Surg. 1963;32:509–518.
Reconstr Surg. 1999;103(2):566–569. The technique of otoabrasion is described. The technique was fully
Luckett WH. A new operation for prominent ears based on the embraced by a large number of surgeons.
anatomy of the deformity. Surg Gynecol Obstet. 1910;10:635. Tanzer RC. The constricted (cup and lop) ear. Plast Reconstr Surg.
Matsuo K, Hirose T, Tomono T, et al. Nonsurgical correction of 1975;55:406–415.
congenital auricular deformities in the early neonate. A preliminary Thorne CH. Otoplasty. Plast Reconstr Surg. 2008;122(1):291–292.
report. Plast Reconstr Surg. 1984;73:38–51. The author of this chapter demonstrates his preferred otoplasty technique
McDowell AJ. Goals in otoplasty for protruding ears. Plast Reconstr in a video and emphasizes the role of endpoint visualization when
Surg. 1968;41:17–27. performing the procedure.
This is the first report showing the enormous potential for neonatal Webster GV. The tail of the helix as a key to otoplasty. Plast Reconstr
molding of congenital ear deformities. Surg. 1969;44(5):455–461.
Mustarde JC. The correction of prominent ears using simple mattress This paper describes a technique for repositioning the lobule that is a
sutures. Br J Plast Surg. 1963;16:170–178. classic but with which the author of this chapter has not had success.
Spira M. Otoplasty: what I do now – a 30-year perspective. Plast
Reconstr Surg. 1999;104(3):834–840.
Abdominoplasty and lipoabdominoplasty
This chapter was created using content from Neligan & Rubin, Plastic Surgery
4th edition, Volume 2, Aesthetic, Chapter 23, Abdominoplasty procedures, Dirk F.
Richter and Nina Schwaiger and Chapter 24, Lipoabdominoplasty, Osvaldo Saldanha,
Paulo Rodamilans Sanjuan, Sabina Aparecida Alvarez de Paiva, Osvaldo Ribeiro
Saldanha Filho, Cristianna Bonnetto Saldanha, and Andrés Cánchica.

SYNOPSIS Brief introduction

■ Assessment of the abdominal region includes a detailed medical and ■ Abdominoplasty is one of the most commonly
physical history, including pregnancies; prior surgeries, especially in
performed aesthetic procedures, which encompasses not
the lower truncal area; and weight changes. Preoperative identification
only aesthetic features but also structural reconstruction
of any existing ventral hernia, including diastasis recti, is imperative.
■ Essential abdominal exam findings include the existence and
of the abdominal wall.
■ Due to the number of variations and modifications of
localization of vertical and horizontal tissue excess, the relationship
between fatty excess and skin excess, and examination of the umbilical abdominoplasty procedures, it is critical to select the
stalk with exclusion of umbilical hernia. appropriate technique based upon patient characteristics
■ Further perioperative adjuncts include preoperative bowel evacuation in order to minimize morbidity and postoperative
for reduction of intra-abdominal pressure, careful intraoperative tissue disability while providing a desirable and predictable
handling, maintenance of an adequate body temperature, sufficient result.
medical thromboembolism prophylaxis, precise intraoperative ■ Pregnancy is the most common cause of abdominal

preparation with respect to anatomical key points, postoperative wall aesthetic deformities because the skin and
compression treatment, and early management of postoperative musculoaponeurotic structures are stretched beyond
complications such as seromas. their biomechanical capability to retract.
■ The fleur-de-lis abdominoplasty allows an improvement of the ■ Massive weight loss after dieting or bariatric
entire abdominal area with simultaneous tightening of the waist surgery results in excess, inelastic skin and
circumference. Hereby it is essential to initially assess and temporarily subcutaneous tissue and a laxity of the abdominal
close the vertical line prior to resection of the lower abdominal wall musculature.
redundant tissue. Care should be taken to avoid extending the vertical ■ Fat accumulation occurs in a distribution pattern that
incision line cranially between the breasts. varies according to the gender. Normal anatomic
■ In patients after massive weight loss, aesthetic outcome will improve
abdominal proportions can be found in Fig. 6.1.
by high-lateral-tension (HLT) and fleur-de-lis abdominoplasty. However,
• Women tend to add local adiposity in the lower trunk
in most cases, circumferential truncal procedures are necessary for
and hip region as well as posterior thigh region,
superior results.
■ The preservation of the loose areolar epifascial tissue allows
which can result in cellulite or fibrous septa within
preservation of subfascial lymphatic vessels, which reduces the the subcutaneous tissue.
incidence of seroma formation. • Men tend to add intra-abdominal adipose tissue,
■ It is mandatory to analyze any suspected skin tumor in the area of resulting in an increase in abdominal girth.
excised tissue.
■ Lipoabdominoplasty is a powerful technique that can improve

abdominal contour by combining the effects of abdominoplasty Preoperative considerations

with liposuction. The two fundamental principles of this technique
are preservation of abdominal wall perforators and the use of ■ In addition to standard documentation of other medical
superficial liposuction to reduce the adiposity above Scarpa fascia co-morbidities and medications, the medical history
layer and significantly mobilize the abdominal wall flap. should also include documentation of the following: a

94 6 Abdominoplasty and lipoabdominoplasty

abdominal surgeries, including suction-assisted

lipectomy; and abdominal hernias.
■ Physical examination should be performed in the seated
and upright positions, and should focus on the following
findings and measurements:
• Quality of skin.
• Thickness of adipose tissue by pinching.
• Number and location of folds.
• Location of abdominal wall defects.
• Patient’s favored clothing.
• Pre-existing scars.
• Status of abdominal musculature.
• Distance from umbilicus to top of mons, from
umbilicus to sternal notch, and from anterior vulva
commissure to top of mons.
W • Waist and hip measurement, waist-to-hip ratio.
■ In cases of diagnostic uncertainly, a computed
tomography or magnetic resonance imaging test can be
helpful in determining the presence of hernia.
■ Patient weight should be stable for at least 12 months
C B preoperatively, with any desired weight loss achieved
prior to the surgery.
■ Cessation of smoking should occur ideally 6 weeks prior
to the surgery and after, but at the least 2 weeks prior
and for at least 2 weeks postoperative to minimize the
risk for postoperative wound complications.
■ Patients should take antiseptic showers in the evening
A and morning prior to the surgery; the abdominal folds
H and the umbilicus should be cleaned thoroughly with
cotton sticks and antiseptic solutions.
■ Anticoagulant drugs must be avoided prior to surgery.
The patient should also avoid perioperative use of
various homeopathic drugs and nutritional supplements,
which can induce bleeding.

Anatomical pearls
Figure 6.1  Anatomical landmarks. Normal abdominal anatomic proportions. The
approximate measurements for an average female abdomen are listed. These vary
■ The abdominal wall is embryonically derived in a
according to individual height and bone structure. The umbilicus is located in line segmental manner, reflected in blood supply and
with the most superior point of the iliac crest in 99% of patients. (A) Distance innervation.
between top of mons and anterior vulvar commissure. Average height is 5–7 cm. ■ The umbilicus:
(B) Distance between umbilicus and top of mons. Average height is 11–13 cm. • Situated in the midline, approximately 9–12 cm above
(C) (=A + B) Distance between umbilicus and top of anterior and vulvar the mons pubis.
commissure (C=D). (E) Distance between the costal margin and the iliac crest.
The proportion of this distance to the width of the base of the rib cage (R)
• The periumbical area is characterized by a round or
determines whether the patient is long waisted or short waisted. The normal ellipsoid shape with a slight depression of 4–6 cm in
proportion (E:R) is roughly 1:3 (long waisted approaches 1:2, short waisted diameter.
approaches 1:3).The rib cage tapers inferiorly. A more narrow lower rib cage • The fascia surrounding the umbilicus can be unstable
relative to the width under the armpits helps to emphasize the waist by creating a with an increased incidence for hernias, resulting in a
subtle V. (H) Hip width. A wider pelvis than rib cage emphasizes the waist; the risk of bowel injury during umbilical dissection.
waist is more defined when R<H. W, natural waist – the narrowest point of the
• The blood supply to the periumbilical area is supplied
torso. (Note that the umbilicus usually sits below the natural waist by about
1–4 cm). Relative to the hips, this waist-to-hip (W:H) ratio in healthy women is by branches from the subdermal plexus, from both
roughly 0.72:1; in healthy men, it is roughly 0.83:1. Note that the natural contour deep inferior epigastric arteries as well as the median
of the healthy abdomen reveals a subtle epigastric sagittal depression transitioning umbilical ligament.
to a mild infraumbilical convexity. A subtle vertical sulcus at the lateral rectus ■ The skin of the abdomen has areas of increased adherence
border, which is more distinct in a muscular person, may also be seen. to the underlying fascia (“zones of adherence”), such as
the anterior superior iliac crest and the linea alba.
detailed weight history including current body mass ■ The abdominal subcutaneous tissue is divided by two

index (BMI), history of weight fluctuations, and/or layers of fascia, the superficial Camper fascia and the
history of prior bariatric procedures; a detailed deep Scarpa fascia, a strong fibrous layer of connective
pregnancy history, including number of pregnancies/ tissue, which is continuous with the fascia lata of
children and history of cesarean section; history of other the thigh.
Operative technique 95

■ The superficial fat layer has a more compact character for pregnancy, a history of thromboembolic disease, and
with smaller lobules and a rich vascularization, while the morbid obesity (BMI >40).
deeper fat layer contains larger lobules with a more ■ Patients with disposition to keloids or hypertrophic scars

scattered pattern. have to be informed and must accept the postoperative

■ The abdominal musculature includes four paired scarring associated with these conditions.
muscles, which are the rectus abdominis, connected in
the median linea alba, the external oblique and internal
oblique, and the transversus abdominis muscle, which
incorporate into the anterior and posterior rectus sheath
Operative technique (Video 6.1,
at the linea semilunaris (Fig. 6.2). Video 6.2, Video 6.3)
■ The abdominal lymphatic system is divided into a

supra-umbilical system, which drains into the ipsilateral Marking and positioning
axillary lymph node basin, and an infraumbilical
drainage system, which drains into the ipsilateral ■ The patient should be marked preoperative in the
superficial inguinal lymph node basin. upright position. Borders of underwear, where possible,
■ The lymph vessels in the infra-umbilical area pass should be marked in an attempt to place the scar in a
through the subscarpal plane, explaining the importance hidden position (Fig. 6.5).
of Scarpa fascia preservation in abdominal wall surgery. ■ The expected resection should be estimated by the pinch

■ Huger described different zones of the abdominal blood test (Fig. 6.6).
supply, which should guide the surgeon in planning and ■ The lower incision line will run parallel to the scar line

performing a safe operation (Fig. 6.3): and is normally below the abdominal fold and 6–7 cm
• Zone 1: the midline supplied by the vertically superior to the vulvar commissure.
oriented deep epigastric arcade. ■ The upper incision line is an estimate and should be

• Zone II: the lower abdominal circulation supplied by tailored intraoperatively depending on tension.
the superficial epigastric, superficial external ■ Local fat depots are marked for guidance with adjunctive

pudendal, and superficial circumflex iliac systems. liposuction.

• Zone III: the lateral aspect of the abdominal wall ■ Perioperative thromboprophylaxis with sequential

(flanks) supplied by the six lateral intercostal and four compression devices should be implemented in all
lumbar arteries. patients having abdominal wall surgery. In many cases,
■ In standard abdominoplasty procedures, the cutaneous the intraoperative and postoperative use of heparin may
blood supply to zone I and a main part of zone II is also be indicated.
disrupted, resulting in an abdominal flap perfusion ■ While antibiotic prophylaxis is not universally required,

mainly supplied by zone III. Therefore, it is crucial to it may be indicated as a single preoperative dose,
study any preoperative existing scar, such as subcostal especially if a hernia is present.
cholecystectomy incisions. In certain circumstances, ■ Patient positioning on the operating room table should

even a vertical midline incision can jeopardize flap include adequate padding of feet, knees, buttocks,
perfusion. back (especially for hyperlordosis cases), shoulders,
■ Cutaneous sensation of the abdominal wall is derived and head. In addition, the patient’s hips should
from the anterior and lateral cutaneous branches of the be placed at the level of the break in the table for
intercostal nerves 8 to 12. adequate flexion during the wound closure portion of
■ The anterior branches pass between the internal oblique the case.
and transversus abdominis muscles, enter the rectus
abdominis muscle, and reach the overlying fascia Mini abdominoplasty
and skin.
■ The lateral cutaneous branches penetrate the intercostal ■ Characterized by a transverse incision that is shorter
muscles in the midaxillary line, ending in the than the incision used in full abdominoplasty
subcutaneous layer. procedures.
■ Both branches are responsible for the overlapping of the ■ Indicated in patients with a mild to moderate skin laxity

sensory dermatomes T5 to L1. and tissue excess of the lower (infraumbilical) abdomen,
■ The ilioinguinal and iliohypogastric nerves, not involved together with a sufficient distance between the
in innervation of the abdominal wall, can be disrupted symphysis and the umbilicus.
and injured in lateral transverse lower abdominal ■ Common for young women with a pre-existing

incisions, resulting in consistent sensory loss in the area Pfannenstiel incision to benefit from this technique.
of the groin and medioventral thigh (Fig. 6.4). ■ A distance of at least 9 cm between the upper resection

■ Patients with significant health risks, unrealistic surgical line and the umbilicus should be strictly respected to
goals, and body dysmorphic disorder are primary avoid an unaesthetic appearance. If, after skin resection,
contraindications for an elective abdominoplasty the distance is expected to be less than 9 cm, umbilical
procedure. transposition should be preferred (Fig. 6.7).
■ Relative contraindications to abdominoplasty include ■ The primary limitation of this procedure is the presence

right, left, or bilateral upper quadrant scars, further of upper abdominal skin folds and rolls; these patients
severe co-morbid conditions (e.g., heart disease, diabetes, will require one of the more extensive procedures
morbid obesity, cigarette smoking), eventual future plans described subsequently in this chapter.
96 6 Abdominoplasty and lipoabdominoplasty

Pectoralis major

Anterior rectus
Rectus abdominis epigastric artery

External oblique

Internal oblique
Superficial inferior
epigastric artery

Superficial circumflex
circumflex iliac artery
iliac artery

Superficial external pudendal artery Deep inferior epigastric artery

Semilunaris line

Arcuate line

Figure 6.2  (A) Anatomy of the musculature of the abdominal wall with arterial supply. (B) Arcuate line and linea semilunaris.
Operative technique 97

Superior epigastric artery

Intercostal artery

Zone I
Subcostal artery

Lumbar branches

Ascending branch of deep

circumflex iliac artery
Zone III Zone III
Inferior epigastric artery

Superficial epigastric artery Zone II

Figure 6.3  Zones of blood supply (Huger WE, 1978).

Table 6.1  The different techniques used in abdominoplasty are discussed in detail below. This table shows the indications for the
various techniques

Mini Modern Short-T Standard HLT Anchor Circular Reverse

Lower abdomen + ++ ++ +++ +++ +++ +++ 0
Periumbilical (+) + + ++ ++ +++ ++ (+)
Upper abdomen 0 (+) + ++ ++ +++ ++ +++
Diastasis/hernia (+) + ++ ++ ++ +++ ++ (+)
Flanks/hips/thighs 0 0 0 (+) + ++ +++ 0
Abbreviations: HLT, High lateral tension.

Abdominoplasty with umbilical transection Standard abdominoplasty (Fig. 6.9)

(Fig. 6.8 and Table 6.1)
■ Indicated in patients presenting with skin and soft tissue
■ Abdominoplasty with a prefascial release and excess of the upper and lower abdomen who will accept
transposition of the umbilicus without circumferential a periumbilical scar.
release from the abdominal flap, thereby avoiding a ■ The inferior incision is made first and carried down

periumbilical scar. through Scarpa fascia to the rectus fascia.

■ Therefore, this technique represents a good alternative ■ The abdominal flap elevated in a suprafascial plan.

between mini abdominoplasty and standard ■ Through a circumferential, periareolar incision, the

abdominoplasty procedures. umbilicus is freed from the abdominal flap.

98 6 Abdominoplasty and lipoabdominoplasty

Latissimus dorsi

Serratus anterior
Lateral cutaneous branches
of intercostal nerve

Intercostal nerve
Lateral cutaneous branches
External oblique (cut)

Internal oblique (cut)

Anterior cutaneous branch Tenth intercostal nerve

Rectus abdominis (cut)
External oblique Eleventh intercostal nerve
Transversus abdominis
Subcostal nerve

Arcuate line
Transversalis fascia
Iliohypogastric nerve
Ilio-inguinal nerve

Inguinal ligament Anterior lamina of rectus sheath

Round ligament of uterus

Figure 6.4  Abdominal nerves.

■ Supraumbilically, the abdominal flap is undermined ■ The umbilicoplasty can be performed in many ways,
primarily in the midline to the level of the xiphoid. including skin incisions involving an ellipsoid, chevron,
■ In cases of rectus diastasis, plication of the anterior or shield shape.
rectus sheath from the xiphoid to the symphysis is ■ The umbilicus is best secured using absorbable

accomplished using non-absorbable suture material. deep-dermal sutures and a running skin closure.
■ Paramedian plication of the anterior rectus sheath may ■ Two subcutaneous drains are often inserted to assist with

facilitate a correction of an asymmetrically located postoperative fluid drainage.

umbilical stalk or for accentuation of an hourglass figure
with further waist tightening. High-lateral-tension abdominoplasty
■ The patient is flexed at the hip approximately 30°,

and the abdominal flap is pulled inferomedially to ■ Extended modification of the traditional abdominoplasty
determine the appropriate position of the superior skin procedure that also treats the hips and the lateral thigh.
incision. ■ A modified skin incision/resection is utilized to lead to

■ Once the superior skin incision is made, the medial more conservative resection centrally with wider excision
portion of the wound is temporarily closed to allow of the lateral skin (Fig. 6.10).
marking of the new location for the umbilicus. ■ Suitable for patients that want their hips and lateral

■ Wound closure is performed in layers, and if significant thighs addressed, patients after massive weight loss, and
dead space exists, progressive tension sutures may in patients for whom an abdominoplasty is deficient and
be used. a lower bodylift is beyond their needs (Fig. 6.11).
Operative technique 99



Figure 6.5  Markings are to be performed with respect to the anterior vulva
commissure and the umbilicus.
Figure 6.7  Preoperative markings for a short scar abdominoplasty. The red line
demonstrates the resulting scar line. It is essential to respect the umbilico–pubic
distance. The distance from the upper resection line to the umbilicus should be at
least 9 cm.

■ The key in planning this procedure is to independently

assess the horizontal and vertical excess of skin and fat
tissue (Fig. 6.12).
■ In this technique, the umbilicus must be integrated into

the vertical scar.

■ In general, the vertical resection should be performed

first and prior to horizontal resection to reduce the risk

Figure 6.6  Pinching of the abdominal tissue in upright and supine position. of over-resection (Fig. 6.13).

Reverse abdominoplasty
Fleur-de-lis abdominoplasty ■ Performed in patients who require tightening of skin in
the upper abdomen alone.
■ Includes a vertical midline scar that allows elimination ■ The most common indication is the massive weight loss

of horizontal and vertical skin/subcutaneous tissue patient who has undergone a conventional
redundancy. abdominoplasty and still suffers from persistent skin and
■ Suitable for patients suffering from a tissue excess of the soft tissue excess of the upper abdomen.
lower and particularly of the upper abdomen in the ■ The marking is performed with the patient in upright

horizontal direction. This often includes patients after position. The patient is asked to slightly bend forward
massive weight loss and in those who have pre-existing for demonstration of tissue excess. This enables an
midline abdominal scars. optimal assessment of the vertical and horizontal tissue
100 6 Abdominoplasty and lipoabdominoplasty

excess. The inframammary fold is then marked Vertical abdominoplasty

extending laterally to the anterior axillary line.
The width of resection is generally less than 15 cm ■ The vertical abdominoplasty refers to a purely vertical
(Fig. 6.14). incision with lateral mobilization of abdominal soft
■ In selective cases, the excess tissue may be utilized tissue.
de-epithelialized and rotated cranially for autologous ■ Indicated in patients with a pre-existing scar in the

augmentation of the breast as part of a mastopexy abdominal midline who seek improvement of abdominal
procedures. contour without additional transverse scars.




Figure 6.8  Intraoperative view of abdominoplasty with umbilical transection. (A) Markings in the supine position; (B,C) preservation of Scarpa fascia; (D,E) preparation of
the umbilical stalk; (F) closure of the umbilical base with nonresorbable suture material;
Operative technique 101



Figure 6.8, cont’d (G,H) assessment of the distance between upper resection line and the umbilicus with resection of the redundant tissue; (I) refixation of the umbilical
stalk to the anterior rectus sheath; and (J) the intraoperative result.


Figure 6.9  A 42-year-old woman with remarkable amount of striae distensae in the periumbilical region after a single pregnancy. Pre- (A,B) and postoperative
(C,D) oblique and front images of a standard abdominoplasty procedure with incomplete elimination of striae.
102 6 Abdominoplasty and lipoabdominoplasty


90˚ 90˚


Figure 6.11  A 54-year-old patient with a massive skin and soft tissue redundancy
at the abdominal and flank region. Pre- (A,B) and 3 months postoperative
(C,D) oblique and front images of a high-lateral-tension (HLT) abdominoplasty
procedure with fascial tightening without any additional liposuction.

Figure 6.10  High-lateral-tension (HLT) abdominoplasty pattern.

A B Figure 6.12  Fleur-de-lis markings.

(A) AP view. (B) Oblique view.
Postoperative considerations 103


Figure 6.13  A 49-year-old patient with weight reduction of 50 kg with circumferential skin excess in the abdominal, flank, lateral/medial thigh, and gluteal regions. After
rejecting a lower bodylift, the patient underwent a fleur-de-lis abdominoplasty. Pre- (A,B) and 3 months postoperative (C,D) oblique and front images of a fleur-de-lis
abdominoplasty procedure with fascial tightening.


Figure 6.14  A 52-year-old patient after an open laparotomy procedure with a transverse scar. Pre- (A,B) and postoperative (C,D) front view following a reverse
abdominoplasty procedure.

■ After the liposuction is completed, the incisions are

Lipoabdominoplasty made in the lower abdomen, and the senior author
preserves Scarpa fascia laterally and up to the level of
■ Lipoabdominoplasty combines the benefits of liposuction the umbilicus (Fig. 6.18).
and traditional abdominoplasty to improve abdominal ■ In the midline overlying the diastasis, the tunnels created

contour and preserve abdominal perforators. by the superficial liposuction can be selectively
■ Fundamentals of the technique involve avoidance of undermined, only to the medial border of the rectus
wide undermining superiorly and instead relying upon muscles, to complete rectus plication. By limiting the
the tunneling from superficial liposuction to create undermining to this region alone, you can avoid injury
abdominal flap mobility (Fig. 6.15). to the abdominal perforators originating over the rectus
■ Patients are marked in similar fashion to traditional muscle proper (Fig. 6.19).
abdominoplasty; however, the rectus diastasis should ■ Excess skin resection and closure can be performed in

also be marked, as this represents the area in the similar fashion to traditional abdominoplasty
supraumbilical region where the tunneling is to (Video 6.1).
be performed rather than traditional undermining
(Fig. 6.16).
■ The patient is placed in the supine position, and the

epigastric and subcostal areas are infiltrated with Postoperative considerations

tumescent solution. Liposuction is performed in this
region with the patient in a hyperextended position. ■ The operation can be performed as outpatient or
Care is made to maintain flap thickness to avoid vascular inpatient surgery.
impairment and contour deformities. The lower ■ Drains are left in place until discharge is less than 30 mL

abdomen should not be aspirated (Fig. 6.17). in 24 h.

104 6 Abdominoplasty and lipoabdominoplasty

Abdominoplasty Lipoabdominoplasty
‘Saldanha’s technique’

100% 30%


Figure 6.15  (A) Surgical undermining in conventional abdominoplasty interrupts the vascular perforators from the rectus muscles. (B) Lipoabdominoplasty preserves
vascular perforators from the rectus muscles but allows for a relatively avascular midline tunnel to perform rectus plication. The broken lines indicate the incisions; note
that they are shorter in lipoabdominoplasty.

Figure 6.17  Superior abdominal liposuction.

Figure 6.16  Previous demarcation of diastasis.

Further reading 105

■ Persistent seromas may require an indwelling drain or,

in the case of a late encapsulated seroma, a secondary
surgical procedure.
■ Minor wound dehiscence is common and is normally a

self-limiting problem.
■ Many local problems of a cosmetic nature can result

from abdominoplasty, including lateral dog ears,

widened or hypertrophic scars, malpositioned scars, and
numerous cosmetic problems directly related to the
■ Most of these problems can be avoided with proper

preoperative planning and attention to surgical detail.

■ If liposuction has been done simultaneously, issues

pertaining to that procedure include contour

irregularities and dermal tethering.
Figure 6.18  The Scarpa fascia is preserved. ■ Systemic complications include deep vein thrombosis,

pulmonary embolism, respiratory compromise due to

increased intra-abdominal pressure, and systemic
infections including toxic shock syndrome.
■ All of these complications are potentially lethal and must

be dealt with expeditiously.

■ Abdominoplasty, especially when combined with other

procedures such as liposuction, has a higher systemic

complication rate than any other type of routine cosmetic
surgical procedure.


Aly AS. Body Contouring After Massive Weight Loss. St Louis: Quality
Medical; 2006.
This work is published by a currently “leading postbariatric surgeon”. Aly
has composed a unique work on all reliable techniques for body contouring
of patients after massive weight loss.
Bozola AR. Abdominoplasty: same classification and a new treatment
concept 20 years later. Aesthetic Plast Surg. 2010;34(2):181–192.
Figure 6.19  Selective undermining of the tunnel. Costa-Ferreira A, Rebelo M, Vásconez LO, et al. Scarpa fascia
preservation during abdominoplasty: a prospective study. Plast
Reconstr Surg. 2010;125(4):1232–1239.
■ The patient should rest in a relaxed position with a Dellon AL. Fleur-de-lis abdominoplasty. Aesthetic Plast Surg. 1985;9:27.
flexion of approximately 30° at the hip joint. Dellon first published, in 1985, his approach to a vertical and horizontal
■ This position should be retained for 2–3 weeks restoration of the abdominal wall through a combined resection, the
postoperatively in order to assure a tension-free healing “fleur-de-lis” technique.
Huger WE Jr. The anatomic rationale for abdominal lipectomy. Am
of the scar. Surg. 1979;45(9):612–617.
■ Sporting activities should be omitted for 6 weeks
Hunstad JP, Repta R. Atlas of Abdominoplasty. Philadelphia: Saunders
postoperatively and, in cases of fascial reconstruction, for Elsevier; 2009.
8 weeks. This major work on all current abdominoplasty procedures is written
■ Patient should be advised to avoid saunas and by a leading authority on this subject, covering all topics from patient
selection, incision placement, and ancillary procedures up to all possible
tanning beds. complications by highlighting key considerations for a safe and successful
■ A compression garment should be worn for the same performance.
period of time. Lockwood T. High lateral-tension abdominoplasty with superficial
fascial system suspension. Plast Reconstr Surg. 1995;96:603–608.
This article describes the principles and details of this new approach to

Complications and outcomes abdominoplasty. It offers an alternative technique, especially in patients

after massive weight loss with limited treatment of the flanks.
Pitanguy I. Abdominolipectomy. An approach to it through an analysis
■ Patients can expect postoperative pain or soreness, of 300 consecutive cases. Plast Reconstr Surg. 1967;40:384.
Saldanha OR, Pinto EB, Matos WN Jr, et al. Lipoabdominoplasty
numbness of the abdominal flap, bruising, general
without undermining. Aesthet Surg J. 2001;21(6):518–526.
fatigue, and discomfort due to increased abdominal Song AY, Jean RD, Hurwitz DJ, et al. A classification of contour
tension for many weeks. deformities after bariatric weight loss: the Pittsburgh Rating Scale.
■ Local complications include hematoma, seroma, wound Plast Reconstr Surg. 2005;116(5):1535–1546.
infection, fat necrosis, wound dehiscence, paresthesia, Rubin, as a currently “leading postbariatric surgeon”, has published
an interesting work on the different deformities in patients after
and persisting numbness. bariatric weight loss, which may serve as a guideline for plastic surgeons
■ Seromas are the most common problem and are usually
during preoperative planning and for evaluation of their postoperative
handled with serial punctures and drainage. outcomes.
Body contouring
This chapter was created using content from Neligan & Rubin, Plastic Surgery
4th edition, Volume 2, Aesthetic, Chapter 25.1, Circumferential approaches to
truncal contouring: Introduction, J. Peter Rubin, and Chapter 25.2 Circumferential
approaches to truncal contouring: Belt lipectomy, Al S. Aly, Khalid Al-Zahrani,
and Albert Cram, 25.3 Circumferential approaches to truncal contouring: The lower
lipo-bodylift, Dirk F. Richter and Nina Schwaiger, Chapter 25.4, Circumferential
approaches to truncal contouring: Autologous buttocks augmentation with purse
string gluteoplasty, Joseph P. Hunstad, and Nicholas A. Flugstad, and Chapter 25.5,
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.

Brief introduction
■ The skin/fat envelope is tethered to the underlying musculoskeletal
anatomy in zones of adherence. These include the spine, the sternum, ■ Circumferential approaches to body contouring are a
the linea alba of the abdomen, the inguinal area, the suprapubic area, cornerstone for reshaping of the trunk after pregnancy,
and the area between the hip and lateral thigh fat. weight loss, or aging.
■ Massive weight loss (MWL) patients make up the majority of patients ■ Procedures for trunk contour reshaping differ in design

who undergo lower bodylift/belt lipectomy surgery. Second are and execution, and body contouring surgeons should
females with a body mass index (BMI) in the range of 26–28. Third are understand the fundamental principles of each
normal-weight females who wish a more dramatic improvement than procedure and be able to apply these in an
an abdominoplasty alone. individualized approach to meet each patient’s unique
■ Three factors affect patient presentation: the BMI, the fat deposition
anatomical features and aesthetic goals.
pattern, and the quality of the skin/fat envelope. • In broad strokes, the belt lipectomy is a powerful tool
■ Bodylift/belt lipectomy procedures can be thought of as a
for refining the waistline, while the lower bodylift
circumferential wedge excision of the lower trunk. One end of the generally has a more inferior zone of resection and
spectrum of procedures is the lower bodylift type II (Lockwood effectively enhances lateral thigh and buttock shape.
technique), and the other end is the belt lipectomy/central bodylift ■ Innovations in tissue repositioning during
(Aly and Cram technique).
■ Patients presenting for this surgery require a complete medical
circumferential bodylifting have enabled significant
advances in buttock shaping with local flaps.
assessment and a thorough physical examination.
■ Body contour deformities of the lower trunk can range
■ In planning a bodylift/belt lipectomy, scar position can be approximated

by simulating the tissue dynamics at the time of closure. Anteriorly, the from “anterior only” to “circumferential” deformities.
inferior marks control the scar position, and posteriorly, the superior • If problems are restricted to isolated moderate
marks control the scar position. lipodystrophy deposits, then liposuction may be the
■ The operative sequence usually involves anterior surgery first, followed only treatment modality needed.
by posterior surgery and closure. • Anteriorly, if skin laxity and/or abdominal wall
■ Postoperative care requires hospital-level nursing with attention to weakness are encountered, then abdominoplasty
patient positioning, early ambulation, fluid infusion, and pain control. techniques are needed to create the best contour.
■ While major complications are possible, the commonest problem is • If the deformities involve skin and subcutaneous
seroma. laxity circumferentially, then bodylift/belt lipectomy

Preoperative considerations 107

procedures are usually required to adequately address • If the concept of maintaining tension around the trunk
the issues. is ignored in patients who need improvements
■ Although it is true that tension is bad for scarring and circumferentially, either by doing an abdominoplasty
blood supply, tension is essential for improving body or a T-type (fleur-de-lis) resection, the results are less
contour in excisional procedures. than ideal, with the lateral and posterior aspects of
• In abdominoplasty, the elliptical excision creates the the lower trunk remaining unchanged after surgery
greatest amount of tension in the central zone of the (Fig. 7.3).
abdomen. Thus, the areas above and below this
region, superiorly the epigastric region and inferiorly
the mons pubis, demonstrate the greatest amount of Preoperative considerations
• As the elliptical excision is followed laterally, the ■ There are three groups that can potentially benefit from
amount of tension decreases, reaching zero at its bodylift/belt lipectomy procedures: massive weight loss
lateral edges (Fig. 7.1). Thus, the improvements above (MWL) patients, the 20–30 pounds overweight group,
and below the excision, the anterior thighs, and the and the normal-weight patients group.
lateral abdomen also decrease in magnitude as the ■ MWL patients:

elliptical excision is traversed from medial to lateral. • Make up the majority of patients who undergo
• In an ordinary low BMI patient with “anterior only” bodylift/belt lipectomy.
deformities, there is little need for improvement above • The lower trunk of MWL patients can be thought of
and below the excision, outside of the anterior as a balloon. As patients gain weight and then lose it,
abdomen. the balloon is initially stretched by the weight gain,
• However, in most massive-weight patients, many then deflated as weight loss ensues. The intrinsic
20–30 pounds overweight patients, and some elasticity of the skin is often irreversibly altered,
normal-weight patients, there is a need for significant leading to redundant lax skin, which is almost always
improvements above and below the level of excision circumferential in nature. The usual pattern is of an
circumferentially around the entire lower trunk inverted cone (Fig. 7.4).
(Fig. 7.2). Thus, with the tension maintained ■ The 20–30 pound overweight group (BMI range of

circumferentially, the improvement is also maintained 26–28):

circumferentially above and below the excision. • Women who have never lost any significant weight
despite reasonable exercise and nutritional habits.
• Often present with lipodystrophy of the lower trunk
that is circumferential in nature, which leads to
generalized lack of definition of the lower trunk
(Fig. 7.5).
■ Normal-weight patients group:

• Ordinarily would be considered candidates for an

abdominoplasty but desire more dramatic
improvements in lower truncal contour.
• These patients often desire a remarkable improvement
in their anterior thighs, lateral thighs, buttocks, and
lower back.
• In many similar patients, liposuction can improve
all of these areas when combined with an
abdominoplasty; however, if patients desire significant
lifting and contour delineation, then a circumferential
excisional procedure is required (Fig. 7.6).
• A subgroup of normal-weight patients who can
benefit from a bodylift/belt lipectomy is the older
patient whose skin will not contract with liposuction
due to skin laxity and will require the pull created by
the circumferential excision (Fig. 7.7).
■ Three factors seem to affect the presentation of patients

seeking truncal contouring procedures: the BMI at

presentation, the fat deposition pattern, and the quality
of the skin/fat envelope.
Figure 7.1  The black arrows indicate the amount of tension that will be created at • MWL patients will present to the plastic surgeons at
closure after the proposed resection of the abdominoplasty ellipse. The greatest different BMI levels (Fig. 7.8).
amount of tension is central and trails off to zero at the lateral edge of the elliptical • The type of deformity that an MWL patient presents
closure. The extent of body contour improvement above and below the resection is
directly related to the amount of tension. Thus, the extent of improvement, light
with also depends on their particular fat deposition
blue, above and below the final scar will also be greatest centrally and fizzle to pattern. Humans are born with a genetically
zero, laterally. This patient does not need improvement laterally, above and below controlled pattern of fat deposition, as well as a fat
the proposed excision, thus is an ideal candidate for an abdominoplasty. loss pattern. Females generally tend to store fat in the
Text continued on p. 112
108 7 Body contouring

Figure 7.2  In a patient with circumferential deformities above and below the proposed area of excision, there is a need to maintain excisional tension circumferentially to
attain the appropriate improvements in all the involved areas.
Preoperative considerations 109

Figure 7.3  Note in this massive weight loss patient, the improvements attained by a traditional abdominoplasty are limited to the central anterior abdomen, shown below.
Because there is no tension created by the abdominoplasty laterally and posteriorly, shown by the loss of light blue color, above, there is no improvement in these areas.

Figure 7.4  The figure demonstrates the typical shape of the lower trunk after massive weight loss; a three-dimensional “inverted cone”.
110 7 Body contouring

Figure 7.5  This patient is typical of the “20–30 pound overweight” group. Note the generalized circumferential lipodystrophy of the lower trunk.
Preoperative considerations 111

Figure 7.6  This patient presented in her mid-30s with a desire to improve her abdominal contour but also desired the best possible contour of her entire lower trunk,
which included better waist definition, lifting of her anterior and lateral thighs, as well as a buttocks lift.
112 7 Body contouring

Figure 7.7  A patient in her 60s is shown before and after a belt lipectomy. Patients in this age group often do not attain enough skin retraction through liposuction and
may require an excisional procedure to attain the best possible contour.

extraperitoneal space, the lower abdomen, hips, and • If the pinch demonstrates very little translation of pull
thighs – a pattern often referred to as “pear shaped” to these areas, as in the case of patients who present
(Fig. 7.9). Males tend to store fat more centrally in with high BMIs and thick, non-pliable skin/fat
what is often referred to as an “apple-shaped” envelopes, this can be used to predict the final result.
configuration, where fat is deposited intraperitoneally • As a general rule, the greater the BMI drop, the more
and in the flanks (or “love handles”), and less fat is translation of pull will be present.
deposited in the thighs (see Fig. 7.9).
• The skin/fat envelope is important in determining
what must be done to meet patient goals. Some
patients present with very pliable and thin skin/fat
Common presentation of the massive
envelopes, while others will present with very thick, weight loss patient
non-pliable tissues.
■ A concept that is helpful in examining these patients is • Almost all present with a “hanging panniculus”
the “translation of pull” (Fig. 7.10). (Fig. 7.11).
• The lateral abdominal tissues are pinched, simulating • Almost every patient will present with a “ptotic mons
the effects of the lateral abdominal resection of a pubis”.
bodylift/belt lipectomy on the distal thigh, which can • The waist, which is the narrowest aspect of the lower
be predictive of the final result with a certain degree trunk between the ribs and the pelvic rim, can be
of accuracy. blunted in many MWL patients by the hanging skin/
Figure 7.8  Six massive weight loss patients are shown at presentation after weight stabilization. Note the significant amount of variability in BMI, fat deposition pattern,
and quality of the skin/fat envelope.

Figure 7.9  Two patients demonstrating the two most common fat deposition patterns. On the left, the “apple” shape is shown, most often encountered in males, although
demonstrated in a female here. On the right, the typical “pear-shaped” female pattern of fat deposition is shown.
114 7 Body contouring

Figure 7.10  The “translation of pull” is demonstrated in this figure. The patient in the middle picture is demonstrating the potential distant effects of the proposed
resection, simulated by the pinching hands. Note the postoperative anterior thigh contour is fairly similar to the preoperative pinch.
Common presentation of the massive weight loss patient 115

Figure 7.11  Six massive weight loss patients demonstrating the variety in shape and size of their presenting panniculi.

soft tissue envelope, as it drapes from the ribs to ■ Patients with collagen vascular disease should also be
below the pelvic rim. approached with extreme caution.
• The anterior and lateral thighs are usually ptotic. ■ The BMI at presentation should be a very important

• The buttocks are usually ptotic due to the effects of factor in determining whether a plastic surgeon should
the weight gain/loss process. This can present with a operate.
lack of demarcation between the lower back and • Complications increase with increasing BMIs, and as a
buttocks (Fig. 7.12). result, many plastic surgeons do not operate on
• Many patients present with back rolls. Some are patients who present with a BMI >32.
located in the lower back and may be improved with • If choosing to operate on higher BMI patients, these
bodylift/belt lipectomy. Some present superiorly, patients must accept a much higher complication rate,
usually contiguous with breast rolls, and are not especially if the BMI is > 35, where the complication
affected by bodylift/belt lipectomy and must be rate is around 100%.
addressed through upper bodylift procedures ■ Ideally, it is best to delay body contouring procedures

(Fig. 7.13). until patients have stabilized their weight loss for a
minimum of 3 months.
Patient selection criteria • For lap-band patients, the average time to weight
stability is around 2 years.
■ Significant cardiopulmonary disease is a contraindication • For gastric bypass and gastric sleeve procedures, the
for bodylift/belt lipectomy procedures. average is around 18 months.
■ Smoking is considered a contraindication by most • For duodenal switch procedures, the average is 12–14
surgeons. months.
116 7 Body contouring

Figure 7.12  The variety in shape and size of the buttocks is demonstrated in these six massive weight loss patients. The accompanying lipodystrophy of the hip region, as
well as the descent of the buttocks, often contribute to a lack of buttocks definition and demarcation from the lower back.

■ If a patient presents with too much intra-abdominal

BOX 7.1  Patient selection
content to allow flattening of abdominal contour by
muscle wall plication, then the result of a circumferential
• Medical stability
procedure is very similar to that attainable by
• Psychiatric stability
panniculectomy, and thus, it would thus be prudent to • Non-smoker (most surgeons but not all)
avoid the increased risk of the circumferential excision • Low intra-abdominal content
and limit the procedure to a panniculectomy only. • Weight stability
■ The recovery period after a circumferential

dermatolipectomy can be quite challenging, both

physically and psychologically. Choosing a patient with
unstable psychological problems to go through the ascertain the etiology of their lower trunk abnormalities,
prolonged and arduous recovery can result in disastrous which include aging, child birth, skin laxity due to sun
consequences. exposure, and MWL. If the main cause is weight loss,
■ Criteria for patient selection are given in Box. 7.1. then the following questions should be answered:
• What was their greatest weight?
• How did they lose weight?
Preoperative evaluation • What was their lowest weight?
• How long have they been at their present weight?
■ A detailed weight history is essential in patients who • Do they think they are going to lose more weight?
present for lower truncal contouring. It is important to • Are they prone to “heroic methods” of weight loss?
Preoperative evaluation 117

Figure 7.13  Six different massive weight loss patients demonstrating the variety of back roll presentations. The mid- to lower back rolls are often reduced or eliminated
after bodylift/belt lipectomy, but the upper back rolls are not.

■ A careful history of all significant medical problems, • The degree of rectus diastasis and/or the presence of
including nutritional habits, nutritional supplementation hernias.
requirements, and nutritional deficits, should be • The amount of intra-abdominal content must be
obtained. noted. This can be assessed with the patient lying
■ Some surgeons my require psychiatric clearance for each supine and relaxed. If the abdominal contour is
belt lipectomy/bodylift patient to emphasize the scaphoid and the abdominal wall falls below the rib
extensive nature of the surgery to the patient as well as cage, then it would be expected that rectus fascia
alerting the mental healthcare provider that their services plication will be effective in flattening the contour.
may be required in the postoperative period. If the abdominal tissues are above the level of the
■ The following points should be carefully noted on ribs, then it can be presumed that intra-abdominal
physical examination: contents are large enough to prevent effective
• The degree of skin laxity. plication (see Fig. 7.9).
• The amount of subcutaneous fat. • The degree of buttocks projection and ptosis.
• The translation of pull, as described above. • The degree of anterior and lateral thigh lipodystrophy
• The presence of scars (e.g., subcostal cholecystectomy and ptosis.
scars may jeopardize the flap vascularity, and vertical • An extensive set of labs should be obtained as early
midline scars may limit abdominal flap inferior as possible in the care of the patient because it may
mobility). take some time to correct abnormalities. These labs
• Waist definition. should include a complete blood count, blood urea
• The presence of abdominal or back rolls. nitrogen, creatinine, electrolytes, glucose, urinalysis,
118 7 Body contouring


Strong adherence Less adherent Variable adherence

Figure 7.14  The zones of adherence of the trunk. Note the inferomedial descent of tissues that occurs with aging and/or weight loss.

liver function tests, iron, calcium, albumin, Operative techniques (Video 7.1)
pre-albumin, total protein, vitamin B, magnesium,
and thiamine. ■ The main differences between a belt lipectomy and lower
• Chest X-ray and electrocardiogram are obtained if bodylift:
indicated. • Belt lipectomy procedures overall have a more
superiorly based wedge excision of the trunk when
compared with a lower bodylift.
Anatomical pearls • The lower bodylift can be thought of as a truncal–
thigh lift with a lower scar and greater effects on
■ When contemplating circumferential dermatolipectomy thigh soft tissues as compared to just a truncal lift
of the lower trunk, a thorough understanding of with a belt lipectomy.
abdominal wall blood supply is critical. • Although there is some weakening of the zone of
■ Subcutaneous abdominal fat is divided into superficial adherence between the hip and lateral thighs in a belt
and deep layers by the superficial fascial system (Scarpa lipectomy, no attempt is made to completely disrupt
fascia). them; thus, less effect is seen in the thighs.
• In thin patients, the two layers are fairly close to each • In contrast, the lower bodylift often utilizes
other in thickness. In patients who have a high BMI, discontinuous undermining of the thigh zone of
the superficial layer is often much thicker than the adherence using a Lockwood dissector or via
deep layer. aggressive liposuction to allow greater thigh
■ Zones of adherence: areas within the trunk where effects.
the skin/fat envelope is tethered to the underlying • Thus, a belt lipectomy results in a more superiorly
musculoskeletal anatomy, restricting either descent positioned scar, circumferentially around the lower
or elevation, which can occur with aging, weight trunk.
fluctuation, or surgical manipulation.
• Act like “hooks” for the skin/fat envelope to hang on See Box 7.2, Box 7.3 and Fig. 7.15.
to as it falls down, especially after the skin has been
stretched by excess weight and then deflated by
weight loss (Fig. 7.14). Belt lipectomy
• Strong zones of adherence include zones overlying the
spine, sternum, and bilateral inguinal region. ■ Overall, a bodylift/belt lipectomy procedure treats
• Weak/variable zones of adherence include zones over the lower trunk as a unit and should address most of
the midline linea alba of the abdomen and in the the patient’s concerns in this region. Box 7.4 shows the
horizontal suprapubic crease. general goals that should be sought after.
• Other important zones of adherence: between the hip ■ The markings in bodylift/belt lipectomy surgery are the

and lateral thigh. “roadmap” to success.

Belt lipectomy 119

Scar above ASIS


Scar below ASIS

Scar at natural
lower back/buttocks

Scar below natural

lower back/buttocks

Buttock unit

Buttock unit

Figure 7.15  Overall, the scar in a lower bodylift type II is more inferiorly placed than in a belt lipectomy. Anteriorly, the final scar is below the anterior superior iliac spine
(ASIS) in a lower bodylift type II (A, left), and above it in a belt lipectomy (A, right). Laterally and posteriorly, the scar is below the natural junction of the lower back with
the buttocks (B,C, left), whereas it is located at, or just above, the natural junction in a belt lipectomy (B,C, right).
120 7 Body contouring

BOX 7.2  Belt lipectomy/central bodylift

• Lifts the trunk
• Leads to waist narrowing
• Improves buttocks contour
• Demarcates the lower back from buttocks

• High position of scar outside of normal swim/underwear
• Thigh reduction is not as aggressive as other technique
• May result in more extensive thigh reduction surgery than
other technique

BOX 7.3  Lower bodylift type II

• Lifts the trunk
• Very aggressive thigh lift
• Reduces the amount of surgery that maybe subsequently
needed on the thighs Figure 7.16  The horizontal mark of the mons pubis. Note the mons pubis is
• Low scar position to be covered by low-lying swim/underwear elevated to a pleasing appearance, and the mark is made 1–3 cm above the pubic
• Blunts the waist in most patients
• Scar violates the buttocks unit posteriorly
• Lack of demarcation between lower back and buttocks principle, scar position can be approximated by simulating
• Bulge over the anterior superior iliac spine in patients with the tissue dynamics at closure.
thick panniculi ■ It is important to note that anteriorly, the inferior marks

control scar position due to the fact that the inferior

zones of adherence are far less mobile and act to keep
the scar closer to them, rather than the fairly mobile
abdominal flap.
BOX 7.4  Goals
Anterior surgical markings
1. Elimination of the panniculus/flattening the abdomen
2. Elimination of mons pubis ptosis and redundancy ■ The midline is marked from the xiphoid to the pubic
3. Creation of waist definition (usually a desire in females) region.
4. Lifting the anterior and lateral thighs ■ The horizontal mons pubis line is marked 1–3 cm above
5. Elimination of lower back rolls, and in some patients, mid- the midline bony prominence, from one lateral edge
back rolls of the mons to the other.
6. Lifting the buttocks
• If measured, the distance from the vaginal fourchette
7. Creation of better buttocks contour
to the top of the proposed superior aspect of the
mons, under tension, is usually 6–8 cm (Fig. 7.16).
• The mark is measured on either side of the midline to
maintain symmetry.
• Although decisions will be made intraoperatively, the ■ The horizontal mark from the mons pubis to the anterior

majority of planning and decision making should be superior iliac spine (ASIS) is done with the patient in a
done during the marking process. slightly flexed position.
• Many surgeons will photograph their markings to • To simulate tissue dynamics at the time of closure, the
evaluate them prior to surgery and make needed non-dominant hand pushes the abdominal tissues
adjustments and to compare the patient’s final superomedially in a fairly aggressive manner to
contour, usually at 12 months after surgery, to the simulate the pull of the resected abdominal flap on
markings in an effort to improve one’s technique. the closure in this area (Fig. 7.17).
■ In general, the abdomen is the patient’s greatest concern, • The mark is made where the surgeon desires the final
and the surgeon should strive to attain the best possible scar to be. If the surgeon desires a high “French
abdominal contour, not compromising that for lateral or bikini” angled scar, then the ASIS is palpated and the
posterior contour. mark is aimed just superior to it. If the surgeon
■ Controlling scar position is something that every prefers a lower scar, the same maneuver is performed,
surgeon should aspire to attain, and as a general but the line is drawn in a lower position.
Belt lipectomy 121

Figure 7.18  The superior lateral mark should be marked without much angulation,
especially if the patient is marked in the supine position. A severely angulated
mark, shown in red, could lead to central abdominal flap necrosis due to a
Figure 7.17  The mark from the lateral edge of the mons pubis to the anterior
significant reduction in the remaining blood supply.
superior iliac spine. The mark is made with the non-dominant hand pushing the
tissues superomedially to simulate the pull of the resected abdominal flap on the
inferior line of resection.

■ With the patient in a semi-flexed position, the superior

proposed line of excision is marked, usually a few
centimeters above the umbilicus in MWL patients and
less so for patients who are 20–30 pounds overweight or
normal-weight patients.
• These marks, unlike the inferior marks described
above, are guidelines that are adjusted
intraoperatively based on tissue mobility and desired
• The authors prefer to match the distances of the upper
marks to those of the lower marks to help alignment
at closure.
• Centrally, matching the mons pubis horizontal mark,
the superior marks are at or slightly “V” shaped,
especially if one wants to avoid a “W” shape to the
final scar (Fig. 7.18).
• Acutely angulating the superior lateral mark to match Figure 7.19  Marking the extent of central midline of the back excision is done
the lower mons–ASIS mark should be avoided with the patient in the flexed position to simulate the position that the patient will
be in after their abdominoplasty component is completed. This will reduce the risk
because it leads to less remaining intercostal,
of dehiscence because it accounts for the competing anterior and posterior
subcostal, and lumber vessels reaching the inferior tensions at the end of the entire procedure.
midline of the abdominal flap, resulting in potential
tissue necrosis centrally.

Posterior surgical markings • Once the inferior point is decided upon, the superior
midline mark is made by pinching the tissue superior
■ The posterior vertical midline is marked. to the inferior point while the patient is flexed at the
■ The posterior midline extent of resection is marked. waist to simulate the position they will be in after
• The inferior point of the midline extent of resection is their abdominoplasty component is completed (Fig.
generally marked at the transition of smooth to 7.19). This maneuver is essential to reduce the risk of
wrinkled skin along the lower back/buttocks. dehiscence.
122 7 Body contouring

Low mobility Posteriorly superior

mark controls scar

High mobility

Figure 7.20  The inferior posterior mark is made in a smooth, shallow, “S”- Figure 7.21  The posterior superior mark is made by lifting the inferior mark at a
shaped fashion. Because the greatest descent occurs out laterally, at the posterior number of points, noting the appropriate buttock contour created by the lift and
axillary line, this shape of excision allows for the greatest resection at this level. then connecting these points. It is important to note that the superior mark is what
controls final scar position because it is located in a less mobile area than the
highly mobile buttocks.
• At this point, the surgeon evaluates the level of
anterior marks and compares them to the position of Vertical alignment marks
the posterior midline back marks. If there are great
discrepancies, adjustments can be made. ■ After the anterior and posterior marks are completed,
■ The inferior back is marked from the midline of the back vertical alignment marks are made circumferentially to
to the lateral extent of the anterior marks in a smooth assist with alignment at closure.
shallow “S” fashion (Fig. 7.20). • It is important to note that in most patients, the
• This mark is made first by the authors rather than the inferior marks are almost always longer in diameter
superior mark because it is helpful in creating the than the superior mark, necessitating adjustments,
shape of the resection, which is important in or “cheating” during the closure. This can often lead
controlling contour. to little puckers that almost always resolve in the
• The lowest aspect of the “S” should be located at the long term.
posterior axillary line because that is the area of
greatest vertical descent of the lower trunk due to
aging and/or weight loss. Positioning sequence
■ The superior back is marked from the midline to the

lateral extent of the anterior markings by pinching the ■ There are many potential positioning sequences that can
tissue to bring the buttocks and lateral thigh tissues up be utilized to perform a bodylift/belt lipectomy. As long
as high as needed to create the desired lateral buttocks/ as the desired contour is attained, it matters little what
thigh contour (Fig. 7.21). sequence is utilized.
• It is easiest if the top of the pinch is marked at a ■ Prone/supine positioning:

number of points that are then connected to each • The most commonly utilized sequence.
other, from the midline to the lateral aspects of the • Advantages: requires only one turn, ability to judge
anterior mark. symmetry of the back excision, allows for augmenting
• Some authors prefer the final midline scar to have a the buttocks in a natural position.
“V” shape to create the scar at a natural junction • Disadvantages: more risk of positioning injuries (e.g.,
between the lower back, sacrum, and buttocks, while respiratory difficulties, shoulder injuries, ulnar nerve
others prefer a straight line closure. injuries, eye injuries), especially if operative times are
• The superior marks of the back control scar position prolonged in this position.
in a belt lipectomy because the superior back tissues ■ Supine/prone positioning:

are much less mobile than the buttocks tissues • Advantages: single-turn sequence, ensures that the
below. The final scar is usually within 2–3 cm of highest priority of contour is the anterior resection by
this mark. performing it first.
Surgical technique 123

• Disadvantages: turning the patient to the prone

position after the anterior resection is completed is
more difficult because of the risk of dehiscing the
anterior closure during the turn.
■ Supine/lateral decubitus/lateral decubitus positioning:

• The preferred sequence of these authors (Aly et al.).

• Advantages: allows for creation of the best possible
anterior contour first, with remainder of the resection
adjusted to it, ability to abduct the legs in the lateral
decubitus position, and to allow for greater lateral
resection of excess tissue.
• Disadvantages: potential for back/buttock asymmetry
due to the inability to visualize the entire back/
buttocks during the resection; augmenting the
buttocks in the lateral position is more challenging, Medial edges
requires three turns. of rectus muscles Elevation at
Scarpa fascia level

Anesthesia and deep vein thrombosis/ Figure 7.22  All infraumbilical elevations are performed at, or just deep to, Scarpa
fascia level. This figure demonstrates flap elevation in a “thick panniculus” patient,
pulmonary embolism prophylaxis where the authors routinely liposuction the supraumbilical flap. To avoid vascular
supply issues, this type of patient has a very limited supraumbilical elevation, just
to the medial edges of the rectus muscle, to allow for a full complement of rectus
■ The majority of surgeons performing bodylift/belt
perforators to remain intact.
lipectomy utilize a general anesthetic.
■ Some authors advocate for thoracic epidural placement

prior to surgery to decrease postoperative discomfort,

and potentially reduce the risk of deep vein thrombosis/
pulmonary embolism (DVT/PTE). • If the flap is thin, then a more traditional elevation
■ If an epidural is not utilized, the surgeon must towards the costal margins and xiphoid is performed.
make a decision as to whether they should add The extent of abdominal flap elevation should be just
chemoprophylaxis to the routine of lower extremity enough to attain the proper advancement of the flap,
alternating compression stockings and early ambulation. create the best possible contour, and preserve as many
vascular perforators as possible.
• If the abdominal flap is thick, then a very limited
Surgical technique dissection tunnel, up to the xiphoid, is performed to
expose the medial edges of the rectus muscle, and
■ The technique that is described here is a belt lipectomy concomitant liposuction of the flap is performed to
procedure as performed by the authors utilizing the thin the flap (see Fig. 7.22).
supine/lateral decubitus/lateral decubitus positioning ■ After abdominal flap dissection is completed, abdominal

sequence. wall vertical plication is then performed from xiphoid

■ In the operating room, the patient is first put in the to pubis.
supine position on a bean bag, arms are abducted at 90°, • Horizontal plications are performed if deemed
and the markings are reinforced prior to prepping and necessary.
draping. ■ In order to achieve maximum flap advancement, the

■ The umbilicus is incised, and the umbilical stalk is freed patient is flexed at the waist, and the flap is advanced
from surrounding tissues using scissors. inferiorly.
• Traction sutures are placed at the 6 and 12 o’clock • The flap is then tailored with the upper mark used as
positions, at the appropriate depth within the a guide.
umbilicus, to facilitate the incision. • When resecting the excess flap, it is often necessary to
• Some patients may have an undetected periumbilical bevel the resection if the flap is thick.
hernia, so care must be taken while dissecting • If the mons pubis is deemed too thick, it can either be
the stalk. reduced by liposuction or by direct excision of
■ The inferior lower abdominal mark is incised, and the subscarpal fat. Direct excision usually requires tacking
dissection is taken down to, or just deep to, Scarpa down of the mons Scarpa fascia to the underlying
fascia. rectus fascia at the appropriate level.
• Scarpa fascia is preserved from the incision line and ■ With the abdominal flap tailored and temporarily tacked

upward toward the umbilicus (Fig. 7.22), as the in place, a 1.5- to 2-cm vertical incision is made in the
authors believe that leaving some fatty tissue on top midline overlying the umbilical stalk, and a path for the
of the rectus fascia reduces the risk of seroma. umbilical stalk to be brought through is created by blunt
■ The type of supraumbilical dissection performed is dissection, with no fat removal.
dependent on the thickness of the presenting • The authors feel that fat resection in the neoumbilical
abdominal flap. region may lead to vascular compromise of the flap.
124 7 Body contouring

• The desired inversion of the umbilicus is attained

through “three-point fixation sutures”, placed at 3, 6,
and 9 o’clock (Fig. 7.23).
• The remainder of the umbilicus is sutured to the
surrounding abdominal flap with interrupted inverted
subcuticular sutures. No external sutures are utilized,
to avoid suture marks.
• The scar should also be located on the inner aspect of
the umbilical depression so that it is well hidden.
■ Quilting sutures, or progressive tension sutures, can
then be placed between the abdominal flap and the Figure 7.23  Three-point fixation sutures that are utilized to create inversion of the
underlying abdominal wall to obliterate potential dead umbilicus and a final periumbilical scar that is located internally to avoid external
space in the hope of reducing the risk of seroma scar prominence. Note the authors do not defat the umbilical defect because it is
formation (Fig. 7.24). felt that this may lead to an increased risk of flap necrosis.
■ Abdominal closure is usually accomplished over closed
suction drains, and involves reapproximation of Scarpa
fascia and one to two superficial layers for skin closure.
• The lateral dog ears created by the anterior resection
are temporarily closed with staples to allow for the
upcoming turns.
■ Turning of the patient to the lateral decubitus position
should be accomplished by the coordinated effort of the
anesthetist and at least four other operating room
• It is very important to keep the waist flexed at all
times during the turning process to prevent
dehiscence of the abdominal closure. The best way to
ensure this is to assign one person to this task.
• All pressure points need to be padded, including an
axillary roll.
• The hips are abducted to allow for the maximum
excision of the lateral tissues, which can be
accomplished with pillows placed between the knees
(Fig. 7.25).
■ With the patient re-prepped and draped, the back
excision from the lateral dog ear to the midline of the
back is undertaken. Most patients will undergo
liposuction of the lateral thighs, which is performed at
this juncture.
• The authors prefer to make the superior mark incision
■ The level to which the dissection is deepened is
dependent on the desired amount of fat to be left in the Figure 7.24  The figure demonstrates the pattern of quilting sutures utilized by the
buttocks. authors.

Axillary roll

Figure 7.25  The authors prefer the lateral decubitus position to excise the tissues from the lateral dog ear created by the anterior resection to the midline of the back.
This position allows for maximal hip abduction and easy access for lateral thigh liposuction. It is essential that the patient is appropriately padded, including an axillary roll.
Surgical technique 125

• In patients with overprojected buttocks, the desired Autoaugmentation of the buttocks

goal is to reduce the projection and create a
depression at the waist by cinching above the hip. ■ Autoaugmentation of the buttocks for patients who
This is best accomplished by dissecting down to just present with underprojected buttocks is advocated by
above the muscle fascia and then elevating an some surgeons.
inferiorly based flap down to the level of the ■ In these procedures, the proposed tissue to be excised

proposed excision line (Fig. 7.26). When tailoring the from the back is de-epithelialized and rotated into the
flap, the resection is beveled to further create buttocks region to create bulk rather than excised and
narrowing of the waist. discarded.
• In patients who have normal or deficient buttocks ■ Advantages of autoaugmentation: autologous increase in

projection, the goal of surgery is to maintain as much buttock projection.

projection as possible. Thus, the superior mark ■ Disadvantages: autoaugmentation flaps can augment the

incision is deepened to the superficial fascia level, buttocks in the wrong position; lead to malposition of
and the flap is dissected inferiorly to the level of the the back scar; can result in fat necrosis, major skin
proposed excision at this level (see Fig. 7.26). During necrosis, chronic pain, chronic seromas, major
the tailoring process, the inferior flap is not beveled. dehiscence, and sepsis.
■ The inferior dissection of the lateral thigh region of this
segment of the procedure is usually limited to the
proposed inferior excision line.
■ After tailoring the inferiorly based flap, closure is
BOX 7.5  Synopsis
performed in a similar manner to the anterior closure.
• A drain is inserted prior to closure.
• A two-position circumferential approach for body contouring
• Closing one side will lead to a midline dog ear, which
of the lower trunk is presented as an alternative technique to
is temporarily closed with staples to allow for the the belt lipectomy described by Aly.
next turn. • Mostly indicated in patients after massive weight loss, this
■ The patient is then turned, and the same steps are procedure arose from the original lower bodylift from Ted
repeated for the other side. Lockwood.
■ After the back resection and closure is completed, the • It allows the simultaneous skin resection and reshaping in the
patient is then turned to the supine position while abdominal, flank, lateral thigh, back, and gluteal regions in the
making sure they are maintained in the flexed position same operation with only two position changes.
and transferred to a flexed hospital bed under the • Besides the reconstruction of the abdominal wall, the gluteal
supervision of the operating surgeon. restoration presents a major aspect of this procedure,
allowing a volume and shape enhancement with autologous
tissue transpositioning.
Lower bodylift • This technique requires precise patient selection, discussion
of the desired result with the patient and clarification of
■ Although the surgical steps to a lower bodylift can realistic expectations.
be quite similar to that described above for the belt • The lipo-bodylift is the ideal procedure for skin laxity around
lipectomy procedure, key differences include: the trunk after weight loss, aging, or liposuction-induced
• Lower surgical markings to allow a greater effect on deformities.
the thighs, and a lower final scar (Figs. 7.27–7.28). • Focus more on the gluteal area and add gluteal reconstruction
• Purposeful disruption of the lateral thigh zone of to the technique.
adherence using a Lockwood dissector or aggressive • Do NOT perform a bodylift procedure on patients with BMI
• Divide weight loss patients in three groups: large buttocks
• Greater use of adjunctive liposuction to debulk areas with excess adipose tissue; normal-sized buttocks with ptosis
of resection or mobilize the thigh soft tissues and skin redundancy; flattened, hypoplastic buttocks with
(Fig. 7.29). ptosis and skin redundancy.
■ See Box 7.5.

Superficial fat layer

Superficial fascial system

(Scarpa fascia anteriorly)
Deep fat layer
Deep muscular fascia

Figure 7.26  The level of elevation of the inferiorly based flap during the back resection is dependent on the presenting anatomy and the desired goals of the patient.
(A) In patients with high BMIs and/or overprojected buttocks at presentation, the dissection is deepened to the just above the muscle fascia to allow for narrowing of the
waist and reduction of buttocks projection. (B) In patients with low BMIs and/or underprojected buttocks at presentation, the dissection is deepened to the superficial
fascial system level to maintain fullness and increase final projection.


Figure 7.27  Bodylift markings showing the future scar line in red.

Figure 7.28  Marking of the posterior vectors is necessary to avoid a “tentlike” appearance of the back after the bodylift. (A) Schematic and (B) intraoperative
demonstration of posterior vector lines. (C) Intraoperative lateral view after incision of vectors. (From Rubin P, Jewell M, Richter DF et al. (eds). Body Contouring and
Liposuction. St. Louis, MO: Elsevier Saunders; 2012:389–390.)
Surgical technique 127


Figure 7.28, cont’d

Figure 7.29  Liposuction should only be performed within the area of resection to
avoid compromised blood supply.

■ Proper patient selection and experience are important in

minimizing risk with autoaugmentation procedures. Figure 7.30  The area of intended augmentation is marked within the resection
■ Common techniques include: pattern, and in this case labeled “pursesting gluteoplasty”.
• The pursestring gluteoplasty (Figs. 7.30, 7.31–7.37;
Hints and Tips box).
• Island gluteal flaps (Figs. 7.38–7.40).
Text continued on p. 132

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 do 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. Figure 7.31  In the operating room, towel clamps are used to check the markings
and estimate the amount of tension required.
128 7 Body contouring

Figure 7.32  The gluteoplasty mounds are de-epithelialized, and dissection around Figure 7.35  Undermining of the buttock soft tissue is done inferiorly to create a
the mounds is performed straight down to the deep fascia, taking care not to bevel pocket for the gluteoplasty mound to fit in and allow proper soft tissue recruitment
or undermine the augmentation mounds. to facilitate closure.

Figure 7.33  The pursestring suture is placed in the superficial fascial system in Figure 7.36  Temporary towel clips are used to align the skin edges during
running fashion and tightened, narrowing the base of the gluteoplasty mound, closure. The superficial fascial system layer is closed with 1 Vicryl. Laterally, a
imparting shape and projection to the soft tissue. temporary V–Y closure is done, to be finalized when the patient is turned supine.

Figure 7.34  The gluteoplasty mounds are secured to a central remnant of Figure 7.37  Final closure in the operating room.
superficial fascia tissue to keep the mounds from migrating laterally.
Surgical technique 129




Figure 7.38  Island gluteal flaps: (A–D) Centeno–island flap; (E,F) Hunstad–pursestring flap; Continued
130 7 Body contouring



Figure 7.38, cont’d (G–J) Colwell–Borud–SGAP (superior gluteal artery perforator) flap.

1 2

Figure 7.39  Incremental gluteal flaps: (A) Pascal;

Surgical technique 131

Figure 7.39, cont’d (B) Raposa–Amaral; (C) Koller.


Figure 7.40  Transpositional gluteal flaps: (A–E) Centeno–moustache flap; (F) Sozer–Split gluteal turnover flap; (G,H) Rohde. Continued
132 7 Body contouring


Figure 7.40, cont’d

Postoperative considerations ■ For the first week, the patient is ambulated bent at the
waist and then allowed to slowly straighten up over a
■ Postoperatively, care should be made to control patient couple of days.
body position to prevent excessive tension on the ■ Activity is slowly increased as tolerated over the first 3–4

incisions. weeks, with most patients being able to return to

■ In general, patients should not be moved in any way, by non-physical work in 4 weeks.
nursing or staff, until completely awake and alert. ■ A compression garment is worn by the patient starting

• While the patient is drowsy from anesthesia, simple a few days after surgery when the surgeon feels
body position movements by the nursing staff can comfortable that it will not compromise blood supply of
lead to dehiscence. the abdominal flap.
■ Once the patient is awake and alert, they can sense tension ■ Subsequently, the patient is asked to wear the garment

and will be able to prevent dehiscence on their own. for as long as they can tolerate it.
■ The patient is educated prior to surgery about the ability ■ Most drains will be removed at 2 weeks; however, drain

to sense tension and how they are to help the nursing removal is often based on strict output guidelines
staff with this aspect of their postoperative care. (Box 7.6).
■ Some surgeons will utilize epidural catheter infusion for ■ Most patients will not attain their final contour for at

postoperative pain management and may keep patients least 1 year, with a few patients continuing to improve
in the hospital for a 2-day stay. for up to 2 years.
Complications and outcomes 133

• Of these factors, the patient’s BMI is the most

Complications and outcomes important.
• As a general rule, the lower the BMI at presentation,
■ As with the patient presentation, the prognosis after belt the better the result and the lower the complication
lipectomy depends on the patient’s BMI, fat deposition rate.
pattern, and the quality of their skin/fat envelope. • Conversely, the higher the BMI, the less attractive
the result, and the higher the complication
BOX 7.6  Postoperative care summary ■ In MWL patients, the authors (Aly et al.) have

categorized patients by BMI level: group I, BMI ≥ 36;

• “Patient is not to be moved in any way till completely awake group II, BMI 30–35; and group III, BMI ≤ 29. Although
and alert” should be posted on the patient’s bed. the cutoffs between groups are arbitrary, the intent of the
• Ambulate the same day of surgery with assistance. categorization is to help the surgeon and
• Do not allow patient to straighten up for 1 week
patient predict, in a general manner, the expected
• A 1- to 2-day monitoring period is highly recommended. results.
• Garments should be worn for extended periods of time. • Group I patients (Figs. 7.41 and 7.42) will demonstrate
• Maturation of results take at least 1 year. less improvement and more complications after
bodylift/belt lipectomy than those in group II.

Figure 7.41  This figure demonstrates preoperative (above) and postoperative (below) photographs of a patient who presented with a BMI >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 a 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.
134 7 Body contouring

Figure 7.42  The figure demonstrates 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.

• Group II (Figs. 7.43 and 7.44) will demonstrate less to this area, with the apex descending and the base
improvement and more complications than those in becoming narrower.
group III (Figs. 7.45 and 7.46). • What has been observed by the authors is that the
■ It is important to explain to patients, prior to surgery, that area of sensory loss in circumferential procedures is
their contour is improved significantly after bodylift/belt usually circumferential, with varying and sometimes
lipectomy, but their skin quality is unchanged. asymmetric patterns. It generally improves from 6
• Once the swelling associated with surgery is resolved, months to 1 year.
skin elasticity on palpation is unchanged from its ■ Patients should be warned prior to surgery that

preoperative characteristics, especially in the significant weight gain or loss can dramatically affect
epigastric region. results. In fact, significant weight gain has the potential
■ It is important to educate the patient preoperatively on to reverse most or all of their body contour
expected postoperative sensory loss associated with improvement.
circumferential dermatolipectomy procedures. ■ Circumferential bodylift/belt lipectomy procedures

• Traditional abdominoplasty sensory loss is usually performed on normal-weight patients tend to have
located inferior to the neo-umbilicus in a triangular similar complication profiles to their abdominoplasty
pattern, with the base straddling the midline at the counterparts.
abdominal scar and the apex at the neo-umbilicus. ■ MWL patients, on the other hand, who undergo

Over a 1- to 2-year period, sensation tends to return bodylift/belt lipectomy have significant risk of
Complications and outcomes 135

Figure 7.43  This figure demonstrates a patient who belongs to group II, who present 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.

complications, more so than in any other area of and making sure the pocket closes from deep
aesthetic surgery. As a general rule, the higher the BMI, the to superficial by the use of a “wick”-type
higher the complication rate. dressing.
■ The most common complication of bodylift/belt ■ Wound separation following these procedures is

lipectomy, outside of small non-healing areas along the common due to the long incisions combined with the
incision line, is seroma. high-level tension created by the procedure.
• In patients with BMIs >35, one should expect a • Most often, they will heal without much difficulty or
seroma in almost all cases. negative sequelae, but they can be bothersome to the
• Leaving a layer of fat on the rectus fascia in the patient.
infraumbilical dissection of the abdominal flap and • It is best to warn patients about these areas prior to
utilizing quilting sutures may reduce seroma surgery.
frequency. • Treatment is usually conservative, allowing secondary
• Treatment of seromas can include serial aspiration, intention healing to occur.
seroma cavity sclerosant instillation (e.g., ■ A dehiscence is defined as a wound separation at

doxycycline), or surgical excision. the superficial fascial system level (Scarpa fascia) or
• If the fluid-filled pocket is small and non-expanding, deeper.
it often does not need treatment, as it will usually • Circumferential procedures are more prone
resolve on its own. to dehiscence because of the competing
• If a seroma should become infected, it usually tensions, especially the anterior and posterior
requires incision and drainage, antibiotic coverage, closures.
136 7 Body contouring

Figure 7.44  This figure demonstrates another group II patient, BMI 30–35, before (above) and after belt lipectomy/bodylift (below). Note the patient subsequently also
underwent an upper bodylift.

■ Risk of incisional dehiscence can be reduced by: emergency room, or the application of a wound VAC.
• Marking the extent of the back midline resection The area involved may require a scar revision in the
preoperatively with the patient in the flexed waist long run.
position that is to be attained after the anterior ■ The most common cause for infections after a bodylift/

resection is completed. belt lipectomy is undetected seromas.

• Avoiding manipulation of the patient in the • It is wise to see these patients for at least a year after
postoperative period until they are awake and alert surgery to make sure that there are no undetected
and able to sense tension and protect themselves. seromas.
• Educating patients and nursing staff preoperatively • Occasionally a patient will develop a skin cellulitis,
on how a patient is be “rolled out of bed” with the which is unrelated to a seroma. Those are treated as in
aid of the patient “sensing tension” and avoiding any other cellulitis encountered after a surgical
body positions that strain the closures. procedure, usually with appropriate antibiotic
■ It is important to advise patients that all their coverage.
movements, for the first 3 months after surgery, should ■ Tissue necrosis can occur after bodylift/belt lipectomy,

be slow and deliberate, which will lead to a sense of especially in the anterior midline of the inferior aspect of
tension before the tension reaches the level required to the abdominal flap.
dehisce. • Risk factors: smoking, excessive tension on the
■ Early dehiscence can be treated by a return to the closure, acute angulation of the superolateral
operating room for attempted closure, closure in the excision line of the abdominal flap, and old
Complications and outcomes 137

Figure 7.45  This figure demonstrates a group III patient, BMI <30, before (above) and after belt lipectomy/bodylift (below). Note that group III patients overall demonstrate
a greater degree of body contour improvement than either group I or II patients.
138 7 Body contouring

Figure 7.46  This figure demonstrates another group III patient, BMI <30, before (above) and after belt lipectomy/bodylift (below). Note the greater overall improvement
over group I or II patients.

abdominal scars interfering with the normal blood ■ The postoperative recovery from a bodylift/belt
supply. lipectomy can be quite stressful psychologically, and
■ Patients undergoing bodylift/belt lipectomy have MWL patients may deteriorate after their bodylift/belt
multiple factors that increase the risk of DVT/PE lipectomy.
postoperatively. • Psychiatric clearance on all bodylift/belt
• Standard prophylaxis in these patients should include lipectomy patients preoperatively can be helpful
early mobilization and use of sequential compression in reducing the rate of psychological problems
stockings. postoperatively.
• Many surgeons advocate for use of chemoprophylaxis;
however, more randomized trials must be conducted
before definitive recommendations can be made.
Liposuction and fat grafting
This chapter was created using content from Neligan & Rubin, Plastic Surgery 4th
edition, Volume 2, Aesthetic, Chapter 22.1 Liposuction: A comprehensive review
of techniques and safety, Phillip J. Stephan, Phillip Dauwe, and Jeffrey Kenkel,
Chapter 24, Fat grafting to the breast, Henry Wilson, Scott L. Spear, and Maurice
Y. Nahabedian, Chapter 27, Upper limb contouring, Joseph F. Capella, Matthew J.
Trovato, and Scott Woehrle, and Neligan & Gurtner, Plastic Surgery 4th edition,
Volume 1, Principles, Chapter 20, Reconstructive fat grafting, Wesley N. Sivak, and J.
Peter Rubin.

SYNOPSIS Fat grafting

■ Autologous fat has demonstrated success when it comes to correcting

■ Incorporation of a diet and exercise program in conjunction with mild to moderate contour deformities in reconstructed breasts.
liposuction will allow patients to achieve their optimal shape and ■ Fat grafting may be used safely and effectively for a variety of

contour. Patients who do not adhere to diet and exercise are least reconstructive indications.
happy with their results. ■ There is a variety of specific harvesting and processing techniques

■ A thorough history and physical exam should be performed and a available.

preoperative clearance obtained, especially for large-volume or long, ■ Fat grafting for breast augmentation is effective, but its precise role in

combined cases. the cosmetic plastic surgeon’s armamentarium is yet to be defined.

■ Marking the patient in front of a mirror allows both the surgeon and ■ Fat grafting to the breast has become common practice for

patient to see and understand the areas of concern and intended reconstructive and aesthetic breast surgery; however, it remains
treatment. Cellulite and other contour irregularities can be pointed out controversial for some indications.
preoperatively to the patient. ■ Complications are minor and infrequent if a proper technique is

■ Over-the-counter herbal and diet medications may have unfavorable followed.

interaction with surgery and/or anesthesia and should be discontinued ■ External pre-expansion and adipose-derived stem cells hold promise for

3 weeks prior to surgery. future enhancement of the results and treatment of difficult problems.
■ Knowledge of the differing thickness and consistency of fat throughout

the body is crucial to determining proper depth and technique for each
region of the body. Brief introduction
■ Superficial liposuction should be reserved for significant superficial

irregularities and be performed by those experienced in liposuction ■ Suction-assisted lipectomy, or liposuction, continues to
techniques. be one of the most popular means of body contouring
■ Wetting solutions should always be used, and a strict record of volume
and overall treatment modalities offered in aesthetic
infused and aspirated should be kept by the operating room personnel. surgery today.
■ Surgical access sites should be concealed, often asymmetric, and
■ With greater understanding of the biochemical and
utilized to allow the best access and treatment results. Excessive use of
physiologic properties of liposuction, as well as
a single access incision may result in a deformity.
■ Patients with surgical scars on their abdomen must be thoroughly
biomedical technological advancements, suction-assisted
examined to rule out the presence of a hernia. lipoplasty has undergone tremendous evolution, leading
■ There are many tools one can use to perform liposuction. Physician to overall improvements in technique, patient safety, and
experience and judgment supersedes any technology. outcomes.
■ Over the past 2 decades, it has grown from a procedure
■ Contour irregularities are best diagnosed at the time of the surgical

procedure. If noted, strong consideration for immediate fat grafting that facilitates small or spot reductions to one that has
should be considered. become an almost irreplaceable tool in neck, breast, and
■ Postoperative contour deformities should be clinically evaluated and, circumferential body contouring.
if mild, can respond to lymphatic massage or other non-invasive ■ A number of important innovations and modifications to

methods. A systematic approach should be used to correct contour the standard suction-assisted liposuction (SAL) have
deformities when they occur. progressively refined the procedure, including the use of

140 8 Liposuction and fat grafting

wetting solutions, advances in cannula design,

ultrasound-assisted liposuction (UAL), power-assisted
liposuction (PAL), vibration amplification of sound
energy at resonance (VASER)-assisted liposuction, and Superficial
laser-assisted liposuction (LAL).
■ There has been a strong movement concentrated on Intermediate
defining appropriate safety guidelines for liposuction
and other body contouring procedures focusing on deep Deep
venous thrombosis (DVT) prophylaxis and fluid
resuscitation, ensuring safety and efficacy of the different
treatment modalities for our patients.
Figure 8.1  Surgical layers of subcutaneous fat: superficial, intermediate, and
Preoperative considerations
■ A successful body contouring patient must satisfy four of the back has a more fibrous, compact superficial
key elements to achieve and maintain optimal results: and intermediate layer, with an underlying loose,
• Lifestyle change. areolar layer, while fat of the inner thigh is not as
• Regular exercise. fibrous and is less compact.
• Well-balanced diet. ■ Anatomic “zones of adherence” are areas of relatively

• Body contouring. dense fibrous attachments to underlying deep fascia and

■ Liposuction is contraindicated in patients who are help to define the natural shape and curve of the body
pregnant or in poor general medical health. Likewise, (Fig. 8.2).
patients with morbid obesity, cardiopulmonary disease, • Important to identify during the preoperative
body image perception issues, unrealistic expectations, consultation, as they are high-risk areas for contour
wound healing difficulties, or who have extensive or irregularities after surgical intervention if not properly
poorly located scars should be excluded from respected.
consideration for liposuction.
■ Patient goals must be clearly elucidated, and realistic

expectations must be established. Classification

■ A detailed physical exam is performed, with specific

attention to prior scars, presence or absence of hernias, ■ It is helpful to classify patients based on the three types
evidence of venous insufficiency, and presence of of lipodystrophy and skin redundancy (Fig. 8.3):
preexisting asymmetry or contour irregularity. • Type I: localized lipodystrophy. Often younger patients
■ For liposuction candidates, six key elements are with good skin tone and minimal skin irregularities.
documented: • Type II: generalized lipodystrophy. Patients with lightly
• Evaluation of areas of lipodystrophy and contour diminished skin tone, some skin irregularities, and
deformities. circumferential lipodystrophy throughout their trunk
• Skin tone and quality. and extremities.
• Asymmetries. • Type III: skin redundancy and lipodystrophy. Patients
• Dimpling and cellulite. with significant skin redundancy that would be more
• Myofascial support. amenable to excisional surgical techniques. However,
• Zones of adherence. liposuction may be a useful adjunct in order to
achieve an optimal result.
■ Cellulite: dimpling of the skin, particularly in the areas

Anatomical pearls of thighs and buttocks thought to be related to fibrous,

dermal attachments to the underlying fascia surrounding
■ Anatomy texts divide subcutaneous fat throughout the hypertrophied fat.
body into superficial and deep layers or compartments • There is no predictable, long-term treatment of cellulite.
separated by Scarpa fascia or the superficial fascial • Liposuction in areas of overlying cellulite may soften
equivalent.3 or accentuate the superficial deformity.
■ For the purposes of liposuction and body contouring,

subcutaneous fat is arbitrarily divided into three layers:

superficial, intermediate, and deep (Fig. 8.1).4,5 Operative technique
• The intermediate and deep layers are the most
commonly treated areas. Marking and positioning (Fig. 8.4)
• The superficial layer is one that should be approached
with caution, as aggressive or improper treatment of ■ Guiding marks are performed prior to surgery with the
this layer may result in injury to the subdermal plexus patient in the erect position. Marking the patient in front
and/or contour irregularities. of a mirror allows the patient to contribute to the process
• The relative consistency and thickness of each of these and further confirms exactly what will be addressed
separate layers varies for different anatomic areas: fat during the procedure.
Wetting solutions and perioperative fluid management 141

1. Lateral gluteal

2. Gluteal crease

4. Mid medial thigh

3. Distal posterior thigh

5. Inferolateral
iliotibial tract

Figure 8.2  The zones of adherence are areas where the fibrous support structures of the subcutaneous fat and skin are adherent to the underlying deep fascia.
These attachments create adherence and depressions contributing shape of the body’s surface.

■ Areas to be suctioned are marked with a circle, while ■ Awake liposuction has been performed in the
zones of adherence and areas to avoid are marked with office-based setting with a tumescent technique, and the
hash marks. authors prefer to do such procedures only for single-area
■ Asymmetries, cellulite, and dimpling are marked for treatments or in small revisions.
their respective treatment and to allow patients to see ■ To prevent the patient from being cold during the

problem areas. operation, all areas not being treated should be

■ Access incisions are also marked at this setting. Often, covered by a forced warm air blanket, and the
two incisions are needed per area to be suctioned, and wetting solutions should be warmed and not
these incisions should be placed adjacent to suctioned administered cold
areas and not too distant.
• Avoid placing access incisions in or adjacent to zones Patient positioning
of adherence.
• The surgeon should not hesitate in placing additional
incisions if access is insufficient with the existing Prone/supine
markings. ■ Patient position is best determined once marked.
■ If positioning changes are required, it is generally
better to start with the patient prone, followed by
Anesthesia technique/location supine.
• An alternative method is to prep the patient
of operation circumferentially while standing and to then position
the patient on a sterile table.
■ It is up to the surgeon to determine the optimal surgical ■ The lateral decubitus position can be used to access the

setting for each patient undergoing liposuction. Factors flanks, lateral back, buttocks, thighs, and lower legs.
that influence this decision are the amount of expected • A disadvantage of this method is that a side-by-side
lipoaspirate, length and extent of procedure, patient comparison to the contralateral area is not available to
positioning, operating surgeon preference, assess symmetry.
anesthesiologist preference, and overall health of the
■ As a general rule, small-volume liposuction cases can be

performed with local anesthesia, with or without mild

Wetting solutions and perioperative
sedation, while complex, large-volume liposuction and fluid management
combined cases should be performed under general
anesthesia or regional block. ■ Infiltrating wetting solutions (saline or lactated Ringer’s
■ The anticipated postoperative course and the need for mixture with dilute amounts of epinephrine and
possible overnight observation both factor into choice lidocaine) prior to suctioning provide hydrodissection,
between inpatient observation or outpatient hospital improve hemostasis, and potentially provide some
settings. perioperative analgesia.
Type I patient Type I patient

Type I patient Type I patient

Type I patient Type I patient

Figure 8.3  Patient examples of three types of patients (I–III): first six images, patient type I; second six images, patient type II; third six images, patient type III.
Type II patient Type II patient

Type II patient Type II patient

Figure 8.3, cont’d

Type II patient Type II patient
Type III patient Type III patient

Type III patient Type III patient

Type III patient Type III patient

Figure 8.3, cont’d
Liposuction techniques 145

the liposuction setting, numerous studies have

documented the safety of lidocaine in concentrations
>35 mg/kg and as high as 55 mg/kg in large-volume
■ The epinephrine contained in wetting solutions, with its

vasoconstrictive properties, is the key to minimal blood

loss during liposuction. This effect also decreases the rate
of vascular absorption of lidocaine, potentiating the local
anesthetic effect.
• Epinephrine toxicity can result in tachycardia,
hypertension, and arrhythmias.
• Most commonly, epinephrine in 1 mg with 1/1000
dilution is injected into a 1-L bag of infiltrate, either
normal saline (NS)/lactated Ringer’s (LR).
■ Perioperative fluid management during liposuction

procedures requires attention to maintenance of

intravenous fluids, third-space losses, wetting solution
infiltration, and lipoaspirate.
• Liposuction is considered a moderate surgical stress;
therefore, 3–5 mg/kg per h of crystalloid solution is
adequate volume for maintenance replacement and
third-space losses.
• Additional fluid may be given during procedures in
which the lipoaspirate amount is more than 5 L, with
Figure 8.4  Patient has been marked prior to surgery. Markings demonstrate the the ratio of 0.25 mL of crystalloid solution for each
contours of the areas to be suctioned as well as the planned incision sites. aspirated mL over 5 L considered appropriate.
■ Body contouring procedures can result in significant

fluid shifts and intravascular volume changes for the

■ There are four different terms used to describe the types • Awareness of four key elements will guide the
of wetting technique based on the volume of infiltrate as intraoperative fluid management of liposuction
a ratio of the volume suctioned: dry, wet, superwet, and patients: intravenous fluid maintenance (body
tumescent (Tables 8.4 and 8.5). weight dependent), third-space losses, volume of
• The dry technique uses no wetting solution and has wetting solution infiltrated, and total lipoaspirate
few, if any, indications in liposuction. volume.
• The wet technique involves pre-infiltrating
200–300 mL of solution per region to be treated,
regardless of the anticipated amount to be aspirated. Liposuction techniques
• The superwet technique employs an infiltration of
1 mL of solution per estimated 1 mL of expected ■ There are multiple options for liposuction technique,
aspirate. with the most commonly utilized options including
• The tumescent technique involves extensive traditional SAL, PAL, UAL, VASER-assisted liposuction,
infiltration of wetting solution that creates significant and LAL.
tissue turgor and results in total infiltration of ~3 mL ■ SAL

of wetting solution per 1 mL aspirated. • Remains the most common and popular modality for
■ Regardless of the technique used, the infiltrate should be liposuction.
allowed to set for 10 min and no longer than 30 min • Uses a two-stage technique: site is infiltrated with a
prior to suctioning. predetermined wetting solution and then evacuated
■ Most wetting solutions utilize lidocaine as the local after allowing time for the solution to set and take
anesthetic component to be included in the wetting effect.
solution. • Advantages: ease of use, malleable cannulas, a wide
• It can provide analgesia for up to 18 h postoperatively variety of cannulas for use, and decades of experience
when injected in dilute concentrations into the and results.
subcutaneous space. • Disadvantages: more difficult to use in fibrous areas
• Toxicity from lidocaine affects the heart and central and secondary liposuction, requires more physical
nervous system most commonly, with initial signs and work to break up and remove fat.
symptoms including circumoral numbness, tinnitus, ■ PAL

and lightheadedness. • Uses an externally powered cannula, which is variable

• Increasing levels can yield tremors, seizures, and in size, and oscillates in a reciprocating motion at
eventually cardiopulmonary arrest. rates of 4000–6000 cycles/min.
• The traditional recommended maximum dose of • May be best used for large volumes, fibrous areas,
lidocaine with epinephrine is 7 mg/kg; however, in and revision liposuction.
146 8 Liposuction and fat grafting

• Advantages: faster and less labor intensive for the

surgeon than traditional SAL, most units are
compatible with standard aspiration equipment, many
systems have multiple power settings that can be
programmed for a variety of areas and tissue types.
• Disadvantages: more expensive than traditional SAL,
noise creation, handpieces can be heavy, and the
vibration can be an issue.

• Uses ultrasonic energy to break down fat and

facilitate suction-assisted removal. The mechanism
of action is primarily mechanical in nature, but Figure 8.5  Ultrasound-assisted liposuction: superficial to deep.
cavitation and some thermal effects may also occur.
• UAL is performed in three stages: (1) infiltration,
(2) fat emulsification, and (3) evacuation and
• Skin protection may be utilized to help protect the
skin from thermal injury. This can also be achieved by
limiting the application of energy and bathing the
access site with saline.
• A towel should cover the region behind the access site
to prevent direct contact of the probe with the skin
during excursion.
• The UAL treatment is begun at a depth of
approximately 1–2 cm, depending on the body area.
This plane is treated uniformly, beginning at one side Figure 8.6  Ultrasound-assisted liposuction: deep to superficial.
of the area and moving in a radial fashion to the
contralateral side (Fig. 8.5) until the endpoint is
reached. When this occurs, the probe is moved to a
deeper plane. Most treatment sites will have a
minimum of two planes and sometimes three. When
the last plane is completed, evacuation begins in the
deeper plane first (Fig. 8.6) to remove the emulsified
fat, followed by final contouring of the more
superficial plane using standard cannulas.
• Advantages: less surgeon fatigue, improved results in
fibrous areas and in secondary procedures.
• Disadvantages: cost, requires slightly larger incisions,
longer operative times, potential for thermal injury to
the skin, requires superwet environment, and requires
continuous movement to prevent excessive exposure
of the tissues to heat (Fig. 8.7).
■ VASER-assisted liposuction

• Uses newer-generation UAL device that incorporates

less energy with more efficient, solid probes that emit
acoustic energy through the sides of the probe rather
than through the end of the cannula.
Figure 8.7  Liposonix ultrasonic liposuction machine.
• May be most useful in large-volume liposuction to
reduce blood loss and fibrous areas.
• Performed in three stages: (1) infiltration, (2) VASER • Most surgeons utilizing these devices employ a
emulsification, and (3) evacuation. four-stage technique: (1) infiltration, (2) application of
• Advantages: advantages of UAL but uses less energy, energy to the subcutaneous tissues, (3) evacuation,
thus decreasing its thermal component to the tissues. and (4) subdermal skin stimulation. For smaller
• Disadvantages: same as UAL. regions (such as the neck), some vendors suggest
■ LAL skipping the evacuation phase, allowing the body to
• Uses a laser fiber to deliver laser energy in the form of absorb the liquefied contents.
heat to the treated tissues. The mechanism of action is • While these devices have also been marketed for
through heat disruption of adipocyte cell membranes purported skin-tightening effects from subdermal skin
and emulsification. heating, there have been no clinical papers supporting
• Performed in three stages: (1) infiltration, (2) laser this claim.
emulsification, and (3) evacuation. In small-volume • Advantages: less postoperative pain, potential for skin
areas, the evacuation stage may be eliminated. tightening, useful for fibrous tissue.
Cannulas and probes 147

• Disadvantages: longer operative times, cost, still Table 8.1  Surgical endpoints for UAL and SAL/PAL
potential for full-thickness skin injury with direct
subdermal application. Primary Secondary
treatment treatment
Modality Mechanism endpoints endpoints
Non-invasive devices SAL/ Direct tissue Final Treatment
PAL cutting/ contour and time, number
■ Available non-invasive “lipo-contouring” devices deliver avulsion at symmetrical of cannula
transcutaneous energy to the subcutaneous fat layer cannula holes pinch test strokes, and
either by ultrasound, radiofrequency, tissue cooling treatment
(cryotherapy), low-level laser therapy, physical massage,
or some combination of these modalities. UAL Cavitation to Loss of Treatment
■ All devices have differing characteristics that may disrupt and tissue time and
influence suitability for a particular practice, such as emulsify tissue, resistance aspiration
operator dependence, delegation capabilities, followed by and volume
aspiration. appearance
maintenance, and consumables.
Direct cutting of blood in
■ All devices lack the evacuation phase inherent to
less important aspirate
liposuction, so fat clearance is accomplished by a
physiologic macrophage-mediated phagocytic process.
■ While these devices have been shown to be safe, the • Other indicators such as treatment time, blood in
non-invasive lipo-contouring market is largely industry aspirate, and amount of aspirate are important factors
driven, with most scientific data on device efficacy to consider.
published after devices are granted FDA clearance. • Measured volume aspirated is a good indicator for
■ “Low-level laser therapy” bilateral procedures in order to judge symmetry and
• The proposed mechanism of lipolysis is creation of contour, comparing each side to the opposite.
transitory pores in the adipocyte membrane, from However, preoperative asymmetries must be noted
which intracellular lipids egress. and considered.
■ Focused external ultrasound therapy ■ UAL

• One of the most popular fat-reducing technologies • The most important endpoint is loss of tissue
currently being marketed. resistance, which is appreciated through the treatment
• Currently two competing technologies that attempt to as well as the non-dominant guiding hand.
achieve fat destruction by either thermal or • Secondary endpoints include site-specific treatment
non-thermal ultrasound-mediated mechanisms. time and volume. Contour should not be judged
■ Radiofrequency (RF) ablation during emulsification or the evacuation phase
• The proposed mechanism of lipolysis is through (Table 8.1).
energy delivery to adipocytes through oscillating ■ If contour irregularities are recognized intraoperatively

electromagnetic currents, which creates heat and due to aggressive fat removal, they can be treated with
causes destruction of the cells. autologous fat grafting immediately at the site of the
■ “Cryolipolysis” deformity. Trying to feather edges of the defect most
• One of the most popular modalities for non-invasive often leads to an even greater problem, further
fat reduction over the past 5 years. complicating its treatment.
• The proposed mechanism of lipolysis is controlled
cooling of the subcutaneous fat, with selective
destruction of fat cells without epidermal or dermal Cannulas and probes
injury due to adipose tissue’s relative sensitivity to
cold. Injured adipocytes then undergo apoptosis and ■ Suction of fat is achieved through cannulas [hollow
are cleared by a macrophage-mediated process. tubes with opening(s) at tips]. Cannulas come in a wide
■ While non-invasive fat removal has become a major variety of sizes (diameter of the tube), tip configurations
player in the area of body contouring and there is a clear (number and location of holes at the tip), and lengths.
role for it now and in the future as technology continues Each factor alters the amount, speed, and viability of fat
to improve, it will not replace formal liposuction. removed.
■ Most tips are blunt with multiple apertures (openings)

set back from the end to allow suctioning.

Surgical endpoints ■ The most common cannula sizes utilized in liposuction

are between 2.5 and 5.0 mm, although there are cannulas

■ Surgical endpoints vary according to the technique used available in smaller and larger sizes.
and have been divided into primary and secondary • As cannula size increases, the amount and speed of
endpoints. tissue removal increases; however, the risks of causing
■ SAL, PAL contour deformities and tissue damage also increases.
• Symmetrical skin pinch and final contour are the most • In general, large cannulas are used for deeper fat
critical endpoints, with a reduction in convexity to a deposits, and the smaller cannulas are utilized for
smooth contour being the ultimate goal. superficial deposits and final contouring.
148 8 Liposuction and fat grafting

Table 8.2  Typical cannula size and location utilized

Site Evacuation (mm) Contouring (mm)
Neck 2.4 2.4 and 1.8
Arms 3.7 3.0 and 2.4
Back 3.7 3.0
Hips 4.6 (deep plane only) 3.7 and 3.0
Abdomen 3.7 (deep plane only) 3.7 and 3.0
Thighs 3.7 (deep plane only) 3.0
Knees 3.0 2.4
Calves/ankles 3.0 2.4

■ Length of the cannula can vary from 10 cm to 30 cm.

As the length increases, the ability to finely control
evacuation is more limited.
• With greater cannula length, more areas can be
suctioned with fewer access incisions (Table 8.2).

Treatment areas Figure 8.8  Patient with back rolls.

■ Upper limb contour is often of great concern following ■ Techniques: due to fibrous nature of the fat and the
weight loss. dense tissue, UAL and PAL are extremely useful.
■ Correction of contour deformities for these patients often • Volume of fat removed can be moderate, but
involves the combination of liposuction and excision of improved results are often observed with release of
soft tissue redundancy (brachioplasty). folds and attachments to deeper tissue.
• In this case, liposuction is often performed first to • Access incisions will depend on the distribution of fat
debulk the area to be excised and contour the and/or skin rolls and should often be placed medially
remaining posterior arm. and laterally, and in the bra/bathing suit line if
■ Skin/fat anatomy: possible (Fig. 8.8).
• In obese patients, fat deposits are usually most • Avoid forceful excursion of the cannula, and avoid
prominent along the axilla, anterior, posterior, and areas off of the thoracic cage toward the posterior
medial arm. Thus, these areas manifest the greatest back to prevent intra-abdominal and intrathoracic
soft tissue excess with weight loss. penetration of the cannula (Fig. 8.9).
• Medial arm skin is thin, and care should be taken in
this area to avoid deep or aggressive suctioning,
which could injure important neurovascular Abdomen
structures. ■ Limitations and benefits of abdominal liposuction are
■ Preferred suction position: supine, with arms often misunderstood by patients.
circumferentially prepped and mobile. ■ Many patients seeking contouring of the abdomen may

■ Techniques: amenable to all of the various modalities of not be candidates for liposuction alone and require
liposuction; however, SAL or PAL may be most common, excisional techniques to allow them the best possible
as arm contouring often combines liposuction with change in contour.
excisional components. ■ Skin/fat anatomy:

• Typically use a 3- to 4-mm cannula, although finer • The skin of the abdomen can be prone to contour
cannulas can be used if performing liposuction alone. irregularities; thus, constant feedback from the tissues
by means of manual palpation, pinch, and symmetry
assessment helps decrease the likelihood of contour
Back irregularities.
■ Skin/fat anatomy: • The subscarpal fat below the umbilicus is loose, while
• Very thick dermis and a dense, fibrous characteristic the area above the umbilicus tends to be more
to the underlying fat that is more superficial in compact and fibrous.
location. • The distribution of fat in the abdomen can vary;
• Beneath this superficial fat layer, there lies a loose, people with large volumes of intra-abdominal fat will
areolar plane of fat on top of the deep fascia. not respond well to abdominal liposuction and should
■ Preferred suction position: prone, with the bed in a be counseled accordingly to prevent unwanted
head-down flexed position. outcomes and disappointment.
Cannulas and probes 149


Figure 8.9  Patient in position for suction of back rolls.

■ Preferred suction position: supine; it is also useful to ■ Preferred suction position: the prone position allows
extend the table at the waist up to 15 or 20° to allow for simultaneous treatment of both sides and for
excursion of the cannula away from the suprapubic comparison.
region and specifically the pubic ramus. ■ Techniques:
■ Techniques: the subcutaneous abdominal fat is amenable • Suctioning in this area can provide excellent results,
to all of the various modalities of liposuction and and all modalities have proven effective.
continues to be one of the most popular and desired • Access if often through the bilateral or single midline
areas for liposuction. paraspinous region and/or an incision in the lateral
• Suctioning the deep two-thirds of the fat is safe and gluteal fold. Caution should be used when contouring
effective. via the lateral gluteal fold incision, as overzealous
• Superficial liposuction should be reserved for the resection through the trochanteric adherent zone has a
linea alba or for the correction of secondary high likelihood of resulting in a contour deformity.
deformities, and only then with extensive experience • When performing liposuction of the hips and flanks,
and care. knowledge of the differing aesthetic consideration of
• Access is often through an umbilical incision, bilateral the hips and flanks in males and females is crucial to
lower abdominal incisions, and/or suprapubic preventing inappropriate masculinization or
incisions. In patients with a long torso and a moderate feminization: Males tend to have fullness in the
degree of lipodystrophy overlying their costal margin, superior and lateral region, while females usually
an inframammary fold incision can be made to access exhibit prominence more inferiorly and posteriorly
this fatty area. (Fig. 8.10).
• Never approach an area of convexity from an area of • It is essential to mark the lateral gluteal depression
concavity, to avoid intra-abdominal or thoracic prior to liposuction, as violation of this important area
penetration (Fig. 8.9). can lead to either a persistent or exacerbated irregular
• Short, controlled strokes should be used to avoid contour deformity (Fig. 8.11).
inadvertent fascial perforation, particularly when
working in and around scars.
■ The buttock area must also be approached with caution.
Hips/flanks ■ A uniform reduction of the buttock can be achieved
■ Skin/fat anatomy: through cautious treatment of the intermediate fat layer,
• Significant striae may be seen in patients with weight resulting in a decrease in buttock projection in an
fluctuations or in postpartum women. anterior/posterior dimension.
• In general, the fat in this region is loose and, in some ■ Preferred suction position: prone.

cases, fibrous, with thick overlying skin. For example, ■ Techniques:

the hip extends down to the level of the lateral greater • Access incisions are often placed asymmetrically to
trochanteric adherent zone, and the fat in this region avoid an operated look.
is typically loose but fibrous as it becomes more • Avoid deep, aggressive suctioning and ensure the
superficial, due to the thickness of the overlying length, position, and integrity of the inferior gluteal
dermis. crease is maintained.
150 8 Liposuction and fat grafting


Figure 8.10  Difference in configuration of the (A) female and (B) male hip region.


Figure 8.11  The violin deformity may require fat grafting to the zone of depression in addition to liposuction of the surrounding areas of excess fullness.

• Overzealous treatment in the deep or superficial plane medially and laterally. Cellulite may also be seen
may result in buttock ptosis. more commonly in women, as well as superficial
• Often, patients requesting buttock contouring actually irregularities and preoperative contour problems.
desire increased shape and projection and will require • Men tend to accumulate more compact fat in the
augmentation and/or fat transfer. proximal thighs, and the fatty layer tends to be more
fibrous, which tends to prevent extensive superficial
contour irregularities and cellulite.
Thighs • Common terms for deformities related to the thigh
■ Skin/fat anatomy: and hips include saddlebag (a trochanteric bulge lateral
• Women tend to accumulate fat either in a diffuse, to gluteal crease), banana roll (preoperative or
circumferential manner or in significant amounts postoperative roll inferior to the gluteal fold), and
Postoperative considerations 151

violin deformity (female contour of narrow waist, full ■ Techniques:

hips, full lateral thighs, and depression in the zone of • Treatment is relatively straightforward with small stab
adherence between the hips and thighs). incisions for access, and use of small cannulas.
■ In many instances, patients undergoing contouring of the • The posterior knee should be avoided.
thigh are best suited for a circumferential approach in • Suction volume is usually small in this area, with the
the prone/supine position. goal to improve and taper the distal thigh.
■ The adherent areas of the thigh to recognize include the • Suctioning of the calves and ankles remains
gluteal crease; the lateral gluteal depression; the challenging and requires more prolonged recovery,
posterior, inferior, and distal lateral thigh; and the area of with an increased risk of contour irregularities.
the mid-inner thigh (see Fig. 8.1). • Small, fine cannulas should be used through multiple
■ Techniques: access sites.
■ Lateral and posterior thighs

• Best performed in prone position or occasionally the

lateral decubitus position. Neck
• Access incisions are often placed in the lateral gluteal ■ Skin/fat anatomy:
crease. • Patients with minimal to mild skin laxity and
• The lateral thigh is amenable to all forms of lipodystrophy of the neck may be candidates for
liposuction, and both the intermediate and deep liposuction of this region.
planes can be suctioned. ■ Preferred suction position: supine with the neck

• Extreme caution is advised in the superficial plane hyperextended, and a shoulder roll or pill beneath the
for fear of worsening preexisting contour upper back.
irregularities. ■ Techniques:

• Cannulas in the 3.0–4.6 mm range are used for lateral • Access is often obtained through a single submental
thigh suctioning. incision.
• Suctioning the posterior thigh should be approached • All liposuction devices may be used in this region,
with caution as the skin is often adherent to the but care must be taken to avoid contour irregularities,
underlying tissues with a paucity of fatty tissue. skin injury, and nerve injuries.
Overzealous suctioning in this area results in loss • An appropriate amount of wetting solution should be
of the adherent zone and rolling and redundancy placed and ample time utilized to allow for the
of the skin. epinephrine effect.
• Special care should be taken when addressing the • Direct subdermal suctioning should be avoided, and
proximal posterior thigh as contour deformities in this overzealous treatment can result in hollowing and
area are challenging to correct, and overtreatment of skeletonizing the neck or potential neurapraxia of the
this area in females can masculinize the female marginal mandibular nerve that usually resolves
silhouette. within a few weeks.
■ Medial thigh

• The most unpredictable and difficult area to treat.

• Fat in the medial thigh is loose and soft, and the Postoperative considerations
overlying skin is thin and often lax.
• The plane of suctioning is intermediate fat, and ■ At the conclusion of surgery, patients are placed in a
smaller cannulas, such as 3.0 mm and 2.4 mm, are compression garment, which is customized based on
generally utilized. surgeon preference and procedure performed.
• This area can be treated in both the prone and supine ■ Some type of compression foam may also be used under

position together or supine with legs “frogged”. the garment for the first week to assist in contouring and
• Realistic expectations must be established with also help diminish bruising and edema.
the patient, as well as risk of skin redundancy or ■ Patients who have undergone any large-volume

laxity. procedure (>5000 mL aspirate), liposuction of multiple

■ Anterior thigh areas, or liposuction in addition to abdominoplasty or
• Characterized by compact fat of limited thickness, another excisional body contouring procedures are often
often with more fullness proximally. kept overnight for 23 h observation.
• Often accessed medially through the same incision as ■ Patients are asked to ambulate the day of the surgery,

the medial thigh and laterally with an incision on the and sequential compression devices are placed on the
proximal anterior thigh. patient in the preoperative holding area and continued
• Fine cannulas should be used in this area, as it is until discharge.
compact and fairly thin. ■ Patients are allowed to shower as early as 1 or

2 days postoperatively and are instructed to keep

the compression garment on 24 h a day for at least
Knees/ankles 2 weeks.
■ Skin/fat anatomy: lipodystrophy around the knees is ■ Return to activity/work can occur as early as 3–4 days

usually confined to the areas of medial and anterior leg. or at 2 weeks, depending on the procedure.
■ Preferred suction position: supine positioning or frog-leg ■ Walking is encouraged immediately, and light activity is

position. allowed 2 weeks after surgery unless the patient has

152 8 Liposuction and fat grafting

undergone an associated abdominoplasty or other warrant immediate evaluation and treatment

invasive procedure. (Table 8.3).
■ Patients should expect to initially gain some weight after • Although rare, wound infections, including
liposuction due to volume shifts and postoperative necrotizing fasciitis, are serious complications known
swelling, with edema peaking 3–5 days after surgery. to occur in liposuction. Complaints of persistent
Bruising should be minimal and dissipate by 7–10 days postoperative fevers and/or cellulitis should be
after surgery. closely monitored and aggressively treated.
■ Contour changes in the waist may be visible by 2 weeks, ■ Late postoperative complications include delayed seroma

and at 6 weeks, significant changes in shape should be formation, edema and ecchymosis, paresthesia,
noticeable. However, the final aesthetic result will often hyperpigmentation, and contour irregularities.
not be seen until 3–6 months after surgery, depending on • Seromas are rare and thought to be secondary to
the patient. overzealous treatment of an area, which denudes
■ Postoperative volume changes and swelling are often a the fascia. A loose closure of cannula sites,
source of angst for patients and are best discussed in the postoperative compression garments, and expressing
preoperative consultation to alleviate any postsurgical residual fluid over liposuction areas at the end of
complaints/worries and allow for appropriate patient procedure all can potentially reduce the incidence
expectations. of seroma formation.
■ Postoperative lymphatic massage is encouraged to • Postoperative edema and ecchymosis occur to a
help with swelling and induration and is often started varying extent in all patients; however, prolonged
prior to surgery and resumed shortly after the edema can occur up to 3 months post surgery and is
procedure. best treated with supportive care and lymphatic
• Significant ecchymoses may result in hemosiderin
Complications and outcomes deposition and ultimately hyperpigmentation, which
can be challenging to eliminate.
■ Liposuction, especially large-volume liposuction, can be • Postoperative paresthesia/dysesthesia can occur in all
associated with significant morbidity and should be forms of liposuction, are usually reversible, and can
performed by appropriately trained physicians. take up to 10 weeks to recover.
■ Complications can vary from mild postoperative nausea ■ The most common late postoperative complication is

and vomiting to DVT/pulmonary embolism (PE) and contour deformity or irregularities, which can occur in
even death. They often occur in three different windows: up to 20% of patients.
the perioperative period (0–48 h), the early postoperative • Mild irregularities are often present after suctioning
period (days 1–7), and the late postoperative period and are treated conservatively with lymphatic
(1 week to 3 months). massage as swelling and edema resolve.
■ Perioperative complications can include anesthesia and • Once a contour deformity is identified, it is best to
cardiac complications, hypothermia, cannula trauma to define the etiology, so proper treatment can be
skin and/or internal organs, and volume loss/overload considered.
from bleeding or excess fluid administration. • Blind suctioning of the surrounding areas is not often
• Hypothermia is generally defined as a core body the correct treatment and can significantly worsen the
temperature of <36.4°C. Preventative measures problem.
include warming of the wetting solutions and prep, • Proper treatments can include re-injecting fat into the
increasing the ambient room temperature, and use of over-resected region, suctioning adjacent areas, or
preoperative and intraoperative warming devices revision liposuction.
(Bair Hugger, Arizant, Eden Prairie, MN).
• Fluid shifts following liposuction are common and, if
improperly managed, can lead to hypovolemia or Brief introduction
volume overload.
■ Early postoperative complications can include venous ■ Autologous fat grafting was pioneered by European
thromboembolism, infection, and skin necrosis. surgeons in the late 1800s, with the first documented
• The incidence of DVT in liposuction has been case in the breast being a lipoma autotransplanted to
reported at <1%, but a marked increase in this reconstruct a breast defect, by Czerny in 1895.
percentage is demonstrated when liposuction is ■ Fat grafting enjoyed intermittent popularity throughout

combined with other surgery (abdominoplasty/belt the early 20th century, but never became popular until
lipectomy). Appropriate risk assessment is critical the 1980s, when the widespread adoption of liposuction
preoperatively. by plastic surgeons resulted in easy access to large
• Administration of enoxaparin has resulted in a volumes of donor fat.
decreased incidence of DVT but has been associated ■ Fat grafting has been used successfully for facial

with an increased risk of perioperative bleeding and rejuvenation, breast augmentation, mitigating radiation
hematoma. Classical clinical signs, including lower damage, breast capsular contracture, post-traumatic
extremity swelling, Homan’s signs, shortness of deformities, congenital anomalies, and burn injuries.
breath, chest pain, and/or tachycardia, should alert ■ Autologous fat grafts have numerous beneficial

the provider to the possibility of DVT/PE and characteristics for reconstruction including low donor
Preoperative considerations 153

Table 8.3  UT Southwestern modification of Davison–Caprini model

Step I: Exposing risk factors
1 Factor 2 Factors 3 Factors 5 Factors
Minor surgery Major surgery (general Previous MI/CHF Hip/pelvis/leg fracture
anesthesia or time >1 h)
Immobilization Severe sepsis Stroke
Central venous access Free flap Multiple trauma
BMI >30 Circumferential abdominoplasty
Step II: Predisposing factors
Clinical setting (factors) Inherited (factors) Acquired (factors)
Age 40–60 (1) Any genetic hypercoagulable Lupus anticoagulant (3)
state (3)
Age >60 (2) Antiphospholipid antibody (3)
History DVT/PE (3) Myeloproliferative disorder (3)
Pregnancy (1) HIT (3)
Malignancy (2) Homocystinemia (3)
OCP/HRT therapy (2) Hyperviscosity (3)
Total of Step I and Step II:__________
Step III: Orders
  1 Factor Low risk Ambulate TID
  2 Factors Moderate risk Intermittent pneumatic compression device and elastic
compression stocking on patient at all times while not ambulating
  3 Factors High risk Intermittent pneumatic compression device and elastic
compression stocking on patient at all times while not ambulating
  >4 Factors Highest risk Intermittent pneumatic compression device and elastic
compression stocking on patient at all times while not ambulating
Lovenox 40 mg SQ daily postoperative
(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(1):269–279.)

Table 8.4  Estimated blood loss with different liposuction Table 8.5  Techniques of liposuction and infiltrates19
Technique Infiltrate Volume aspirate
Estimated blood loss as %
Dry No infiltrate To treatment endpoint
Technique of volume aspirated
Wet 200–300 mL/area To treatment endpoint
Dry 20–45
Superwet 1 mL infiltrate:1 mL 1 mL aspirate/infiltrate
Wet 4–30
aspirate (treatment endpoints)
Superwet 1
Tumescent Infiltrate to skin 2–3 mL aspirate/mL
Tumescent 1 turgor
(Data from Fodor PB. Wetting solutions in aspirative lipoplasty: a plea for safety (Data from Fodor PB. Wetting solutions in aspirative lipoplasty: a plea for safety
in liposuction. Aesthet Plast Surg. 1995;19(4):379–380.) in liposuction. Aesthet Plast Surg. 1995;19(4):379–380.)

site morbidity, simplicity of procedure, low cost, and

resultant living autologous tissue at the site of treatment.
■ Adipose-derived stem cells are prevalent within human Preoperative considerations
adipose tissue, surrounding blood vessels and residing
within the connective tissue framework. These non-lipid- Autologous fat grafting is indicated to restore normal

laden stromal cells are easily isolated from either contour in an area of deformity. These deformities
suction-aspirated adipose tissue or excised human fat via commonly occur after previous surgery, including prior
enzymatic collagenase digestion. reconstructive or cosmetic breast surgery.
154 8 Liposuction and fat grafting

■ A relative contraindication is the thin patient who ■ Contour deformity after flap reconstruction:
does not have sufficient fat stores from which to • In the case of flap reconstruction, the border of the
harvest fat. flap is a common location for a depression, often
• This is rarely a concern for fat grafting to the face, as occurring as a “step-off” where the flap ends and the
only small volumes are necessary. normal residual tissue begins.
■ It is important to inform the patient preoperatively that ■ Contour deformities after implant or flap reconstructions

postoperative weight loss following fat grafting can lead in a radiated field:
to loss of volume and failure to maintain adequate • It is important to note that radiation increases the
correction. risks, complexities, and problems associated with fat
grafting, including an increased risk of infection,
wound healing issues, difficulty in creating enough
Common breast deformities space for the fat in the recipient site, reduced skin
elasticity, and reduced vascularity for the fat grafts
■ Contour deformity after implant reconstruction: to take.
• With implant reconstructions, thin overlying tissue ■ Lumpectomy deformities:

can lead to sharp implant borders (Fig. 8.12) and • Lumpectomy deformities of up to 10%–15% of the
visible rippling (Fig. 8.13), both of which can be breast volume often result in satisfactory aesthetic
effectively softened by fat grafting. results and require no intervention.
• If the implant is very mobile in a large pocket, • Fat grafting for lumpectomy defects is appealing
patients may require a combination of implant because most of what is missing is usually all, or in
exchange to different size, capsulorrhaphy, capsular part, fat.
reinforcement with acellular dermal matrix, and fat • There is heightened concern for monitoring and
grafting. detecting local breast cancer recurrence in



Figure 8.12  A 55-year-old patient who underwent bilateral nipple-sparing mastectomies. (A) Preoperative view. (B) postoperative view after reconstruction with tissue
expanders and acellular dermal matrix illustrates typical marginal contour deformities surrounding a prosthetic device. (C) Preoperative markings and (D) the 3-month
postoperative result for fat grafting to margins with exchange of tissue expanders for permanent implants.
Operative techniques 155

A Figure 8.14  (A,B) V-shaped dissectors. (©Tulip, Bryon Medical, with permission.)

■ Fat harvest:
• Donor site selection: any area that has sufficient fat to
donate (most commonly the abdomen, hips, flanks,
and thighs).
• Wetting solution infiltration minimizes trauma to the
grafts upon harvest.
• Syringe aspiration, SAL, or PAL techniques are
commonly used for harvest.
• Most surgeons use a 3 mm or smaller, multi-hole
aspiration cannula.
■ Graft processing:

• Grafts can be processed by gravity separation and

decanting, filtration, washing, rolling over an
B absorbent material, and centrifugation methods.
• The goal of all of these techniques is to purify the
Figure 8.13  (A) Bilateral implant reconstructions with visible implant borders grafts prior to reinjection by removing oil, blood,
superiorly on both sides and substantial rippling on the left. (B) The 6-month impurities, and infiltrate fluid.
postoperative results after fat grafting superior poles bilaterally (80 cc right, 50 cc
• Regardless of processing technique, one must consider
left) and left inferior capsulorrhaphy. Note softening of implant contour bilaterally
and resolution of visible rippling on the left. the balance between purification and trauma to the
adipocytes. Both can have effects on cell viability.
• To avoid contamination and maximize tissue viability,
exposure to air and mechanical damage should be
lumpectomy patients, and currently there is little in ■ Recipient site preparation:

the literature on lumpectomy deformities being • The recipient site is often prepared by choosing access
reconstructed with autologous fat grafting. Thus, a incisions, which allow grafting of the area in a
thorough discussion of risks and detailed informed crosshatch fashion.
consent is critical in these patients. • In many cases, scar release may be necessary to allow
■ Congenital deformities: room for the graft. This can be performed in many
• Fat grafting may be a useful tool in the reconstruction ways, including pretunneling with sharp cannulas
of patients with Poland syndrome, tuberous breast (Fig. 8.14) or large-bore needles.
deformity, and anterior thoracic hypoplasia. ■ Grafting technique:

• Cannulas used for injection are different than those

used for harvesting and are typically small and
Operative techniques (Video 8.1) blunt-tipped with a single hole for more precise fat
deposition (Fig. 8.15).
■ Fat grafting is typically performed in four stages: (1) fat • The best results for grafting typically occur
harvest, (2) fat graft processing, (3) recipient site with injection of multiple small aliquots, beads, or
preparation, and (4) grafting. ribbons of fat during withdrawal of the cannula,
• Currently, there is no consensus on the optimal through multiple planes and passes in crosshatch
harvesting, processing, or grafting techniques. fashion.
156 8 Liposuction and fat grafting

■ Persistent contour deformities following grafting can

occur as a result of graft resorption or underfilling.
• If a contour deformity remains after swelling has
resolved, it is recommended to wait at least 6 months
prior to attempting another round of grafting.
■ Rarely, excess grafted fat can create contour irregularities

and appear as lumps beneath the skin. This is generally

Figure 8.15  Injection cannulae by Tulip (1.4 mm) and Byron (2 mm). (©Byron the result of placement of volume that was too large just
Medical, with permission.) beneath thin skin.
• Treatment can be challenging and can include
liposuction, direct excision, or potentially off-label use
of Kybella (deoxycholic acid), a fat-dissolving
■ Major complications following fat grafting are rare and

Postoperative considerations include many of the potential risks associated with

liposuction, as mentioned above.
■ Skin closure of the access sites are useful to prevent ■ Specific to the breast, there are some events or risks

egress of graft and can be performed with sutures or which should be discussed with the patient
adhesive strips. preoperatively during the consent process, including:
■ Grafted areas do not routinely need dressings; however, • Mammographic abnormalities – most commonly seen
for breast reconstruction cases, a loosely supportive as calcifications as a result of fat necrosis. They can
breast garment, with cotton fluffs over the grafted areas, usually be readily distinguished from suspicious
can be used. patterns by an experienced radiologist; however, those
• Avoid tight garments or dressings. that cannot should be biopsied.
• Direct pressure on the grafted area should be avoided • Oil cysts – areas of walled-off liquefaction necrosis.
for at least 1 week. These can be multiple and small, or occasionally
■ Patients should minimize activities for 1–2 weeks. large. Large cysts are effectively treated by excision.
■ Deep massage should be avoided for 1 month. Risks of oil cysts are likely related to improper
■ The donor site can be treated with a compressive technique of attempting to graft too much fat into a
garment similarly to any area of liposuction. particular area.
■ Acute swelling can occur postoperatively and can last • Neoplasia risk – perhaps theoretical. The same
from 1–2 weeks to months. qualities of adipocyte-derived stem cells that make
them regenerative (such as angiogenesis) might be
shown in the future to increase the risk of breast
Complications and outcomes cancer for the patient. Only further research will
prove or disprove any correlation between fat grafting
■ Early reports of graft survival ranged from 25% to 50%; and the development of subsequent breast cancer;
however, graft survival percentage varies with the until that time, the risk of neoplasia must be classified
methods used to aspirate, prepare, and transplant the fat, as unknown.
as well as with the recipient site and other ■ Infection may occur after fat injection and typically

patient-related variables. presents as painful swelling with erythema, warmth, and

■ While many surgeons advocate for overgrafting to sometimes fever. Successful treatment typically involves
account for this graft loss, until more specific research is a short course of antibiotics.
performed on the subject, it is recommended that ■ Significant fluctuates in patient weight can result in

surgeons begin conservatively until they acquire a “feel” related changes in the size of the area grafted; therefore,
for how much overgrafting should be performed based patients are encouraged to have fat-grafting procedures
on the technique being used and the quality of the performed when they are at their ideal body weight and
recipient bed. to maintain that weight indefinitely.
Facial injuries
This chapter was created using content from Neligan, Rodriguez & Losee, Plastic
Surgery 4th edition, Volume 3, Craniofacial, Head and Neck Surgery, Chapter 3,
Facial injuries, Eduardo D. Rodriguez, Amir H. Dorafshar and Paul N. Manson.

examination remains the most sensitive detection of the

character and functional implications of the facial injury.
■ Access to the craniofacial skeleton can be achieved
■ The teachings of John Converse, Nicholas Georgiade, and Reed
through strategic incision placement (Fig. 9.1).
Dingman provided the benchmark for an entire generation of surgeons
in facial injury repair.
■ The treatment concepts discussed in this chapter were developed at

the University of Maryland Shock Trauma Unit and ultimately employed Preoperative considerations
at the International Center for Facial Injury Reconstruction at Johns
■ Management begins with an initial physical examination
■ The proportion of severe injuries seen at these centers is high. and is followed by a radiologic evaluation accomplished
■ The treatment concepts, however, may be modified for common with CT scanning (Table 9.1).
■ Bone injuries are suggested by soft tissue symptoms
fractures and less significant injuries.
■ Greater emphasis has been placed on minimizing operative techniques such as contusions, abrasions, ecchymosis, edema, and
and limited exposures, whereas the decade of the 1980s witnessed distortion of the facial proportions.
craniofacial principles of broad exposure and fixation at all buttresses
for a particular fracture across all degrees of severity.
■ Presently, the treatment of injuries is organized both by severity and Frontal bone and sinus injury patterns
anatomic area to permit the smallest exposure possible to achieve a
good result [computerized tomographic (CT)–based facial fracture
Brief introduction
■ The frontal sinuses are paired structures that begin to
be detected at 3 years of age. Significant pneumatic
Brief introduction expansion does not begin to occur until approximately 7
years, with full sinus development complete by the age
■ Bone and soft tissue injuries in the facial area should be of 18–20.
managed as soon as the patient’s general condition ■ The frontal sinuses are lined with respiratory epithelium,

permits. which consists of a ciliated membrane with mucus-

■ Classically, facial soft tissue and bone injuries are not secreting glands. A blanket of mucin is essential for
acute surgical emergencies, but both the ease of normal function, and the cilia beat this mucin in the
obtaining a good result and the quality of the result are direction of the nasofrontal ducts.
better with early or immediate management. ■ When injured, they serve as a focus for infection,

■ Less soft tissue stripping is required, bones are often especially if duct function is impaired.
easily replaced into their anatomic position, and easier ■ One-third of fractures involve the anterior table alone,

fracture repairs are performed. and 60% involve the anterior table and posterior table
■ The definitive radiographic evaluation is the craniofacial and/or ducts.
CT scan with axial, coronal, and sagittal sections of bone ■ Forty percent of frontal sinus fractures have an

and soft tissue windows. However, the clinical accompanying dural laceration.

158 9 Facial injuries

Table 9.1  Key components of initial evaluation

Coronal incision Upper
blepharoplasty I. ABCs
incisions II. History
1. Mechanism of injury (was the patient restrained, mobile,
2. Time of injury (i.e., how much time has elapsed since injury)?
3. Penetrating vs. blunt injury?
4. What type of object involved (e.g., fist, bat, windshield, etc.)?
Transcon- 5. Does the patient complain of any symptoms to particular
junctival facial area (e.g., numbness, pain)?
incisions 6. How does it feel when the patient bites down – pain?
Do teeth feel “normal”? Does bite “feel normal”?
7. Does the patient complain of visual problems, nasal
problems, hearing problems, or abnormal/painful bite?
Transcon- 8. Any significant PMH, meds, allergies, social history (e.g.,
junctival diabetes, aspirin, coumadin, steroid use, ETOH, etc.)?
incisions III. Exam
Intraoral 1. Inspect face/head for asymmetry, lacerations, abrasions,
incisions hematomas, ecchymoses (especially periorbital), epistaxis.
2. Document any bony irregularities, enophthalmos, proptosis,
Extraoral telecanthus.
incisions 3. Document visual acuity (e.g., Can you read my ID badge
from 12 inches away?).
4. Check pupils and ocular muscles.
a. Is there a hyphema (blood in the anterior chamber)?
b. Are extraocular movements intact, or is there a restriction
in gaze?
c. Are pupils reactive and equal?
5. Inspect oral cavity – pay particular attention to dentition,
Figure 9.1  Cutaneous incisions (solid line) available for open reduction and occlusion, lacerations.
internal fixation of facial fractures. The conjunctival approach (dotted line) also 6. Palpate the facial bones and soft tissue: document bony
gives access to the orbital floor and anterior aspect of the maxilla, and exposure
step-offs, crepitance, mobile segments, significant pain, and
may be extended by a lateral canthotomy. Intraoral incisions (dotted line) are
also indicated for the Le Fort 1 level of the maxilla and the anterior mandible. numbness.
The lateral limb of an upper blepharoplasty incision is preferred for isolated a. Palpate orbital rims.
zygomaticofrontal suture exposure if a coronal incision is not used. A horizontal b. Palpate radix and nasal bridge for instability, crepitance.
incision directly across the nasal radix is the one case in which a local incision c. Check for integrity/mobility of medial canthus.
can be tolerated over the nose. In many instances, a coronal incision is preferable d. Palpate zygoma/zygomatic arch.
unless the hair is short or the patient is balding. e. Palpate frontal bone, maxilla/maxillary sinus, cranium.
f. Palpate temporomandibular joint at rest and through
mandible range of motion.
g. Palpate mandible along its length.
Preoperative considerations h. Using gloved hand, palpate teeth for instability, fractures,
■ Lacerations, bruises, hematomas, and contusions i. Using gloved hand, grab maxilla/alveolus and check for
constitute the most frequent signs of frontal bone or midface instability/pain.
sinus fractures. j. Inspect nasal passages and external auditory canal to
■ Occasionally, the first presentation of a frontal sinus rule out septal hematoma, CSF rhinorrhea, otorrhea.
fracture may be an infection or symptom of frontal sinus 7. Perform sensory exam of all branches of trigeminal nerve
obstruction, such as mucocele or abscess formation. (supraorbital, infraorbital, marginal mandibular).
Infection in the frontal sinus may produce serious 8. Perform motor exam of facial nerve – raise eyebrows, smile,
complications because of its location. grit teeth, close eyes tightly.
■ Frontal sinus fractures should be characterized by IV. Imaging
describing both the anatomic location of the fracture,